Strategies to improve the HIV care continuum among key populations in India

改善印度重点人群艾滋病毒护理连续性的策略

• 批准号: 9145654
• 负责人: GREGORY M LUCAS
• 金额: $ 142.44万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-09-30 至 2021-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9145654
• 关键词: AIDS prevention; Acquired Immunodeficiency Syndrome; Address; Adherence; Adoption; Behavior; Caring; Cities; Client; Clinic; Clinical Trials; Cluster randomized trial; Communities; Continuity of Patient Care; Cost Analysis; Counseling; Country; Data; Effectiveness; Eligibility Determination; Epidemic; Ethnography; Focus Groups; Food; Fostering; General Population; Goals; Government; HIV; HIV Infections; HIV diagnosis; Health; Health Personnel; Health Policy; Health Services Accessibility; Household; Human immunodeficiency virus test; Hybrids; Incentives; Incidence; Income; India; Injecting drug user; Intervention; Interview; Medical; Methods; Modeling; Outcome; Pathway interactions; Patients; Penetration; Persons; Phase; Policy Maker; Population; Prevalence; Process Measure; Public Health; Research; Research Infrastructure; Respondent; Sampling; Services; Side; Site; Societies; Target Populations; Testing; Time; Travel; Treatment outcome; Ursidae Family; Viral; Viral Load result; Wages; antiretroviral therapy; cohort; compare effectiveness; cost effectiveness; criminal behavior; design; disability-adjusted life years; economic value; evidence base; implementation science; implementation trial; improved; incremental cost-effectiveness; interest; low and middle-income countries; meetings; men who have sex with men; multidisciplinary; primary outcome; public health relevance; randomized trial; secondary outcome; social stigma; success; therapy adherence; treatment as usual; trial design; uptake; virology

 DESCRIPTION (provided by applicant): The trajectory of the HIV epidemic in coming decades will be determined by the degree to which we can identify infected persons and engage them in care - a point implicit in the ambitious UNAIDS "90-90-90" target, which sets 90% goals for HIV diagnosis, linkage of infected persons to sustained antiretroviral therapy (ART), and viral suppression in those treated. Meeting this target requires successful engagement of difficult to reach populations, such as people who inject drugs (PWID) and men who have sex with men (MSM), who bear a disproportionate share of the epidemic particularly in low to middle income countries. Our team is nearing completion of a multi-site cluster-randomized trial in India to assess the effectiveness of integrated care centers (ICCs) for PWID and MSM compared to usual care (fragmented service delivery). The ICCs, which separately target PWID and MSM, provide vertically integrated, evidence-based HIV prevention and treatment services in a single stigma-free setting. ICC process measures from the first year show robust uptake of HIV counseling and testing, the primary outcome for that trial, but slower than anticipated ART uptake. Ethnography with stakeholders identified travel time and loss of wages as barriers to attending ICCs regularly, as required for medical management of HIV. Demand-side interventions in public health (such as treatment incentives) can be particularly effective when paired with optimized treatment accessibility (i.e., supply). Consequently, we propose to examine whether provision of HIV care and treatment incentives to ICC clients - redeemable for food and household goods - will improve overall utilization of the clinics and downstream HIV care continuum outcomes. We propose a hybrid effectiveness-implementation design. This will include a 16- site, pair-matched cluster randomized trial to compare the effectiveness of adding of HIV care incentives to ICCs (ICC+) versus standard ICCs on HIV care continuum outcomes, including ART initiation, adherence and viral suppression (aim 1). Effectiveness will be compared at the ICC level (from a cohort of HIV-infected ART- eligible clients followed in each ICC and process measures deriving from all ICC clients) and at the community- level through a cross-sectional sample accrued via respondent-driven sampling (RDS) 2 years after initiation of the intervention. Because PWID and MSM will be sampled independently from the ICCs in the RDS, it provides an opportunity to characterize outcomes like community viral load and HIV incidence, reflecting impact within the broader PWID/MSM communities. As an exploratory sub-aim, we will use a rigorous scientific design to assess the effects of withdrawing (vs. continuing) incentives beyond the initial intervention phase. Additionally, we will characterize barriers and facilitators to implementation of the ICC and ICC+ interventions (aim 2), and determine the cost-effectiveness of the ICC+ intervention (aim 3). This proposal is strengthened by infrastructure from our prior trial, detailed data on the target populations in the 16 sites for the proposed tria, and an expanded multidisciplinary team with new expertise in implementation science and cost-effectiveness.

 描述（由申请人提供）：未来几十年艾滋病毒流行的轨迹将取决于我们能够识别感染者并使他们参与护理的程度-这一点隐含在雄心勃勃的联合国艾滋病规划署“90-90-90”目标中，该目标为艾滋病毒诊断，感染者与持续抗逆转录病毒治疗（ART）的联系以及治疗者的病毒抑制设定了90%的目标。要实现这一目标，就需要成功地让难以接触到的人群参与进来，如注射毒品者和男男性行为者，他们在艾滋病流行中所占比例过高，特别是在中低收入国家。我们的团队即将完成一项在印度进行的多中心随机分组试验，以评估综合护理中心（ICC）与常规护理（分散式服务提供）相比对PWID和MSM的有效性。国际社区中心分别针对艾滋病感染者和男男性行为者，在一个没有耻辱感的单一环境中提供纵向一体化、循证的艾滋病毒预防和治疗服务。ICC第一年的流程措施显示，艾滋病毒咨询和检测（该试验的主要结果）得到了有力的吸收，但比预期的ART吸收要慢。与利益攸关方进行的人种学研究发现，旅行时间和工资损失是定期参加国际社区中心的障碍，而这是艾滋病毒医疗管理的要求。公共卫生方面的需求方干预措施（如治疗激励措施）在与优化治疗可及性（即，供应）。因此，我们建议研究是否提供艾滋病毒的护理和治疗的奖励，以ICC客户-兑换食品和家庭用品-将提高整体利用诊所和下游艾滋病毒护理连续成果。我们提出了一个混合的有效性，实施设计。这将包括一项16个地点、配对的随机分组试验，以比较在ICC（ICC+）中添加HIV护理激励措施与标准ICC对HIV护理连续结局的有效性，包括ART启动、依从性和病毒抑制（目标1）。将在ICC水平（来自每个ICC随访的HIV感染ART合格客户队列和来自所有ICC客户的过程测量）和社区水平（通过干预开始后2年的应答者驱动采样（RDS）获得的横断面样本）比较有效性。由于PWID和MSM将独立于RDS中的ICC进行采样，因此它提供了一个描述社区病毒载量和HIV发病率等结果的机会，反映了更广泛的PWID/MSM社区内的影响。作为探索性子目标，我们将使用严格的科学设计来评估退出（与继续）的影响 在初始干预阶段之外的激励措施。此外，我们将描述实施ICC和ICC+干预措施的障碍和促进因素（目标2），并确定ICC+干预措施的成本效益（目标3）。我们先前试验的基础设施、拟议试验的16个地点的目标人群的详细数据以及在实施科学和成本效益方面具有新专业知识的扩大的多学科团队加强了这一建议。