An mHealth implementation strategy to address the syndemic of mental illness, hypertension, and HIV in Uganda

全世界有3800万艾滋病毒感染者，其中68%生活在撒哈拉以南非洲。与 艾滋病毒从急性病转变为慢性病，并发非传染性疾病 例如抑郁症和焦虑症、酒精使用障碍（AUD）和高血压（HTN）已经成为 艾滋病毒/艾滋病感染者中的流行病。尽管采取了循证干预措施，以促进这些艾滋病毒合并症的整合， 在将艾滋病毒纳入艾滋病毒服务的过程中，整合工作面临挑战。首先，集成通常无法识别 这些疾病与贫穷等社会因素的有害影响之间的流行关系， 污名化和缺乏获得护理的机会使其结果恶化，特别是在低收入和中等收入国家。 其次，整合通常会对负担过重的医疗工作者（HCW）施加额外的临床任务 在没有私人空间的忙碌临床环境中操作需要注意这些附加条件， 经常被污名化。一种明确整合生物和社会相互作用的疾病流行病学方法， 导致这些条件集群，已被提议作为一种手段，解决复杂的需求PLWH。 移动的健康（mHealth），一种基于证据的战略，利用移动的的广泛渗透 手机，以减轻繁重的任务，同时使他们的系统，一致的实施， 作为解决艾滋病毒相关综合症的一种解决办法，已经提出，但这种办法尚未得到检验。我们 一个示范性的多学科团队具有良好的协作记录。在目前的提案中， 利用乌干达正在进行的艾滋病毒/HTN整合实施研究的基础设施，我们将 实现这些具体目标：目标1）使Medly Uganda适应检测、与护理的联系和对以下方面的持续支持： 抑郁症、焦虑症和AUD在乌干达HIV和HTN感染者中的应用。 通过以人为本的设计（HCD），我们将让患者、护理人员和专业/非专业HCW参与指导 乌干达Medly的迭代适应，明确关注共同的生物社会驱动因素。适应性应用 将整合广泛使用的（1）筛查工具沿着重大生活事件的有效测量， 经济冲击和耻辱，（2）算法驱动的消息传递和警报，以及（3）与HCW的联系以获得支持 和治疗。我们还将开发和实施一种新型的综合症护理级联（R21阶段）;目标2） 评估乌干达艾滋病适应方案（SAMU）改善精神卫生保健的有效性 通过使用真实世界历史数据（R33阶段）进行单组试验，实现级联指标;目的3）评价 使用混合方法（R33阶段），影响在经过调整的Medly乌干达持续参与的因素。 在整个研究期间，我们将重点加强我们乌干达团队的移动健康研究 能力，并进一步加强我们与政府官员的伙伴关系，以确保SAMU可以在当地维护 反对有效拟议的研究涉及NIH艾滋病指定基金使用的一个高度优先主题， 与PAR-21-303中描述的多个国家精神卫生研究所优先事项保持一致。

There are 38 million people living with HIV (PLWH) worldwide, 68% of whom live in sub-Saharan Africa. With the transition of HIV from an acute illness to a chronic condition, co-morbid non-communicable diseases (NCDs) such as depression and anxiety disorder, alcohol use disorder (AUD), and hypertension (HTN) have become epidemic among PLWH. Despite evidence-based interventions to promote integration of these HIV comorbidities into HIV service delivery, integration efforts face challenges. First, integration commonly fails to recognize the syndemic relationships between these conditions and the deleterious effect of social factors such as poverty, stigma, and lack of access to care that worsen their outcomes, especially in low- and middle-income countries. Second, integration commonly imposes additional clinical tasks upon overburdened healthcare workers (HCW) operating in busy clinical environments without private space needed to attend to these additional conditions that are often stigmatized. A syndemic approach, which explicitly integrates the biological and social interactions that cause these conditions to cluster, has been proposed as a means of addressing the complex needs of PLWH. Mobile health (mHealth), an evidence-based strategy that leverages the widespread penetration of mobile phones to relieve HCW of burdensome tasks while enabling their systematic, consistent implementation, has been proposed as a solution to address HIV-related syndemics, but this approach has not been tested. Our exemplary multidisciplinary team has a strong track record of collaboration. In the current proposal, which leverages the infrastructure of an ongoing implementation study of HIV/HTN integration in Uganda, we will pursue these Specific Aims: Aim 1) Adapt Medly Uganda for detection, linkage to care, and ongoing support of depression, anxiety disorder, and AUD among Ugandans with HIV and HTN using a syndemic approach. Through human-centered design (HCD), we will engage patients, caregivers, and professional/lay HCW to guide iterative adaptation of Medly Uganda with explicit attention to common biosocial drivers. The adapted application will integrate widely used (1) screening instruments along with validated measures of significant life events, economic shocks, and stigma, (2) algorithm-driven messaging and alerts, and (3) linkage to HCW for support and treatment. We will also develop and operationalize a novel syndemic care cascade (R21 phase); Aim 2) Assess the effectiveness of the Syndemic-Adapted Medly Uganda (SAMU) to improve mental health care cascade metrics by conducting a single-arm trial using real-world historical data (R33 phase); Aim 3) Evaluate the factors impacting sustained engagement in the adapted Medly Uganda using mixed methods (R33 phase). Throughout the study period, we will focus on strengthening our Uganda-based team's mHealth research capacity and furthering our partnerships with government officials to ensure that SAMU can be locally maintained and sustained. The proposed study addresses a high priority topic for use of AIDS-designated funds at NIH and aligns with multiple National Institute of Mental Health priorities as described in PAR-21-303.