Structured Peer-delivered ART and Reentry Community Strategy (SPARCS) to overcome barriers to HIV care continuity during community reentry from incarceration in South Africa

项目摘要 尽管有抗逆转录病毒药物，艾滋病毒仍然是南非成年人死亡的主要原因 艾滋病毒治疗方面的差距尤其突出， 在艾滋病毒高风险和艾滋病毒服务使用减少的关键人群中，这一现象尤为突出。一个种群 艾滋病毒感染率是年龄和性别匹配的一般人口的两倍（23%）， 是最近从监狱释放出来的人。在监禁期间，> 90%的人开始抗逆转录病毒疗法; 在重返社区后，只有34%的人继续接受照料。从受控的监狱到 环境及其对社区生活的有限自主权要求重建规划技能，自我， 效率、社会支持和克服进入社区诊所的官僚障碍。我们有 表明，通过直接提供ART和建立 行为技能，通过同行主持人领导的小组会议，提高护理连续性， 监禁。在NIMH支持的一项名为SPARCS的干预试点研究中， 参与者中，36%的人在照顾，而61%的人在干预臂是在照顾 更正后6个月。这些结果提出了重要的问题， 方案规模扩大。扩大规模需要在有效性、可行性和成本之间取得平衡。 值得注意的是，有效性和可行性之间的紧张关系可能需要降低整体有效性，例如 通过消除SPARCS的一个组件-以增加可行性。为了探索这些问题，我们 提出了用RE-AIM框架（Reach， 有效性、采纳、实施、维护）。首先，我们提出了一个2x2析因设计， 最大化Full-SPARCS干预的随机对照试验的功效， 称为"ART-SPARCS"和"Group-SPARCS"的组分和常规护理，以检测病毒载量的差异 监禁6个月后释放。第二，我们建议将实施的特点 覆盖范围、采用或采用潜力、可接受性和保真度。最后，将使用RCT的结果 告知成本计算和成本效益，告知决策者SPARCS和组件的成本 每个组成部分和整个SPARCS的成本效益，以告知实施成本和潜力 长期的可持续性或维护。该项目有可能产生相当大的新的 了解可以改善这一人群护理连续性的干预措施，以及潜在的 与决策者相关的扩大。这项拟议的研究有可能产生可操作的知识， 改善重返社区者的成果，并促进艾滋病毒流行病控制的总体目标。

PROJECT SUMMARY HIV remains the leading cause of death among adults in South Africa despite the availability of antiretroviral therapy (ART) due to failure to initiate ART and failure to remain on ART. Gaps in HIV care are especially prominent among key populations at high risk for both HIV and reduced use of HIV services. One population with an HIV prevalence double the age and sex-matched general population (23%) and with low engagement in HIV care is individuals recently released from incarceration. During incarceration >90% initiate ART; following reentry into the community only 34% remain in care. The transition from the controlled carceral environment and its restricted autonomy to life in the community requires reestablishing planning skills, self- efficacy, and social support and overcoming bureaucratic barriers to accessing community clinics. We have demonstrated that an intervention that circumvents clinic barriers by directly providing ART and builds behavioral skills through peer-facilitator led group sessions improves care continuity following release from incarceration. In a pilot study of this intervention supported by NIMH, termed SPARCS, among 176 participants, 36% of those in the care as usual compared to 61% of those in the intervention arm were in-care 6 months after corrections release. These results raise important questions regarding possibility of programmatic scale-up. Scale-up requires achieving a balance between effectiveness, feasibility, and cost. Notably, the tension between effectiveness and feasibility may require reducing overall effectiveness – such as by eliminating a component of SPARCS – to increase feasibility. To explore each of these questions, we are proposing a hybrid type I effectiveness-implementation study structed with the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). First, we are proposing a 2x2 factorial design to maximize power of a randomized controlled trial of the Full-SPARCS intervention and the two distinct components termed “ART-SPARCS” and “Group-SPARCS” and usual care, to test for a difference in viral load suppression 6 months from correctional facility release. Second, we propose characterize implementation in terms of reach, adoption or adoption potential, acceptability, and fidelity. Finally, will use findings from the RCT to inform costing and cost-effectiveness to inform policy makers regarding cost of SPARCS and components and cost-effectiveness of each component and the full SPARCS to inform implementation cost and potential long-term sustainability or maintenance. This project has the potential to generate considerable new knowledge on interventions that can improve care continuity for this population and key findings for potential scale-up relevant to policy makers. This proposed study has the potential to generate actionable knowledge to improve outcomes for community reentrants and contribute to overall goals of HIV epidemic control.