Innovations in Implementing Decentralized HIV Services in Peru

尽管秘鲁在诊断和启动抗逆转录病毒疗法(ART)方面取得了成功，但 LMIC艾滋病毒流行集中在关键的高危人群，执行差距最大的是 保留护理(RIC)，导致病毒抑制水平较低(43%)，并增加艾滋病毒发病率。艾滋病毒护理 在秘鲁，目前主要集中在大型二级卫生中心。根据世卫组织的建议 为了分散医疗保健，这是一种基于证据的做法，增加了RIC，秘鲁卫生部 2019年建议将艾滋病毒服务下放到初级卫生中心(PHCS)。我们建议在 利马市4个最大的地区，管理着37%的重症监护医院。目前，利马15%的威尔斯亲王医院收到了 支持更有效地实施分散服务的需要。使用RE- 目标执行框架，我们建议通过结合NIATx加速权力下放，这是一个证据- 知情的实施战略和一系列实施工具，以扩大基于证据的做法， 通过Echo项目，一种循证远程教育战略，以提高初级保健的临床技能 有能力提供专业(即艾滋病毒)服务的提供者。我们将首先使用Delphi方法来建立 使用中心(SHC)和辐条(PHC)模型安全地分散威斯康星医院并建立最低 安全地将患者留在PHCS所需的质量健康指标的数量。这些准则可以是 用于创建可用于支持临床实践中指南一致性的临床检查表。我们会 然后对障碍和促进者进行快速、多层次(患者、临床医生、医疗保健系统)评估 到下放艾滋病毒护理，这将在四个中心和辐条区域的每个区域之前进行评估 在阶梯式楔形设计中使用NIATx和ECHO随机实施24个月。初级阶段 有效性结果将是威斯康星医院在初级保健中心接受艾滋病毒护理的比例变化。次要结果 包括RIC和VS，并对死亡率进行探索性分析。实施的主要成果是 有信心在PHCS管理威尔斯亲王医院。合作、工作环境和新PHC对艾滋病毒护理的采用 将在每个枢纽和辐条内对站点进行测量。将在每个区域的新的初级保健中心采用艾滋病毒护理 评估过了。由于卫生部的目标是在城市低/中等收入人群中分散艾滋病毒护理，因此重要性很高 设定艾滋病毒集中在RIC和VS水平较低的关键人群中的情况。创新是当务之急 将NIATx和Echo结合在南美城市的背景下，并在成瘾治疗之外使用它们。 可行性很高，因为团队成员之间的长期关系与强大的 卫生部的承诺。该团队带来了艾滋病毒护理(桑切斯，阿尔蒂斯)、公共卫生方面的专业知识 (康达、阿尔蒂斯)、实施科学(阿尔蒂斯、马登、康达)和服务集成(阿尔蒂斯、马登)。公众 健康收益很高，不仅在系统、临床医生和患者层面通过实施 在秘鲁，非集中化护理不仅是一个模板，也是其他城市、低收入/中等收入环境的模板。

Despite successes in diagnosing and initiating antiretroviral therapy (ART) in people with HIV (PWH) in Peru, a LMIC with an HIV epidemic concentrated in key at-risk populations, the implementation gap is highest for retention in care (RIC), resulting in low levels of viral suppression (43%) and increasing HIV incidence. HIV care in Peru is currently concentrated in large secondary health centers (SHCs). Based on WHO recommendations to decentralize healthcare, an evidence-based practice that increases RIC, the Peruvian Ministry of Health recommended in 2019 to decentralize HIV services to primary health centers (PHCs). We propose to work in the 4 largest regions in urban Lima that manages 37% of all PWH in care. Currently, <15% of PWH in Lima receive care in PHCs, supporting the need for more effective implementation of decentralized services. Using the RE- AIM implementation framework, we propose to accelerate decentralization by combining NIATx, an evidence- informed implementation strategy with a bundle of implementation tools to scale up evidence-based practices, with Project ECHO, an evidence-informed tele-educational strategy to increase clinical skills in primary care providers to competently provide specialty (i.e., HIV) services. We will first use the Delphi method to establish guidelines to safely decentralize PWH using a hub (SHC) and spoke (PHC) model and to establish the minimal number of quality health indicators that are needed to safely keep patients in PHCs. These guidelines can be used to create clinical checklists that can be used to support guideline concordance in clinical practice. We will then conduct a rapid, multi-level (patients, clinicians, healthcare system) assessment of barriers and facilitators to decentralizing HIV care, which will be assessed just before each of the four hub and spoke regions will be randomized to 24 months of implementation using NIATx and ECHO in a stepped wedge design. The primary effectiveness outcome will be proportionate change of PWH receiving HIV care in PHCs. Secondary outcomes include RIC and VS with exploratory analyses for mortality. The primary implementation outcomes are confidence in managing PWH at PHCs. Collaboration, workplace climate and adoption of HIV care at new PHC sites will be measured within each hub and spoke. Adoption of HIV care at new PHCs in each region will be assessed. Importance is high due to the MoH’s goal to decentralize HIV care in an urban, low/middle income setting where HIV is concentrated in key populations with low levels of RIC and VS levels. Innovation is high due to combining NIATx and ECHO in an urban South American context and using them beyond addiction treatment. Feasibility is high due to the longstanding relationships between team members alongside the strong commitment by the Ministry of Health. The team brings expertise in HIV care (Sanchez, Altice), Public Health (Konda, Altice), implementation science (Altice, Madden, Konda) and service integration (Altice, Madden). Public Health benefit is high not only in terms of systems-, clinician- and patient-level benefits through implementing decentralized care in Peru, but also serves as a template for other urban, low/middle income settings.