Implementation Research: Translating the ABC's into HIV Care

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SUMMARY/ABSTRACT Use of highly effective, often single pill HIV antiretroviral therapy has dramatically reduced deaths from AIDS- related causes yielding an aging population among people living with HIV (PLH) who increasingly experience cardiovascular (CVD) morbidity and mortality. Age and sex-adjusted deaths from CVD are appreciably higher among PLH than among the general population. This growing CVD risk among PLH can be substantively reduced through use of established interventions, commonly referred to as ABCS i.e. appropriate use of aspirin, blood pressure control, cholesterol reduction, and smoking cessation, in addition to lifestyle, ie diet, physical activity, and safe drinking. Each of these interventions is underused among PLH. There is a fundamental gap in scientific knowledge regarding which strategies will promote shared decision-making regarding ABCS between PLH and their clinicians. Addressing this gap is vital to reducing the growing CVD burden among PLH. The overall objective of this proposal is to develop and rigorously test implementation strategies to address this gap in scientific knowledge. We propose to test the following patient-, clinician-, and practice-level strategies: patient/activation training and texting support, clinician-targeted academic detailing and audit and feedback, and practice-based engagement. The scientific premise of this application is that use of evidence-based, multilevel implementation strategies will improve discussion and uptake of the ABCS among PLH. Our investigative team is qualified to ensure success. We are experienced in training largely low- income and minority PLH to become `activated patients' using digital technology. Our team is experienced in training to clinicians using implementation strategies. We have been successful in implementation research. Building on this foundation, we will recruit 8 HIV practices of varying sizes and location and recruit 600 patients, 40-60 clinicians and engage them in partnerships to implement patient, clinician and practice-focused strategies for promoting patient-clinician discussion of the ABCS. We will use scientifically rigorous methods, including a stepped wedge randomized trial (SWT) to evaluate the impact on changes in cardiovascular risk using a validated risk assessment tool. Our specific aims are: 1)To assess the impact of the implementation of an evidence-based, multilevel strategy to reduce CVD risk among PLH; 2)To assess the process of implementation of these strategies using RE-AIM QuEST. Using both quantitative and qualitative methods, we will assess the process of implementation by assessing Reach, Effectiveness (as above), Adoption, Implementation and Maintenance. Achievement of these aims will inform the science of translating proven CVD prevention interventions into practice to reduce growing CVD risk among PLH that was highlighted by an NHLBI Implementation Science Work Group. The proposal is innovative in its focus (PLH), its combination of multilevel strategies, and its application of the SWT. Our proposal is significant in its contribution to CVD implementation science and its potential for reducing public health impact of CVD among PLH.