Examining Multilevel System Dynamics Affecting HIV Community Viral Load

描述（由申请人提供）：这项为期三年的案例研究将审查影响通过促进检测和治疗（T&T）在社区一级减少艾滋病毒流行的因素。T&T战略旨在将所有感染者的艾滋病毒载量（VL）降低到检测不到的水平，从而降低每个人的传染性和社区病毒载量（CVL），以预防新病例。这些努力引起了人们对艾滋病毒感染者（PWH）在达到无法检测到的VL之前放弃T&T连续体的问题的新的关注，即所谓的治疗级联。尽管多部门努力解决这一问题，但艾滋病毒流行病仍然存在，因为它是复杂的，嵌入在组织间网络结构的动态系统中，社会和个人力量相互作用，产生影响遏制这一流行病努力的非线性过程。有必要解开这些结构和动态，确定一个科学的设计，以组织服务网络，并建立“系统干预”，以取得更好的效果。诸如社会网络分析、系统动力学建模和混合方法人种学等系统科学方法为实现这些目标提供了概念框架和分析工具。这些系统科学方法可以从系统多个层面直接参与的人的角度和经验来理解表征治疗级联的动态过程。本研究的目的如下：(1)通过构建地方T&T服务组织的整体网络图，识别影响PWH在T&T连续体中高效发展的组织间网络因素（联系密度、集中化/碎片化、桥梁、瓶颈、关系质量）；(2)使用混合方法来详细说明、背景化和跟踪PWH和提供者的经验，研究产生非线性系统动力学（时间滞后、中断、正/负反馈、加速、逆转）特征的个人、组织间和社区社会结构因素；(3)基于对T&T网络和系统特性和动态的研究结果，建立一个以概念SD模型为代表的解释框架，该模型整合了组织网络和SD结构因素和过程，这些因素和过程共同阻碍了减少CVL的进展。该研究将在康涅狄格州哈特福德大都会的高患病率地区进行，这是一个典型的东北中等城市。混合数据收集方法（定性访谈，组织间网络图表/分析，纵向队列调查，案例跟踪，系统模型开发和改进的小组启发）将用于引出PWH和T&T连续体中的提供者的观点和经验。研究结果将为处理级联提供一个可分析推广的SD概念模型，该模型可在后续研究中进行测试、验证和复制。丰富的数据和概念模型对当地利益相关者制定改进的策略以减轻处理级联也具有直接的应用价值。

DESCRIPTION (provided by applicant): This 3-year case study will examine factors that affect efforts to reduce the HIV epidemic at the community level through the promotion of testing and treatment (T&T). The T&T strategy was designed to reduce HIV viral load (VL) to undetectable in all infected persons, thereby lowering each person's infectivity and community viral load (CVL), in order to prevent new cases. These efforts have generated new attention to the problem of people with HIV (PWH) dropping off the T&T continuum before achieving undetectable VL, known as the treatment cascade. Despite multi-sector efforts to tackle it, the HIV epidemic endures because it is complex, embedded in a dynamic system of inter-organizational network structures and interacting social and personal forces that generate non-linear processes affecting efforts to curb the epidemic. It is necessary to unpack these structures and dynamics, identify a scientifically based design to organize service networks, and build "systemic interventions" to achieve better results. Systems science methodologies such as social network analysis, system dynamics modeling, and mixed methods ethnography offer both a conceptual framework and analytical tools to achieve these goals. These systems science methods make it possible to understand the dynamic processes that characterize the treatment cascade from the perspectives and experiences of those directly involved in it at multiple levels of the system. This study has the following aims: (1) Identify inter- organizational network factors (density of linkages, centralization/fragmentation, bridges, bottlenecks, quality of relations) that affect efficient and effective progression of PWH across the T&T continuum by constructing a whole network diagram of local T&T service organizations; (2) Examine the individual, inter-organizational, and community socio-structural factors that generate non-linear system dynamics (time lags, interruptions, positive/ negative feedback, acceleration, reversals) characterizing transitions of PWH through the stages of the T&T continuum using mixed methods to specify, contextualize, and track experiences of PWH and providers over time; and (3) Based on the results of examination of T&T network and systems properties and dynamics, develop an explanatory framework represented by a conceptual SD model that integrates organizational network and SD structural factors and processes that collectively impede progress toward reducing CVL. The study will be conducted in the high prevalence area of metropolitan Hartford, CT, a typical mid-sized, northeast city. Mixed data collection methods (qualitative interviews, inter-organizational network diagramming/analysis, longitudinal cohort survey, case tracking, group elicitation for systems model development and refinement) will be used to elicit perspectives and experiences of PWH and providers across the T&T continuum. Findings will provide an analytically generalizable SD conceptual model of the treatment cascade that can be tested, validated, and replicated in subsequent research. The rich data and the conceptual model also have immediate application value for local stakeholders to develop improved strategies to mitigate the treatment cascade.