PROMISE - Program Refinements to Optimize Model Impact and Scalability based on Evidence

摘要 在纽约，90-90-90目标的实现受到威胁，不是因为获得负担得起的护理和治疗的机会有限， 而是由于HIV病毒抑制（VS）的持续差异。复杂的行为和结构障碍， 维持VS需要协调和结合的方法来满足医疗和社会服务的需要。2009年，28岁的 瑞安白色A部分（RWPA）资助的机构，纽约市（NYC）卫生和心理卫生部 卫生和人口部发起了一项针对最脆弱群体的多组成部分艾滋病毒护理协调方案， 纽约市艾滋病毒感染者（PLWH）的高需求人群。2013年开始进行系统的CCP有效性研究（R 01 MH101028; PI：Irvine，Nash）。迄今为止的研究结果表明，对于高需求的亚组，CCP上级常规护理。 PLWH，但仍有很大的改善空间，在短期和长期VS。 实践反馈循环，DOHMH将在2018年实施一个改进的CCP模型。更好的聚焦、定制和 提供关键组件的提示有望提高CCP的参与度、覆盖范围、忠诚度、可扩展性和有效性 和影响。拟议研究的目的是：1）评估修订后的CCP（与原始CCP相比）在以下方面的有效性 及时VS（≤4个月），使用实验方法（目标1）; 2）估计修订后的CCP的有效性（与“通常”相比 长期VS，包括12个月的VS和24-36个月的持久病毒抑制（DVS），使用 严格的观察比较组方法（目标2）; 3）确定提供者和客户的属性和驱动因素 参与干预以及提供者和客户对未来修订的CCP交付和接收的偏好（目标3）。 以前的研究没有证明任何干预措施可以有效地改善短期和长期VS。 许多艾滋病毒感染者和艾滋病毒护理连续参与的主要障碍。拟议的研究将在一个大型 在现实世界的艾滋病毒服务环境中的规模，将记录循证实施的推出和效果 对以这些最脆弱的艾滋病毒携带者为重点的干预模式进行路线修正。这样，这项工作将推进一个 第二代干预措施，能够加强对那些无法 在现有的干预措施中，由于主要的结构性或心理障碍，无法实现预期的抗逆转录病毒治疗结果。

Abstract In New York, the achievement of 90-90-90 goals is jeopardized not by limited access to affordable care and treatment, but by persistent disparities in HIV viral suppression (VS). Complex behavioral and structural barriers to achieving and maintaining VS require coordinated, combination approaches to meet medical and social service needs. In 2009, at 28 Ryan White Part A (RWPA)-funded agencies, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) launched a multi-component HIV Care Coordination Program (CCP) directed toward the most vulnerable, high-need persons living with HIV (PLWH) in NYC. A systematic CCP effectiveness study began in 2013 (R01 MH101028; PIs: Irvine, Nash). Findings to date suggest that the CCP is superior to usual care for high-need subgroups of PLWH, but there remains substantial room for improvement in short- and long-term VS. In an immediate evidence-to- practice feedback loop, the DOHMH is implementing a refined CCP model in 2018. Greater focusing, tailoring and cues for delivery of key components are expected to increase CCP engagement, reach, fidelity, scalability, effectiveness and impact. The aims of the proposed study are to: 1) Estimate the effectiveness of the revised (vs. original) CCP on timely VS (≤4 months), using experimental methods (Aim 1); 2) Estimate the effectiveness of the revised CCP (vs. `usual care') on longer-term VS, including VS at 12 months and durable viral suppression (DVS) at 24-36 months, using rigorous observational comparison group methods (Aim 2); and 3) Identify attributes and drivers of provider and client engagement in the intervention and provider and client preferences for future revised-CCP delivery and receipt (Aim 3). Prior studies have not demonstrated any intervention to be effective at improving short- and long-term VS among the many PLWH with major barriers to HIV care continuum engagement. The proposed study, to be conducted on a large scale in real-world HIV service settings, will document the rollout and effects of evidence-informed implementation course corrections to an intervention model focused on these most vulnerable PLWH. In this way, the work will advance a second generation of interventions capable of strengthening the care continuum among PLWH who have been unable to achieve desired ART outcomes in existing interventions, due to major structural or psychosocial barriers.