A sequential, adaptive model of differentiated service delivery to reach persons living with HIV who are lost-to-follow-up or who have detectable viral load

摘要 在全球范围内，全世界3700万艾滋病毒携带者中有一半以上正在接受抗逆转录病毒治疗(ART) 在获得艾滋病毒护理方面取得了巨大的、令人鼓舞的成功。抗逆转录病毒药物可预防疾病、死亡和艾滋病毒 传播和HIV阳性的人可以预期活得和他们的HIV阴性同龄人一样长，当他们的病毒 负载检测不到。然而，治疗的成功仍然落后于目标。仅在南非，就有800万人感染艾滋病毒- 积极的人一生都需要艺术，目前只有450万人接受艺术治疗。患者的护理障碍，例如 拖欠工资、交通费用、诊所就诊和ART补药的等待时间过长，都与可检测到的 病毒载量，难以获取和获取艺术品的标志。艾滋病毒差异化服务交付(DSD)具有 简化的艺术交付：奖励、数月脚本、快速通道艺术以及社区或家庭艺术交付 激励客户，减少诊所就诊频率，减少诊所拥堵。DSD是符合以下条件的客户的标准配置 实现病毒抑制并参与护理；然而，DSD需要适应以服务于不是 成功了。事实上，可以说，不从事护理的人需要简化，以客户为中心 比那些能够成功参与的人更多的方法。 一套适应性的DSD策略，包括基于社区的ART，已经在稳定的客户中进行了测试 带有病毒抑制功能。彩票激励有效地改变了短期行为，增加了艺术启蒙。 社区和家庭ART服务增加了ART覆盖范围，简化了ART获取途径，克服了诊所 障碍。对于稳定的客户，这些DSD活动与以诊所为基础的护理在实现和 保持病毒抑制，尽管在稳定的客户中，他们在病毒抑制方面没有表现出优势 或者节省成本。相比之下，DSD具有提高病毒抑制率和护理滞留率的潜力 并在更多难以接触到的群体中节省成本。DSD系统有很大的潜力可以成为客户端- 对于需要额外服务的子组，响应迅速且系统高效，使服务与客户需求相匹配。 顺序、全面的DSD方法包，每一步都会增加服务强度 提供-适应性DSD-尚未进行测试，以确定以下人群的比例和特征 将实现病毒抑制和保留在护理中，并估计成本效益和预算影响。 为了提高人群水平的病毒抑制，具有可检测到病毒载量的人需要响应性DSD 干预措施。序贯多分配随机试验(SMART)设计便于评估 采取循序渐进、适应性强的办法，通过“适当规模”的干预措施实现病毒抑制。我们是一个有经验的人 团队并建议在我们强大的合作伙伴关系的基础上，顺序测试适用于个人的适应性DSD策略 具有可检测到的病毒负载：彩票奖励、基于社区的艺术和家庭艺术交付。我们的目标是 确定南非最有效和最高效的艾滋病毒护理提供战略。

ABSTRACT Globally, more than half of the world's 37 million people living with HIV are on antiretroviral therapy (ART) representing immense and encouraging success with access to HIV care. ART prevents disease, death and HIV transmission and HIV-positive persons can expect to live as long as their HIV-negative peers when their viral load is undetectable. However, treatment success still lags behind goals. In South Africa alone, 8 million HIV- positive persons require ART for life and only 4.5 million are currently on ART. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load, the hallmark of struggling to access and take ART. HIV differentiated service delivery (DSD) has simplified ART delivery: incentives, multi-month scripts, fast-track ART, and community or home ART delivery motivate clients, reduce the frequency of clinic visits, and decongest clinics. DSD is standard for clients who achieve viral suppression and engage in care; however, DSD needs adaptation to serve clients who are not succeeding. Indeed, persons who are not engaged in care arguably need simplified, client-centered approaches even more than those who can successfully engage. A suite of adaptive DSD strategies, including community-based ART, have been tested among stable clients with viral suppression. Lottery incentives effectively change short-term behavior, increasing ART initiation. Community and home ART delivery increases ART coverage and simplify ART access overcoming clinic barriers. For stable clients, these DSD activities are as effective as clinic-based care in terms of achieving and maintaining viral suppression, although among stable clients they have not shown superiority in viral suppression or cost savings. In contrast, DSD has the potential to improve rates of viral suppression and retention in care and save costs among more hard-to-reach groups. There is great potential that DSD systems can be client- responsive and system-efficient for subgroups requiring additional services, matching services with client needs. A sequential, comprehensive package of DSD approaches, with each step increasing the intensity of service provision – adaptive DSD – has not been tested to determine the proportion and characteristics of persons who would achieve viral suppression and retention in care and to estimate the cost-effectiveness and budget impact. To increase population level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates evaluation of a stepped, adaptive approach to achieving viral suppression with `right-sized' interventions. We are an experienced team and propose to build on our strong partnerships to sequentially test adaptive DSD strategies for persons with detectable viral load: lottery incentives, community-based ART, and home ART delivery. Our aim is to identify the most effective and efficient HIV care delivery strategies for South Africa.