Optimizing Care Delivery to Support Reengagement in PLWH Returning to HIV Care after Treatment Lapses in Zambia

摘要 持续保留艾滋病毒护理对抑制病毒至关重要，但艾滋病毒携带者(PLWH)经常 随着时间的推移，进入和退出护理的过渡，使他们处于持续的病毒血症和耐药性的高风险中。连 当PLWH失去随访后恢复护理(LTFU)时，未来再次成为LTFU的比率非常高 很高。我们来自赞比亚的初步数据显示，30%的人在6个月内再次成为LTFU，50%的人 目前在LTFU的人中，有过骑自行车进出护理的人。重新参与护理的时间是 因此，这是干预这一高危人群的关键时期，也是改善返乡后护理提供情况的战略 这是打破目前脱离接触循环的迫切需要。在返回护理后，PLWH经常报告说 受到斥责，医护人员(HCW)出于对坚持的担忧推迟了ART的重新启动，并且不一致 监测病毒学反应，PLWH可能仍然经历生活状况(例如，相互竞争的义务、旅行 离家出走，或心理社会因素)，导致了他们最初的LTFU。1)针对HCW行为的策略 (例如，欢迎返回的患者，迅速重新启动抗逆转录病毒治疗)使用诸如实践等实施战略 促进、审核和反馈，以及2)提供针对LTFU初始原因的PLWH支持服务 (例如，扩展充值、转移协调、对等导航)可能是有希望的。然而，为了取得成功，我们 需要了解如何将这些方法有效地实施到现有护理中，包括1)如何参与 卫生工作者在态度和行为改变策略中，2)针对不同障碍确定优先服务的支持， 以及3)如何将活动集成到现有工作流中。这份R34提案将奠定必要的基础 实施多组件重新参与战略，以支持回国后持续的重新参与 爱滋病护理。在目标1a中，我们评估患者和HCW对重新参与策略的需求和偏好 患者半结构化访谈(n=20)和与卫生工作者和临床领导层的焦点小组讨论(4个FGD， N=8-10)。在目标1b中，我们进行离散选择实验(200个PLWH，100个HCW)来量化相对 我们重新参与策略的内容和属性的首选项。在《目标2》中，我们承担了一个人类- 以设计为中心的流程，吸引关键利益相关者(公共卫生部门、卫生部门、诊所领导、卫生部)参与 共同开发侧重于1)改进的多组件重新参与战略的内容和特点 患者重新参与的体验，2)优化ART重新启动和返回后的病毒载量监测，以及 3)针对个人LTFU的具体原因提供量身定制的服务。在目标3中，我们将试行 在赞比亚卢萨卡的一家城市诊所和一家乡村诊所制定了战略。我们将使用混合方法 评估实施情况(如可接受性、适当性)、服务交付情况(如重新开展工作的时间) 开始、病毒载量监测)和临床结果(例如，6个月后的滞留和病毒抑制) 返回)。这项提案的结果将直接通知未来的R01，以正式测试这种卫生系统干预 对于在II型混合实施-有效性分组随机试验中重新参与艾滋病毒护理的患者。

ABSTRACT Sustained retention in HIV care is critical for viral suppression, but people living with HIV (PLWH) frequently transition in and out of care over time, putting them at high risk for ongoing viremia and drug resistance. Even when PLWH return to care after loss to follow-up (LTFU), rates of becoming LTFU again in the future are very high. Our preliminary data from Zambia suggests that 30% become LTFU again within 6 months, and that 50% of those who are currently LTFU have previously cycled in and out of care. The time of reengagement in care is thus a critical period to intervene in this high-risk population, and strategies to improve post-return care delivery are urgently needed to break ongoing cycles of disengagement. After returning to care, PLWH often report being scolded, health care workers (HCW) delay ART re-initiation due to adherence concerns and do not consistently monitor virologic response, and PLWH likely still experience the life situations (e.g., competing obligations, travel away from home, or psychosocial factors) that led to their initial LTFU. Strategies to 1) target HCW behaviors (i.e., welcoming returning patients, prompt ART re-initiation) using implementation strategies such as practice facilitation and audit and feedback and 2) offer PLWH support services tailored to their initial reasons for LTFU (e.g., extended refills, transfer coordination, peer-navigation) may be promising. To be successful, however, we need to understand how to effectively implement these approaches into existing care, including 1) how to engage HCWs in attitude- and behavior-change strategies, 2) what support services to prioritize for different barriers, and 3) how to integrate activities into existing workflows. This R34 proposal will build the necessary foundation for implementing a multicomponent reengagement strategy to support sustained reengagement after returning to HIV care. In Aim 1a, we assess patient and HCW needs and preferences for reengagement strategies with patient semi-structured interviews (n=20) and focus group discussions with HCWs and clinic leadership (4 FGDs, n=8-10 each). In Aim 1b, we conduct discrete choice experiments (200 PLWH, 100 HCWs) to quantify relative preferences for the contents and attributes for our reengagement strategy. In Aim 2, we undertake a human- centered design process that engages key stakeholders (PLWH, HCWs, clinic leadership, Ministry of Health) in co-developing the content and features of a multicomponent reengagement strategy focused on 1) improving the patient reengagement experience, 2) optimizing ART re-initiation and viral load monitoring post-return, and 3) providing tailored services that target individuals’ specific reasons for LTFU. In Aim 3, we will pilot the developed strategy at one urban and one rural clinic in Lusaka, Zambia. We will use a mixed-methods approach to assess the implementation (e.g., acceptability, appropriateness), service delivery (e.g., time to ART re- initiation, viral load monitoring), and clinical outcomes (e.g., retention and viral suppression at 6 months post- return). Results from this proposal will directly inform a future R01 to formally test this health-system intervention for patients reengaging in HIV care in a Type II hybrid implementation-effectiveness cluster randomized trial.