A sequential, adaptive model of differentiated service delivery to reach persons living with HIV who are lost-to-follow-up or who have detectable viral load

一种连续的、适应性的差异化服务提供模式，旨在覆盖失访或病毒载量可检测的艾滋病毒感染者

• 批准号: 10321966
• 负责人: Ruanne Vanessa Barnabas
• 金额: $ 55.87万
• 依托单位: UNIVERSITY OF WASHINGTON
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-01-01 至 2022-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10321966
• 关键词: Address; Adherence; Back; Behavior; Caring; Cessation of life; Characteristics; Client; Clinic; Clinic Visits; Communities; Cost Savings; Disease; Enrollment; Evaluation; Frequencies; Goals; HIV; HIV Infections; HIV Seronegativity; HIV Seropositivity; Health Benefit; Home; Incentives; Intervention; Interview; Life; Measures; Modeling; Morbidity - disease rate; Participant; Persons; Population; Provider; Randomized; Sampling; Sequential Multiple Assignment Randomized Trial; Service provision; Services; South Africa; Subgroup; System; Testing; Viral; Viral Load result; Wages; Wait Time; antiretroviral therapy; arm; barrier to care; base; budget impact; care delivery; cost; cost effectiveness; cost estimate; experience; follow-up; improved; incentive strategies; intervention delivery; intervention participants; microcosting; mortality; patient-level barriers; peer; preference; prevent; primary outcome; randomized trial; recruit; service delivery; success; transmission process; treatment strategy; trial design

ABSTRACT Globally, more than half of the world's 37 million people living with HIV are on antiretroviral therapy (ART) representing immense and encouraging success with access to HIV care. ART prevents disease, death and HIV transmission and HIV-positive persons can expect to live as long as their HIV-negative peers when their viral load is undetectable. However, treatment success still lags behind goals. In South Africa alone, 8 million HIV- positive persons require ART for life and only 4.5 million are currently on ART. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load, the hallmark of struggling to access and take ART. HIV differentiated service delivery (DSD) has simplified ART delivery: incentives, multi-month scripts, fast-track ART, and community or home ART delivery motivate clients, reduce the frequency of clinic visits, and decongest clinics. DSD is standard for clients who achieve viral suppression and engage in care; however, DSD needs adaptation to serve clients who are not succeeding. Indeed, persons who are not engaged in care arguably need simplified, client-centered approaches even more than those who can successfully engage. A suite of adaptive DSD strategies, including community-based ART, have been tested among stable clients with viral suppression. Lottery incentives effectively change short-term behavior, increasing ART initiation. Community and home ART delivery increases ART coverage and simplify ART access overcoming clinic barriers. For stable clients, these DSD activities are as effective as clinic-based care in terms of achieving and maintaining viral suppression, although among stable clients they have not shown superiority in viral suppression or cost savings. In contrast, DSD has the potential to improve rates of viral suppression and retention in care and save costs among more hard-to-reach groups. There is great potential that DSD systems can be client- responsive and system-efficient for subgroups requiring additional services, matching services with client needs. A sequential, comprehensive package of DSD approaches, with each step increasing the intensity of service provision – adaptive DSD – has not been tested to determine the proportion and characteristics of persons who would achieve viral suppression and retention in care and to estimate the cost-effectiveness and budget impact. To increase population level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates evaluation of a stepped, adaptive approach to achieving viral suppression with `right-sized' interventions. We are an experienced team and propose to build on our strong partnerships to sequentially test adaptive DSD strategies for persons with detectable viral load: lottery incentives, community-based ART, and home ART delivery. Our aim is to identify the most effective and efficient HIV care delivery strategies for South Africa.

摘要 在全球范围内，全世界3700万艾滋病毒感染者中有一半以上正在接受抗逆转录病毒治疗（ART） 这是在获得艾滋病毒护理方面取得的巨大和令人鼓舞的成功。ART预防疾病、死亡和艾滋病毒 在病毒感染和艾滋病毒阳性的人可以预期活得和他们的艾滋病毒阴性的同龄人一样长， 负载无法检测。然而，治疗的成功仍然落后于目标。仅在南非，就有800万艾滋病毒感染者- 阳性者终身需要抗逆转录病毒疗法，目前只有450万人在接受抗逆转录病毒疗法。 错过的工资，交通费用，以及诊所就诊和ART补充的漫长等待时间，与可检测到的 病毒载量，努力获得和采取抗逆转录病毒治疗的标志。艾滋病毒差异化服务提供（DSD） 简化的抗逆转录病毒治疗提供：激励措施、多个月的脚本、快速通道抗逆转录病毒治疗以及社区或家庭抗逆转录病毒治疗提供 激励客户，减少诊所就诊频率，缓解诊所拥挤。DSD是以下客户的标准配置 实现病毒抑制和从事护理;然而，DSD需要适应，以服务客户谁不是 成功。事实上，不从事护理的人可以说需要简化的、以客户为中心的 甚至比那些能够成功参与的人更接近。 一套适应性DSD策略，包括基于社区的ART，已经在稳定的客户中进行了测试 病毒抑制。彩票激励有效地改变了短期行为，增加了ART的启动。 社区和家庭抗逆转录病毒疗法的提供增加了抗逆转录病毒疗法的覆盖面，并简化了抗逆转录病毒疗法的获得，克服了诊所 隔栏.对于稳定的客户，这些DSD活动与诊所护理一样有效， 维持病毒抑制，尽管在稳定的客户中，它们在病毒抑制方面没有表现出优势 或节省成本。相比之下，DSD有可能提高病毒抑制率和护理保留率 并在更难接触的群体中节省成本。渠务署系统有很大的潜力，可以成为客户- 对需要额外服务的子群体作出反应并提高系统效率，使服务与客户需求相匹配。 一个连续的，全面的DSD方法包，每一步都增加了服务的强度 供应-适应性DSD -尚未进行测试，以确定以下人员的比例和特征： 将实现病毒抑制和保持护理，并估计成本效益和预算影响。 为了提高人群水平的病毒抑制，具有可检测病毒载量的人需要响应性DSD 干预措施。序贯多分配随机试验（SMART）设计有助于评价 采取“适当规模”的干预措施，逐步采取适应性办法，实现病毒抑制。我们是经验丰富的 团队，并建议建立在我们强大的合作伙伴关系，以顺序测试适应性DSD战略的人 病毒载量可检测的：彩票激励，基于社区的ART和家庭ART交付。我们的目标是 确定南非最有效和最高效的艾滋病毒护理提供战略。