Strategies to improve the HIV care continuum among key populations in India

改善印度重点人群艾滋病毒护理连续性的策略

• 批准号: 9694664
• 负责人: GREGORY M LUCAS
• 金额: $ 141.33万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-09-30 至 2022-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9694664
• 关键词: AIDS prevention; Acquired Immunodeficiency Syndrome; Address; Adherence; Adoption; Behavior; Caring; Cities; Client; Clinic; Clinical Trials; Cluster randomized trial; Communities; Continuity of Patient Care; Cost Analysis; Counseling; Country; Data; Effectiveness; Epidemic; Ethnography; Focus Groups; Food; Fostering; General Population; Goals; Government; HIV; HIV Infections; HIV diagnosis; Health Personnel; Health Policy; Health Promotion; Health Services Accessibility; Household; Human immunodeficiency virus test; Incentives; Incidence; Income; India; Infrastructure; Injecting drug user; Intervention; Interview; Medical; Methods; Modeling; Outcome; Pathway interactions; Patients; Penetration; Persons; Phase; Policy Maker; Population; Prevalence; Process Measure; Public Health; Research; Respondent; Sampling; Services; Side; Site; Societies; Target Populations; Testing; Time; Travel; Treatment outcome; Ursidae Family; Viral; Viral Load result; Wages; antiretroviral therapy; care outcomes; cohort; compare effectiveness; cost effectiveness; cost estimate; criminal behavior; design; disability-adjusted life years; economic value; effectiveness implementation study; effectiveness implementation trial; evidence base; implementation science; improved; incremental cost-effectiveness; interest; low and middle-income countries; meetings; men who have sex with men; multidisciplinary; prevention service; primary outcome; public health relevance; randomized trial; secondary outcome; service delivery; social stigma; success; therapy adherence; treatment as usual; treatment optimization; treatment services; trial design; uptake; virology

 DESCRIPTION (provided by applicant): The trajectory of the HIV epidemic in coming decades will be determined by the degree to which we can identify infected persons and engage them in care - a point implicit in the ambitious UNAIDS "90-90-90" target, which sets 90% goals for HIV diagnosis, linkage of infected persons to sustained antiretroviral therapy (ART), and viral suppression in those treated. Meeting this target requires successful engagement of difficult to reach populations, such as people who inject drugs (PWID) and men who have sex with men (MSM), who bear a disproportionate share of the epidemic particularly in low to middle income countries. Our team is nearing completion of a multi-site cluster-randomized trial in India to assess the effectiveness of integrated care centers (ICCs) for PWID and MSM compared to usual care (fragmented service delivery). The ICCs, which separately target PWID and MSM, provide vertically integrated, evidence-based HIV prevention and treatment services in a single stigma-free setting. ICC process measures from the first year show robust uptake of HIV counseling and testing, the primary outcome for that trial, but slower than anticipated ART uptake. Ethnography with stakeholders identified travel time and loss of wages as barriers to attending ICCs regularly, as required for medical management of HIV. Demand-side interventions in public health (such as treatment incentives) can be particularly effective when paired with optimized treatment accessibility (i.e., supply). Consequently, we propose to examine whether provision of HIV care and treatment incentives to ICC clients - redeemable for food and household goods - will improve overall utilization of the clinics and downstream HIV care continuum outcomes. We propose a hybrid effectiveness-implementation design. This will include a 16- site, pair-matched cluster randomized trial to compare the effectiveness of adding of HIV care incentives to ICCs (ICC+) versus standard ICCs on HIV care continuum outcomes, including ART initiation, adherence and viral suppression (aim 1). Effectiveness will be compared at the ICC level (from a cohort of HIV-infected ART- eligible clients followed in each ICC and process measures deriving from all ICC clients) and at the community- level through a cross-sectional sample accrued via respondent-driven sampling (RDS) 2 years after initiation of the intervention. Because PWID and MSM will be sampled independently from the ICCs in the RDS, it provides an opportunity to characterize outcomes like community viral load and HIV incidence, reflecting impact within the broader PWID/MSM communities. As an exploratory sub-aim, we will use a rigorous scientific design to assess the effects of withdrawing (vs. continuing) incentives beyond the initial intervention phase. Additionally, we will characterize barriers and facilitators to implementation of the ICC and ICC+ interventions (aim 2), and determine the cost-effectiveness of the ICC+ intervention (aim 3). This proposal is strengthened by infrastructure from our prior trial, detailed data on the target populations in the 16 sites for the proposed tria, and an expanded multidisciplinary team with new expertise in implementation science and cost-effectiveness.

 描述(申请人提供)：未来几十年艾滋病毒流行的轨迹将取决于我们能够识别感染者并让他们接受护理的程度-这一点隐含在雄心勃勃的联合国艾滋病规划署“90-90-90”目标中，该目标为艾滋病毒诊断设定了90%的目标，将感染者与持续抗逆转录病毒疗法(ART)联系起来，并在接受治疗的人中抑制病毒。要实现这一目标，需要成功地接触到难以接触到的人群，如注射吸毒者(PWID)和男男性行为者(MSM)，他们在疫情中承担着不成比例的份额，特别是在低收入和中等收入国家。我们的团队即将在印度完成一项多站点整群随机试验，以评估综合护理中心(ICCs)与常规护理(零散服务提供)相比对PWID和MSM的有效性。ICC分别针对PWID和MSM，在单一的无耻辱环境中提供垂直整合的、基于证据的艾滋病毒预防和治疗服务。从第一年开始的ICC过程测量显示，该试验的主要结果-艾滋病毒咨询和检测的强劲接受率，但低于预期的ART接受率。与利益攸关方的人种学将旅行时间和工资损失确定为定期参加ICC的障碍，这是艾滋病毒医疗管理所必需的。公共卫生方面的需求方干预措施(如治疗奖励)在与最佳的治疗可获得性(即供应)相结合时可能特别有效。因此，我们建议研究向ICC客户提供艾滋病毒护理和治疗激励措施--可兑换食品和家庭用品--是否将改善诊所的总体利用率和下游艾滋病毒护理连续成果。我们提出了一种混合有效性-实现设计。这将包括一项16点配对的整群随机试验，以比较将艾滋病毒护理激励措施添加到ICC(ICC+)和标准ICC对艾滋病毒护理连续结果的有效性，包括抗逆转录病毒治疗的启动、坚持和病毒抑制(目标1)。在干预开始两年后，将在国际刑事法院一级(从每个国际刑事法院跟踪的符合艾滋病毒感染的符合抗逆转录病毒治疗标准的患者队列中进行比较，并处理来自所有国际刑事法院客户的措施)和在社区一级通过受访者驱动抽样(RDS)收集的横断面样本来比较有效性。由于PWID和MSM的抽样将独立于RDS中的ICC，因此它提供了一个机会来表征社区病毒载量和艾滋病毒发病率等结果，反映更广泛的PWID/MSM社区的影响。作为探索性的子目标，我们将使用严格的科学设计来评估撤军(与继续撤军)的效果 最初干预阶段以外的激励措施。此外，我们将确定实施国际刑事法院和国际刑事法院+干预措施的障碍和促进者(目标2)，并确定国际刑事法院+干预措施(目标3)的成本效益。我们先前试验的基础设施、关于拟议三年期审查的16个地点的目标人群的详细数据以及扩大的多学科小组具有执行科学和成本效益方面的新专门知识，加强了这一提议。