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

摘要 持续接受艾滋病毒护理对于抑制病毒至关重要，但艾滋病毒感染者（PLWH）经常 随着时间的推移，他们在护理中和护理外的过渡，使他们处于持续病毒血症和耐药性的高风险之中。甚至 当PLWH在失访（LTFU）后返回护理时，未来再次成为LTFU的比率非常高， 高我们在赞比亚的初步数据表明，30%的人在6个月内再次成为长期家庭成员，50%的人在6个月内再次成为长期家庭成员。 目前LTFU的患者中，有30%以前曾在护理中循环和循环。重新参与护理的时间是 因此，这是对这一高危人群进行干预的关键时期，并制定了改善返回后护理服务的战略 以打破目前的脱离接触循环。返回护理后，PLWH经常报告 由于受到责骂，卫生保健工作者（HCW）由于依从性问题而推迟ART重新开始， 监测病毒学反应，PLWH可能仍然经历生活状况（例如，相互矛盾的义务、旅行 远离家庭，或心理社会因素），导致他们最初的LTFU。1）针对HCW行为的策略 (i.e.,欢迎返回的患者，及时重新开始抗逆转录病毒治疗），采用实施策略， 促进、审计和反馈，2）根据其长期随访的最初原因，提供艾滋病毒携带者支持服务 (e.g.,延长的再填充、转移协调、对等导航）可能是有希望的。为了取得成功，我们 需要了解如何有效地将这些方法应用到现有的护理中，包括1）如何参与 HCW在态度和行为改变战略中的作用，2）针对不同障碍优先考虑哪些支持服务， 以及3）如何将活动集成到现有的工作流程中。这份R34提案将为 实施多方面重新参与战略，以支持返回后的持续重新参与 艾滋病护理。在目标1a中，我们评估了患者和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HCW和诊所领导的焦点小组讨论（4个FGD， 每种n=8-10）。在目标1b中，我们进行了离散选择实验（200个PLWH，100个HCW），以量化相对 我们的再接触策略的内容和属性的偏好。在目标2中，我们承担一个人类- 集中的设计过程，使关键利益相关者（PLWH，HCW，诊所领导，卫生部）参与， 共同制定多部门重新参与战略的内容和特点，重点是：1）改善 患者重新参与的经验，2）优化ART重新启动和返回后的病毒载量监测，以及 3)提供针对个人LTFU具体原因的定制服务。在目标3中，我们将试验 在赞比亚卢萨卡的一个城市和一个农村诊所制定了战略。我们将使用混合方法 评估实施情况（例如，可接受性，适当性），服务提供（例如，时间到ART再- 启动，病毒载量监测），和临床结果（例如，治疗后6个月的尿潴留和病毒抑制 return）。该提案的结果将直接告知未来的R 01，以正式测试该卫生系统干预措施 在一项II型混合实施-有效性群集随机试验中，

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.