Integrating Addiction and Infectious Diseases Services into Primary Care in Rural Settings

摘要 美国结束艾滋病毒流行的战略呼吁扩大对新感染的预防并更加有效 应对艾滋病毒暴发。这些疫情通常发生在疫情不成比例的县和州。 艾滋病毒的负担，但阿片类药物使用障碍(OUD)的共生和共生性质留下了数百人 更多易受新的艾滋病毒(和丙型肝炎病毒)暴发影响的县和地区。西弗吉尼亚州就是其中之一。 这种主要是农村地区的阿片类药物爆炸性流行的环境，表现为人均过量服药率最高 以及最近艾滋病毒暴发的5个县。临床环境中预防和控制艾滋病毒的循证做法 包括药物治疗(Moud)、抗逆转录病毒治疗作为预防(TasP)和暴露前预防 (准备)。然而，使用这些药物治疗首先需要进行筛选和评估，然后 治疗(套装)。如果适当地采用既定的程序，反过来可能转化为更好的健康结果 提供便利。大多数农村地区缺乏提供专门的艾滋病毒/丙型肝炎病毒/艾滋病服务的能力--这是一个重要的 印第安纳州斯科特县的教训。然而，农村地区大多依赖初级保健诊所(PCC)， 提供这些服务的专业知识。为了克服艾滋病毒/丙型肝炎/艾滋病既定程序的采用障碍， 有效的促进是关键，NIATx治疗改进策略与正在进行的临床相结合 由Project Echo提供的教育和支持有可能增加对整合专业的采用 向初级保健中心提供艾滋病毒/丙型肝炎/艾滋病服务。利用i-PARiHS实施框架，我们建议解决这一问题 首先确定采用和扩大艾滋病毒/丙型肝炎病毒/艾滋病服务的障碍，以满足未得到满足的需求。那么我们就会促成 通过将临床提示集成到电子健康记录(EHR)中以筛选 艾滋病毒/丙型肝炎病毒/OUD，然后是治疗提示。治疗将由Echo项目提供支持，该项目提供 持续的临床支持，以激发对治疗的信心，以及嵌入在 EHR作为质量业绩改进活动的一部分，以持续将艾滋病毒/丙型肝炎/艾滋病服务整合到 PCS。然后，我们建议进行阶梯式楔形、类型3、混合实施试验，以评估程度 临床医生采用并维持既定流程，在快速周期的推动下，在20个PCC中整合护理 使用NIATx更改项目。采用设定的流程是主要结果，也是一种综合质量 健康指标(QHI)结合了初级保健、艾滋病毒、丙型肝炎和穆德的QHI是次要效果 结果。组织和临床医生因素，以及参与促进活动(NIATx、ECHO 会议)将作为潜在的调解人和主持人进行探讨。对农村WV背景的意义很高 在那里，不稳定的阿片类药物流行引发了艾滋病毒/丙型肝炎的爆发。通过整合艾滋病毒/丙型肝炎病毒/OUD实现创新 利用我们在国际城市环境中成功使用的框架和战略，将服务引入方案控制中心。公众 由于缺乏将服务纳入农村初级保健服务的知识，健康福利很高。可行性 基于一支经验丰富的团队的记录，该团队具有跨学科的专业知识，并在西弗吉尼亚州拥有更高的经验。

Abstract The US strategy to End the HIV Epidemic calls for expanded prevention of new infections and more effective responses to HIV outbreaks. These outbreaks often occur in counties and states that share a disproportional burden of HIV, but the co-occurring and syndemic nature with opioid use disorder (OUD) leaves hundreds of additional counties and regions highly susceptible to new HIV (and HCV) outbreaks. West Virginia (WV) is one such mostly rural setting with an explosive opioid epidemic manifest by the highest per capita rate of overdoses and 5 counties with recent HIV outbreaks. Evidence-based practices to prevent and control HIV in clinical settings include medications for OUD (MOUD), ART treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). Treatment with these medications, however, first requires screening and evaluation, followed by treatment (SET). Adoption of SET processes may in turn translate to better health outcomes if adequately facilitated. Most rural settings are poorly equipped to provide specialty HIV/HCV/OUD services – an important lesson from Scott County, Indiana. Yet rural settings rely mostly on primary care clinics (PCC) with inadequate expertise to provide these services. To overcome adoption barriers of SET processes for HIV/HCV/OUD, effective facilitation is key and the NIATx treatment improvement strategy combined with ongoing clinical education and support provided by Project ECHO has the potential to increase adoption to integrate specialty HIV/HCV/OUD services into PCCs. Using the i-PARiHS implementation framework, we propose to address this unmet need by first identifying barriers to adoption and scale-up of HIV/HCV/OUD services. Then we will facilitate practice transformation by integrating clinical prompts in the electronic health record (EHR) to screen for HIV/HCV/OUD, followed by treatment prompts. Treatment will be supported by Project ECHO that provides ongoing clinical support to inspire confidence in treatment, alongside a clinical dashboard embedded within the EHR as part of the quality performance improvement activities to sustain integrating HIV/HCV/OUD services into PCCs. We then propose to conduct a stepped wedge, Type 3, hybrid implementation trial to assess the extent to which clinicians adopt and sustain SET processes to integrate care at 20 PCCs that is facilitated by rapid cycle change projects using NIATx. Adoption of SET processes are the primary outcome and a composite quality health indicator (QHI) that combines QHIs for primary care, HIV, HCV and MOUD are secondary efficacy outcomes. Organizational and clinician factors, along with engagement in facilitation activities (NIATx, ECHO sessions) will be explored as potential mediators and moderators. Significance is high for the rural WV context where a volatile opioid epidemic has ignited HIV/HCV outbreaks. Innovation is high by integrating HIV/HCV/OUD services into PCCs using a framework and strategy we successfully used in urban international settings. Public health benefits are high given the lack of knowledge known about integrating services into rural PCCs. Feasibility is high based on the track record of an experienced team with interdisciplinary expertise and prior in WV.