Combining Positive Deviance and Implementation Science to Improve Retention in HIV Care in South Africa

结合积极偏差和实施科学以提高南非艾滋病毒护理的保留率

• 批准号: 9925429
• 负责人: Allison Ober
• 金额: $ 22.13万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-12-01 至 2022-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9925429
• 关键词: Address; Adopted; Caring; Clinic; Clinic Visits; Cluster randomized trial; Collaborations; Country; Data Collection; Educational workshop; Effectiveness; Empathy; Face; Focus Groups; Goals; Guidelines; HIV; HIV Seropositivity; HIV diagnosis; Health; Healthcare; Human; Individual; Intervention; Interview; Lead; Leadership; Learning; Location; Manuals; Methods; Minority; Modeling; Outcome; Patients; Performance; Phase; Prevalence; Primary Health Care; Process; Provider; Province; Qualitative Methods; RNA; Readiness; Research; Research Methodology; Resources; Science; South Africa; South African; Staff Attitudes; Structure; Suggestion; Surveys; Testing; Viral Load result; Workload; antiretroviral therapy; burnout; contextual factors; deviant; effective intervention; experience; health care settings; implementation science; improved; intervention effect; mortality; novel; patient-level barriers; professional atmosphere; retention rate; success; symposium; therapy adherence

PROJECT SUMMARY/ABSTRACT Despite notable increases in antiretroviral therapy (ART) adherence and decreases in mortality, South Africa is not close to achieving the UNAIDS goals of 90% of all people living with HIV (PLWH) diagnosed, 90% of those with a positive HIV diagnosis on antiretroviral therapy (ART), and 90% of those on ART with undetectable HIV RNA by 2020, with only 60% of all PLWH having undetectable RNA as of 2017. Moreover, in the Western Cape, the viral load suppression (VLS) rate (54.7%) is the second lowest in the country, and the average 6- month rate for retaining PLWH in primary health care clinics is 64%. Retention is critical for improving ART adherence and VLS. Clinics face myriad challenges retaining PLWH in care long enough to maintain VLS. Structural-, organizational-, and individual-level patient barriers impede retention. Nevertheless, a handful (about 8%) of health care clinics consistently have retention rates at 80% or above. Information about how these clinics manage to succeed despite pervasive barriers could help improve retention rates in clinics that are not performing as well. Positive Deviance (PD) is an approach to studying ways in which a minority of individuals or organizations succeed despite barriers that typically hinder success. The approach begins with a “discover” phase in which intensive study is undertaken to uncover unique strategies of clinics with better outcomes than those facing similar challenges, followed by an implementation phase in which the strategies are implemented. In a collaboration among the RAND Corporation, the South African Human Science Research Council, and the South African Western Cape Department of Health, we propose (1) to use a PD approach and mixed methods research (a provider survey that assesses contextual factors thought to be associated with performance; patient shadowing; semi-structured interviews with clinic leaders, and focus groups with providers and patients) to discover strategies used by primary health care clinics that retain 80% or more of PLWH in care; (2) to develop an intervention that consists of a toolkit with novel PD strategies identified in Phase 1 and implementation science methods for successfully implementing strategies; and (3) to implement the PD intervention in 3 low-performing pilot clinics and conduct a pilot cluster randomized trial to evaluate (a) feasibility (extent to which the PD strategies are implemented); (b) acceptability (clinic staff attitudes about the toolkit, the strategies, and implementation processes); and (c) preliminary effects of the intervention on PLWH retention in care and VLS. To determine feasibility, we will collect attendance logs and activity worksheets; to assess acceptability, we will conduct focus groups with providers and patients; to assess preliminary effectiveness, we will examine changes in patient retention and VLS at intervention clinics from 6-months before the intervention and during the intervention period, compared to changes in all other low- performing clinics. The proposed study would be the first to experimentally test a PD intervention to improve retention in HIV care for PLWH; if effective, it could lead to higher retention and VLS rates and lower mortality.

项目摘要/摘要 尽管抗逆转录病毒疗法（ART）依从性和死亡率下降显着增加，但南非是 未接近实现90％的艾滋病毒（PLWH）诊断的人的UNAID目标，其中90％ 抗逆转录病毒疗法（ART）的HIV阳性诊断为阳性 到2020年，RNA，截至2017年，所有PLWH的60％。此外，在西方 CAPE，病毒载量抑制（VLS）率（54.7％）是该国第二低，平均6-- 在初级卫生保健诊所保留PLWH的月份率为64％。保留对于改善艺术至关重要 依从性和VLS。诊所面临无数挑战，将PLWH保留在护理中足够长的时间以维持VLS。 结构性，组织和个人级别的患者障碍阻碍了保留。然而，少数 （约8％）保健诊所的保留率始终为80％或更高。有关如何的信息 这些诊所设法取得成功的目的地普遍障碍可以帮助提高诊所的保留率 表现不佳。积极偏差（PD）是研究少数族裔的方法 个人或组织继承了通常阻碍成功的目的地障碍。该方法始于 “发现”阶段进行了深入的研究，以发现更好的诊所的独特策略 结果比面临类似挑战的成果，然后是实施阶段，在该阶段中 已实施。在兰德公司（Rand Corporation）的合作中，南非人类科学 研究委员会和南非西部开普卫生部，我们建议（1）使用PD 方法和混合方法研究（评估背景因素的提供商调查被认为是 与性能相关；患者阴影；与诊所领导者的半结构化访谈，并重点 具有提供者和患者的团体）发现保留80％或 更多的PLWH护理； （2）开发由具有新颖PD策略的工具包组成的干预措施 在第1阶段和实施科学方法中确定，以成功实施策略； （3）到 在3个低绩效的飞行员诊所中实施PD干预，并进行试验群集随机试验 评估（a）可行性（实施PD策略的程度）； （b）可接受性（诊所工作人员 参加工具包，策略和实施过程）； （c）初步影响 干预PLWH保留在护理和VLS中。为了确定可行性，我们将收集出勤日志 活动工作表；为了评估可接受性，我们将与提供者和患者进行焦点小组；到 评估初步有效性，我们将检查干预诊所中患者保留和VLS的变化 从干预前的6个月到干预期，与所有其他低 - 表演诊所。拟议的研究将是第一个实验测试PD干预以改进的研究。 保留在艾滋病毒护理中为PLWH保留；如果有效，它可能会导致更高的保留率和VLS率和较低的死亡率。