Harambee: Integrated Community-Based HIV/NCD Care & Microfinance Groups in Kenya

项目概要/摘要 持续的病毒抑制（VS）仍然是艾滋病毒治疗和预防的主要挑战。 对艾滋病毒感染者来说，继续接受护理是一个特别具有挑战性的问题，因为缺乏适当的护理， 方便的访问和有关经济稳定的问题。我们的长期目标是帮助实现90-90-90 通过在严格的实施研究的基础上改善护理服务来实现目标。本项目的目标 是为了证明差异化护理提供模式的有效性和长期可持续性， 改善艾滋病毒治疗结果。核心假设是，艾滋病毒护理的提供和 以社区为基础的初级保健和以团体为基础的小额信贷将提高老年人的保留率和自愿性卫生服务率， 肯尼亚的艾滋病毒感染者通过两种机制：改善家庭经济状况和更容易获得护理。因此，在本发明中， 具体目标如下：（1）评估以社区为基础的艾滋病毒综合护理与 在肯尼亚西部农村地区，小组小额信贷影响艾滋病毒感染者的护理保留率和VS 现有（完全艾滋病毒阳性）小额供资群体的随机干预设计，以接受：（A）综合 以社区为基础的艾滋病护理，或（B）标准护理。我们还将增加试验数据， 标准治疗患者的同期对照组（C组）比较A、B和 C;（2）确定小额供资和综合社区护理产生影响的具体机制 VS：使用混合方法，我们将描述对患者结局的影响机制。我们 我将进行定量中介分析，以研究两个主要的中介途径（家庭经济 条件和更容易获得护理），以及探索性机制（粮食安全、社会支助、艾滋病毒- 相关的耻辱）。我们还将使用定性方法和多利益相关者小组， （3）评估小额供资和综合金融服务的成本效益， 以社区为基础的护理提供，以最大限度地提高这一有前途的干预措施的未来政策和实践相关性 战略我们的工作假设是，就每个艾滋病毒的成本而言，差异化模式将具有成本效益 抑制的人的时间，每名患者的成本保留在照顾，和每残疾调整生命年节省的成本。这 该项目是肯尼亚西部提供医疗保健的学术模式（AMPATH）项目的一部分 自2001年以来，该组织在肯尼亚西部的500多个地点照顾了15万多名艾滋病毒感染者。主要预期 结果将是有效性的有力证据，机制和成本效益的差异化 这是实现艾滋病毒护理连续性最后一个关键步骤的模式。这些结果预计将有一个重要的 在改善优质服务方面产生积极影响，解决已知的个人和结构性障碍 在艾滋病毒感染率高的农村地区，对艾滋病毒感染者进行护理，并促进护理的长期可持续性。

PROJECT SUMMARY/ABSTRACT Sustained viral suppression (VS) continues to present major challenges to HIV treatment and prevention. Retention in care is a particularly challenging issue for persons living with HIV (PLHIV) because of lack of convenient access and issues related to economic stability. Our long-term goal is to help achieve the 90-90-90 goals through improved care delivery based on rigorous implementation research. The objective of this project is to demonstrate the effectiveness and longer-term sustainability of a differentiated care delivery model for improving HIV treatment outcomes. The central hypothesis is that the integration of HIV care delivery and community-based primary care with group-based microfinance will improve retention and rates of VS among PLHIV in Kenya via two mechanisms: improved household economic status and easier access to care. Thus, the specific aims are as follows: (1) To evaluate the extent to which integrated community-based HIV care with group microfinance affects retention in care and VS among PLHIV in rural western Kenya using a cluster randomized intervention design of existing (fully HIV+) microfinance groups to receive either: (A) integrated community-based HIV care, or (B) standard care. We will also augment trial data with a matched contemporaneous control group of patients in standard care (group C) comparing outcomes in groups A, B and C; (2) To identify specific mechanisms through which microfinance and integrated community-based care impact VS: Using a mixed methods approach, we will characterize the mechanisms of effect on patient outcomes. We will conduct quantitative mediation analysis to examine two main mediating pathways (household economic conditions and easier access to care), as well as exploratory mechanisms (food security, social support, HIV- related stigma). We will also use qualitative methods and multi-stakeholder panels to contextualize the implementation of the intervention; and (3) To assess the cost-effectiveness of microfinance and integrated community-based care delivery to maximize future policy and practice relevance of this promising intervention strategy. Our working hypothesis is that the differentiated model will be cost-effective in terms of cost per HIV suppressed person-time, cost per patient retained in care, and cost per disability-adjusted life year saved. This project is part of the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya which cares for more than 150,000 PLHIV at over 500 sites in western Kenya since 2001. The main expected outcomes will be rigorous evidence of effectiveness, mechanisms and cost-effectiveness of a differentiated model for achieving the last key step in the HIV care continuum. These results are expected to have an important positive impact in terms of improved, high-quality services that address known individual and structural barriers to care and promote long-term sustainability of care for PLHIV in rural settings with high HIV prevalence.