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

摘要 在纽约，90-90-90目标的实现不会因为获得负担得起的护理和治疗的机会有限而受到威胁， 而是由于艾滋病毒病毒抑制(VS)方面的持续差异。实现和实现目标的复杂行为和结构障碍 维持VS需要协调的、组合的方法来满足医疗和社会服务需求。2009年，28岁 瑞安·怀特(RWPA)资助的机构，纽约市(NYC)卫生和精神卫生部门 (DOHMH)启动了一项针对最脆弱人群的多组成部分艾滋病毒护理协调计划(CCP)， 纽约市的高需求艾滋病毒携带者(PLWH)。2013年开始进行系统的CCP有效性研究(R01 MH101028；PI：欧文、纳什)到目前为止的研究结果表明，CCP对高需要亚群的儿童的护理优于常规护理 PLWH，但短期和长期VS仍有相当大的改善空间。在一个直接的证据中- 实践反馈循环，卫生部将在2018年实施改进的CCP模式。更好的聚焦、定制和 交付关键组件的提示有望提高CCP参与度、覆盖率、保真度、可扩展性和有效性 和冲击力。拟议研究的目的是：1)评估修订的(与原来的)CCP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)估计经修订的CCP的有效性(VS 对较长期的VS，包括12个月的VS和24-36个月的持久病毒抑制(DVS)，使用 严格的观察性比较小组方法(目标2)；以及3)确定供应商和客户的属性和驱动因素 参与干预以及供应商和客户对未来修订后的CCP交付和接收的偏好(目标3)。 先前的研究没有证明任何干预措施在改善短期和长期VS方面是有效的 许多PLWH存在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的 在现实世界的艾滋病毒服务环境中进行扩展，将记录循证实施的推广和效果 对干预模型的路线修正集中在这些最脆弱的PLWH上。这样，这项工作将向前推进一个 第二代干预措施，能够加强无法做到的妇女和妇女的护理连续不断 由于主要的结构性或心理社会障碍，在现有干预措施中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.