Effectiveness of Peer Navigation to Link Released HIV+ Jail Inmates to HIV Care

描述(由申请人提供)：寻求、检测和治疗模式认为，广泛、一致的抗逆转录病毒疗法(ART)治疗可以降低社区中可供传播的艾滋病毒RNA病毒载量水平。然而，鉴于获释后护理经常中断，在获释的艾滋病毒携带者被监禁人口中实施这一战略面临着无数挑战。具体地说，许多前囚犯未能在足够长的时间内与社区艾滋病毒护理相联系，以维持病毒载量抑制，或者他们未能重新启动任何监禁前的联系。因此，艾滋病毒阳性的前囚犯迫切需要干预措施，以改善他们在艾滋病毒护理中的留存状态。大多数先前的研究都是关于监狱的；然而，监狱中的人建立最佳抗逆转录病毒治疗方案的机会更少，但在获释后面临同样的治疗中断。通过监狱的人数远远超过监狱人数。被监禁的人还面临频繁的累犯，导致监狱和社区之间的旋转门。这项提议的目标是调整现有的、以理论为基础的干预措施，以最大限度地提高其可行性和对艾滋病毒感染者的接受度。我们将采用随机设计，对176名新近获释的艾滋病病毒感染者和176名对照受试者进行干预，并对其效果进行评估。这项研究将在世界上最大的市政监狱系统洛杉矶县监狱系统释放的HIV+男性前囚犯中进行。拟议的干预措施将使用个人提供的、以同行为基础的学习方法，以解决艾滋病毒+获释囚犯保留艾滋病毒护理的障碍和促进者。该提案有两个主要的具体目标：1.通过对出狱囚犯、案件管理人员和艾滋病毒护理提供者进行形成性的半结构化访谈，检查出狱后艾滋病毒护理的个人层面和结构层面的障碍；以及利用我们获得的信息，为旨在改善与艾滋病毒+囚犯艾滋病毒护理的联系和保持的干预措施的适应和定制提供信息；2.使用两组试验性随机对照试验设计，与通常护理条件相比，测试针对HIV+囚犯出狱后适应的基于同伴的卫生系统导航干预条件，并评估干预措施在改善与HIV护理的联系和保持、自我报告的ART依从性和HIV RNA病毒载量抑制方面的有效性；其次，我们将评估药物滥用的潜在缓和作用、物质滥用治疗的潜在调解作用、以及该计划对再犯罪率和成本的影响。如果成功、具有成本效益，并作为所有获释囚犯的一项更广泛的战略被采纳，前囚犯返回的社区可能受益于社区总体病毒载量的减少，这除了可以改善前囚犯的健康结果外，还可以加强现有的预防战略。 公共卫生相关性：拟议研究的目标是调整和量身定做一种成功的干预措施，最初是为没有接受艾滋病毒护理的低收入艾滋病毒感染者而开发的，以适应出狱前囚犯的需要。我们将在176名干预对象和176名对照的全功率随机对照试验中实施适应性干预。这项研究将在洛杉矶县监狱系统释放的HIV+男性前囚犯中进行。

DESCRIPTION (provided by applicant): The Seek, Test, and Treat model holds that broad, consistent treatment with antiretroviral therapy (ART) could lower the level of HIV RNA viral load in the community available for transmission. However, there are myriad challenges to implementing this strategy among released HIV+ incarcerated populations given the frequent discontinuity in care following release. Specifically, many ex-inmates fail to link to community-based HIV care long enough to sustain viral load suppression, or they fail to re-initiate any pre-incarceration linkage. Consequently, HIV+ ex-inmates urgently need interventions to improve their retention in HIV care. Most prior research has been conducted on prisons; however persons in jails have even less opportunity to establish optimal ART regimens, yet face equal disruption of treatment upon release. Far greater numbers pass through jails than prisons. Jailed persons also face frequent recidivism, resulting in a revolving door between jail and the community. The goal of this proposal is to adapt an existing, theory-based intervention to maximize its feasibility and acceptability to HIV+ ex-inmates. We will utilize a randomized design for 176 newly released HIV+ ex-inmates assigned to the intervention and 176 control subjects to implement the intervention and evaluate its effectiveness. The study will be conducted among HIV+ male ex-inmates released from the Los Angeles County Jail System, the largest municipal jail system in the world. The proposed intervention will use individually delivered, peer-based learning approaches to address barriers to and facilitators of HIV care retention among released HIV+ jail inmates. The proposal has two Primary Specific Aims: 1. To examine individual-level and structural-level barriers to HIV care after release from jail, using formative semi-structured interviews with ex-inmates, case managers, and HIV care providers; and to use the information we obtain to inform the adaptation and tailoring of an intervention designed to improve linkage with and retention to HIV care for HIV+ ex-inmates; 2. Using a two-group experimental RCT design, to test the adapted peer-based health system navigation intervention condition for HIV+ inmates upon release from jail compared to a usual care condition, and to evaluate the intervention's effectiveness at improving linkage with and retention in HIV care, self-reported ART adherence, and HIV RNA viral load suppression; Secondarily, we will assess the potential moderating effects of substance abuse, the potential mediating effects of substance abuse treatment, and the program's effects on recidivism, and costs. If successful, cost-effective, and adopted as a broader strategy for all released inmates, the community to which the ex-inmate returns may benefit from reduced overall community viral load, which could augment existing prevention strategies, in addition to improving the ex-inmates' health outcomes. PUBLIC HEALTH RELEVANCE: The goal of the proposed study is to adapt and tailor a successful intervention, originally developed for low income HIV+ persons who were not in HIV care, to the needs of ex-inmates released from jail. We will implement the adapted intervention in a fully powered RCT with 176 intervention subjects and 176 controls. The study will be conducted among HIV+ male ex-inmates who are being released from the Los Angeles County Jail System.