Bridges2Scale: Testing implementation strategies for an intervention among young people affected by AIDS

项目摘要 撒哈拉以南非洲(SSA)是一个由低资源社区和相对贫穷的家庭主导的区域， 在青少年中艾滋病毒感染率不断上升(AY)。家庭经济困难加剧 AY从事危害健康的行为以及他们对护理的投入不足的风险。这 增加他们感染和传播艾滋病毒以及不坚持抗逆转录病毒治疗的风险。经济上的 赋权(EE)干预措施在减少艾滋病毒相关的风险承担方面显示出了巨大的希望 行为，并改善抗逆转录病毒治疗的依从性和精神健康结果。基于10多年来的 利用储蓄主导的EE干预措施的研究重点是艾滋病毒预防、护理和对受以下因素影响的AY的支持 艾滋病毒[AYA艾滋病](包括携带艾滋病毒的AY[AYLHIV]；以及在SSA因艾滋病[AYoAIDS]成为孤儿的AY，我们组 已经证明了多组分EE干预的有效性，Bridges，在NIH资助的四个 乌干达的随机对照试验(RCT) (R01 HD070727、R01HD074949、R34MH081763、R01MH113486)、 还有一项由基金会资助的肯尼亚研究。桥梁包括：1)金融知识培训(Flt)和指导； 2)家庭创收活动(IGA)；3)通过匹配的青年发展激励储蓄 帐户(YDA)。布里奇斯在艾滋病毒相关的冒险行为、抗逆转录病毒治疗的坚持、 心理健康、心理社会结果、教育成就、家庭经济和家庭凝聚力。然而， 扩展EE干预一直是一项挑战，表明需要确定和测试扩展战略和 审查执行和维持的决定因素。在Bridges2Scale中，我们将比较两个多方面的 双臂混合动力III中桥梁伸缩的策略(标准与增强)--实施 集群RCT。标准实施策略已经在我们以前的RCT中应用，并涉及到教育 会议使员工做好准备，以最大限度地减少对现场工作流程的干扰来交付桥梁。这将与 将使用实施映射制定的增强战略。我们将使用公立学校系统 从乌干达大马萨卡地区的48所学校招募1440名AYaAIDS(13-17岁)，该地区 艾滋病毒感染率为11.7%。学校将作为随机单位(n=24所学校/支；n=720名学生 每只手臂)。四个具体目标指导我们的研究：目标1.比较标准的实施效果 实施策略与强化实施策略；目标2.确定临床有效性 通过标准实施战略与增强实施战略实施的桥梁的对比；目标3.探索实施 过程、机制和决定因素；以及目标4.比较两者的成本和成本效益 实施战略。这项研究将解决一个关键挑战：如何最好地支持执行工作， 扩大和维持环境影响干预措施，事实证明，这些干预措施在改善 以青年为重点的艾滋病毒预防、护理和支持成果，但尚未广泛扩大。

PROJECT ABSTRACT Sub-Saharan Africa (SSA), a region dominated by low-resource communities and relatively poor families, is experiencing rising HIV prevalence among adolescents and youth (AY). Household economic hardships heighten the risk for AY’s engaging in health-compromising behaviors and their poor engagement with care. This increases their risk for contracting and transmitting HIV and non-adherence to ART treatment. Economic empowerment (EE) interventions have demonstrated substantial promise in reducing HIV-related risk-taking behaviors, and improving ART treatment adherence and mental health outcomes. Based on 10+ years of research utilizing savings-led EE interventions focused on HIV prevention, care and support for AY affected by HIV [AYaAIDS] (including AY living with HIV [AYLHIV]; and AY orphaned by AIDS [AYoAIDS] in SSA, our group has demonstrated the effectiveness of a multi-component EE intervention, Bridges, in four NIH-funded randomized control trials (RCT) in Uganda (R01 HD070727, R01HD074949, R34MH081763, R01MH113486), and one foundation-funded study in Kenya. Bridges involves: 1) financial literacy training (FLT) and mentorship; 2) family income-generating activities (IGA); and 3) incentivized savings via a matched Youth Development Account (YDA). Bridges has demonstrated robust effects on HIV-related risk-taking behaviors, ART adherence, mental health, psychosocial outcomes, educational achievement, family economics, and family cohesion. Yet, scaling EE interventions has been a challenge, signaling the need to identify and test scale-up strategies and examine determinants of implementation and sustainment. In Bridges2Scale, we will compare two multifaceted strategies (standard vs enhanced) for scaling Bridges in a two-arm Hybrid III effectiveness-implementation cluster RCT. The standard implementation strategy has been applied in our prior RCTs and involves educational meetings that prepare staff to deliver Bridges with minimal disruption to site workflow. This will be compared to an enhanced strategy that will be developed using Implementation Mapping. We will use the public school system to recruit 1440 AYaAIDS (ages 13-17 years) from 48 schools in the Greater Masaka region of Uganda, a region with 11.7% HIV prevalence. Schools will be the unit of randomization (n=24 schools per arm; n=720 students per arm). Four specific aims guide our study: Aim 1. Compare the implementation effectiveness of the standard implementation strategy vs. an enhanced implementation strategy; Aim 2. Determine the clinical effectiveness of Bridges implemented via a standard vs. enhanced implementation strategy; Aim 3. Explore implementation processes, mechanisms, and determinants; and Aim 4. Compare the cost and cost-effectiveness of the two implementation strategies. The study will address a critical challenge: how to best support the implementation, scale-up, and sustainment of EE interventions, which have been proven to be highly efficacious in improving youth-focused HIV prevention, care, and support outcomes, but are yet to be widely scaled up.