Adapting a disclosure decision-aid to improve HIV outcomes for older adults in Ukraine

乌克兰是东欧和中亚(EECA)的标志性LMIC，是世界上唯一拥有 艾滋病毒发病率和死亡率不断增加。在乌克兰36万威尔斯亲王医院中，OPWH医院占25%的人口 携带艾滋病毒，但确诊时患艾滋病的可能性是前者的1.7倍，开始抗逆转录病毒治疗的可能性比前者低51%，比后者低3.6倍 与那些50岁的人相比，他们更有可能失去后续行动。威尔斯亲王透露自己艾滋病毒状况的人更有可能 以实现更好的社会支持和艾滋病毒结果。但在乌克兰，66%的OPWH没有披露他们的艾滋病毒 在过去的一个月里，接受抗逆转录病毒治疗的可能性降低了20%，坚持接受治疗的可能性降低了两倍 非艾滋病病毒合并症，比同龄人透露。在乌克兰，家庭以外的长期老年护理是 在规划艾滋病毒老龄护理时，有限的艾滋病毒披露决定支持网络是至关重要的。但 到目前为止，披露干预措施已将性/注射吸毒性伙伴通知和孕产妇和儿童健康列为优先事项 关怀，同时忽视对OPWH支持网络的披露。决策辅助(DA)可促进知情 根据患者的独特需求和价值做出决定。在社区工作小组(CWG)的意见下，我们 在乌克兰成立，我们打算使用Adapt-ITT为OPWH量身定制DA，这是一种基于证据的适应 战略，发展Porada(通过决策援助追求老龄化的最佳结果，“Porada”的意思是“建议” 乌克兰语)，并对其进行试点测试，以帮助OPWH做出符合其需求的艾滋病毒披露决定。帮助 参与者权衡利弊，并授权他们在出现耻辱反应的情况下继续接受护理，波拉达说 将包括OPWH代表关键人群的与文化相关的引语，以及指向当地资源的链接，如 威尔斯亲王医院的热线及支援小组。在试点期间，RCT研究助理将向Porada提供 向80名OPWH提供简短咨询，这些OPWH至少有一个他们认为对他们重要的人 没有披露他们的艾滋病毒状况，相比之下，40名OPWH接受TAU治疗。随机化将按时间分层 因为HIV诊断和参与者将被跟踪12个月。结果将包括衡量 可接受性、可行性和初步效果。我们假设波拉达将增加艾滋病病毒的披露 (主要结果)相对于TAU。我们还将收集决策冲突的数据，支持性与污名化 对披露、社会支持、跨部门污名以及若干艾滋病毒和非艾滋病毒指标的反应，以 了解潜在的远端结果，这将是探索性的。公共卫生福利很高，因为不断增长 OPWH的全球数量、OPWH的高度保密以及包括高死亡率在内的糟糕的艾滋病毒结果。 创新的基础是OPWH的发展议程的改编，重点是艾滋病毒披露以支持网络，以及 评估脱离艾滋病毒和非艾滋病毒护理。为了确保与社区的兼容性，调查结果将 与利益相关者共享，包括社区工作组(同行、临床医生)、资助者(PEPFAR，全球 基金)和实施者(卫生部、非政府组织)，为开展混合执行实效试验提供信息 在乌克兰、美国和全球广泛传播该决策援助。

Ukraine, an emblematic LMIC in Eastern Europe and Central Asia (EECA), is the only world region with increasing HIV incidence and mortality. Among the 360,000 PWH in Ukraine, OPWH account for 25% of people with HIV but are 1.7 times more likely to have AIDS at diagnosis, 51% less likely to start ART, and 3.6 times more likely to be lost to follow-up than those <50 years old. PWH who disclose their HIV status are more likely to achieve better social support and HIV outcomes. But in Ukraine 66% of OPWH have not disclosed their HIV status and are 20% less likely to adhere to ART in the last month, and twice less likely to adhere to therapy for non-HIV comorbidities, than peers who disclosed. As long-term geriatric care outside of the family in Ukraine is limited, HIV disclosure decision to support networks is essential when planning for HIV care over aging. But disclosure interventions to date have prioritized sexual/IDU partner notification and maternal and child health care, while overlooking disclosure to OPWH support networks. Decision Aid (DA) can facilitate informed decisions based on patient's unique needs and values. With input from Community Working Group (CWG) we established in Ukraine, we intend to tailor DA for OPWH using ADAPT-ITT, an evidence-based adaptation strategy, to develop PORADA (Pursuing Optimal Results over Aging via Decision Aid, “porada” means “advice” in Ukrainian), and pilot test it to assist OPWH make HIV disclosure decisions aligned with their needs. To help participants weigh pros and cons and empower them to stay in care in case of stigmatizing reactions, PORADA will include culturally relevant quotes from OPWH representing key populations, and links to local resources like hotlines and support groups for PWH. During the pilot RCT Research Assistants will deliver PORADA with a brief consultation to 80 OPWH who have at least one person they consider important to them to whom they have not disclosed their HIV status, compared to 40 OPWH receiving TAU. Randomization will be stratified by time since HIV diagnosis and participants will be followed for 12 months. Outcomes will include measures of acceptability, feasibility, and preliminary efficacy. We hypothesize that PORADA will increase HIV disclosure (primary outcome) relative to TAU. We will also collect data on decisional conflict, supportive vs stigmatizing reactions to disclosure, social support, intersectional stigma, and several HIV and non-HIV indicators, to understand potential distal outcomes, which will be exploratory. Public health benefit is high given growing OPWH numbers globally, high levels of OPWH non-disclosure, and poor HIV outcomes including high mortality. Innovation is high based on the adaptation of a DA for OPWH, focus on HIV disclosure to support networks, and assessing disengagement from HIV and non-HIV care. To ensure compatibility with the community, findings will be shared with stakeholders including a Community Working Group (peers, clinicians), funders (PEPFAR, Global Fund), and implementers (MoH, NGOs) to inform development of a hybrid implementation effectiveness trial with wide dissemination of the decision aid in Ukraine, US, and globally.