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，全球 3700 万艾滋病毒感染者中有一半以上正在接受抗逆转录病毒治疗 (ART) 代表了在获得艾滋病毒护理方面取得的巨大且令人鼓舞的成功。 ART 可预防疾病、死亡和艾滋病毒 当病毒传播时，艾滋病毒呈阳性的人可以预期与艾滋病毒呈阴性的同龄人一样长寿。 负载无法检测到。然而，治疗成功仍落后于目标。仅在南非就有 800 万艾滋病毒感染者 积极的人需要终生接受 ART，目前只有 450 万人正在接受 ART。患者护理障碍，例如 错过的工资、交通费用以及就诊和 ART 补充的漫长等待时间与可检测到的相关 病毒载量是难以获得和接受抗逆转录病毒治疗的标志。 HIV 差异化服务提供 (DSD) 简化的 ART 交付：激励措施、多月脚本、快速通道 ART 以及社区或家庭 ART 交付 激励客户、减少就诊频率并缓解诊所拥挤状况。 DSD 是以下客户的标准 实现病毒抑制并进行护理；然而，DSD 需要进行调整才能为那些不具备这种能力的客户提供服务。 成功。事实上，不参与护理的人可能需要简化的、以客户为中心的 甚至比那些能够成功参与的人还要多。 一套适应性 DSD 策略（包括基于社区的 ART）已在稳定客户中进行了测试 具有病毒抑制作用。彩票激励有效地改变了短期行为，增加了 ART 的启动。 社区和家庭 ART 交付增加了 ART 覆盖范围并简化了 ART 获取克服诊所 障碍。对于稳定的客户，这些 DSD 活动在实现和实现方面与基于诊所的护理一样有效。 维持病毒抑制，尽管在稳定的客户中，他们在病毒抑制方面并未表现出优越性 或节省成本。相比之下，DSD 有潜力提高病毒抑制率和护理保留率 并为更难以接触的群体节省成本。 DSD 系统在客户端方面具有巨大的潜力 对需要额外服务的子群体反应灵敏且系统高效，将服务与客户需求相匹配。 一系列连续、全面的 DSD 方法，每一步都增加了服务强度 条款 – 适应性 DSD – 尚未经过测试以确定以下人员的比例和特征 将实现病毒抑制和护理保留，并估计成本效益和预算影响。 为了增加人群水平的病毒抑制，病毒载量可检测到的人需要响应性 DSD 干预措施。序贯多重分配随机试验 (SMART) 设计有助于评估 逐步采取适应性方法，通过“适当规模”的干预措施实现病毒抑制。我们是一家经验丰富的 团队并提议建立在我们强大的合作伙伴关系的基础上，依次测试针对人员的适应性 DSD 策略 具有可检测的病毒载量：彩票激励、基于社区的 ART 和家庭 ART 交付。我们的目标是 确定南非最有效和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.