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

项目摘要/摘要 持续的病毒抑制继续给艾滋病毒的治疗和预防带来重大挑战。 对艾滋病毒携带者(PLHIV)来说，留住护理是一个特别具有挑战性的问题，因为缺乏 便利的交通和与经济稳定有关的问题。我们的长期目标是帮助实现90-90-90 在严格执行研究的基础上，通过改进护理提供来实现目标。这个项目的目标是 是为了展示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。中心假设是艾滋病毒护理服务和服务的整合 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保留率和VS率 通过两种机制在肯尼亚传播艾滋病毒：改善家庭经济状况和更容易获得护理。因此， 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 集团小额信贷影响肯尼亚西部农村地区艾滋病毒感染者的护理保留率和VS 现有(完全感染艾滋病毒)小额信贷群体的随机干预设计：(A)综合 以社区为基础的艾滋病毒护理，或(B)标准护理。我们还将使用匹配的 同时接受标准护理的患者对照组(C组)比较A、B和 C；(2)确定小额供资和以社区为基础的综合护理产生影响的具体机制 VS：使用混合方法，我们将描述影响患者预后的机制。我们 将进行量化中介分析，以考察两条主要的中介途径(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、社会支持、艾滋病毒-- 相关污名)。我们还将使用定性方法和多方利益攸关方小组来确定 实施干预措施；以及(3)评估小额供资和综合供资的成本效益 以社区为基础的护理提供，以最大限度地提高这一前景看好的干预措施的未来政策和实践相关性 策略。我们的工作假设是，就每艾滋病毒的成本而言，差异化模型将是具有成本效益的 被抑制的人-时间、保留在护理中的每个患者的成本，以及每个残疾调整后的生命年节省的成本。这 该项目是肯尼亚西部提供医疗服务的学术模式(AMPATH)计划的一部分 自2001年以来，该组织在肯尼亚西部的500多个地点照顾了150,000多名艾滋病病毒感染者。主要预期 结果将是差异化的有效性、机制和成本效益的严格证据 实现艾滋病毒护理连续体最后关键一步的典范。这些结果预计将产生重要的 在改善高质量服务方面产生积极影响，以解决已知的个人和结构性障碍 在艾滋病毒感染率较高的农村地区，护理和促进艾滋病的长期可持续性。

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.