Systems analysis and improvement approach to optimize the pediatric HIV diagnosis and care cascade (SAIA-PEDS)

摘要 该实施研究项目旨在调整和评估卫生系统干预措施， 减少儿童艾滋病毒级联（检测、与护理的联系、治疗的启动和病毒感染）的下降 抑制）。儿童艾滋病毒感染的发病率和死亡率很高;及时诊断，与护理联系， 治疗至关重要。然而，儿科艾滋病毒级联反应的所有步骤的完成程度很低，限制了潜在的 艾滋病毒感染儿童的健康福利。提供者发起的测试和咨询（PITC）和索引案例 检测（检测感染艾滋病毒的成人的儿童）是潜在的高产量病例检测策略，但 执行不一致，覆盖面不一。虽然及时与护理和抗逆转录病毒疗法的启动挂钩是紧迫的， 对于儿童，促进和记录诊断后联系的系统很薄弱， 水平落后于成年人。最后，病毒载量监测上级CD 4检测，特别是对儿童，但 及时和一致的病毒载量检测和返回结果的系统薄弱。 儿科HIV级联类似于PMTCT级联，具有复杂的群体和复杂的免疫系统。 系统.在减少PMTCT级联中的下降方面有效的干预措施可能是有效的 优化儿科艾滋病病毒级联。在这项研究中，我们的目标是适应和测试系统分析， 改进方法（SAIA）干预，加入经典的系统工程方法，包括 级联分析，流程图和持续质量改进，并已有效地 改善通过PMTCT级联的流动。在当前的R34提案中，我们的目标是：1）调整SAIA 儿童艾滋病毒级联干预（SAIA-PEDS干预），2）试点和完善SAIA-PEDS 采用混合方法进行干预，3）准备未来集群所需的材料 随机试验，以确定SAIA-PEDS的有效性和成本效益。在这两个R34试点和 未来的R 01应用，我们的主要改进成果是a）采用儿科HIV检测，B）联系 艾滋病毒护理，c）ART启动，和d）病毒载量监测和抑制。 该项目利用了内罗毕大学和华盛顿大学之间超过25年的合作 肯尼亚艾滋病和性传播感染控制计划（NASCOP）的伙伴关系。 学术界和政策制定者之间的这种独特伙伴关系使严谨和有影响力的研究能够 解决与地方优先事项相一致的问题，为国家政策提供信息。

ABSTRACT This implementation research project aims to adapt and evaluate a health systems intervention designed to reduce drop-offs in the pediatric HIV cascade (testing, linkage to care, treatment initiation, and viral suppression). Pediatric HIV infection has high morbidity and mortality; prompt diagnosis, linkage to care, and treatment are critical. However, completion of all steps of the pediatric HIV cascade is low, limiting the potential health benefits for HIV-infected children. Provider initiated testing and counseling (PITC) and index-case testing (testing children of HIV-infected adults) are potentially high yield case-detection strategies but are inconsistently implemented with variable coverage. While timely linkage to care and ART initiation are urgent for children, systems to promote and document linkage following diagnosis are weak and pediatric treatment levels lag behind adults. Finally, viral load monitoring is superior to CD4 testing, particularly for children, but systems for prompt and consistent viral load testing and return of results are weak. The pediatric HIV cascade is similar to the PMTCT cascade, having both complex populations and complex systems. Interventions that have been effective at decreasing drop-off in the PMTCT cascade may be effective in optimizing the pediatric HIV cascade. In this study, we aim to adapt and test the Systems Analysis and Improvement Approach (SAIA) intervention which joins classical systems engineering methods including cascade analysis, process mapping, and continuous quality improvement, and which has been effective in improving flow through the PMTCT cascade. In the current R34 proposal, we aim to 1) adapt the SAIA intervention for the pediatric HIV cascade (SAIA-PEDS intervention), 2) pilot and refine the SAIA-PEDS intervention using a mixed-methods approach, and 3) prepare the materials required for a future cluster randomized trial to determine SAIA-PEDS effectiveness and cost-effectiveness. In both this R34 pilot and the future R01 application, our primary outcomes for improvement are a) uptake of pediatric HIV testing, b) linkage to HIV care, c) ART initiation, and d) viral load monitoring and suppression. This project leverages a >25 year collaboration between University of Nairobi and University of Washington collaborators as well as partnerships with the Kenyan National AIDS and STI Control Programme (NASCOP). This unique partnership between academia and policymakers allows rigorous and impactful research to address questions aligned with local priorities that inform national policy.