Working with HIV clinics to adopt addiction treatments using Implementation Facilitation (WHAT IF?)

 描述（由申请人提供）：烟草，酒精和阿片类药物使用障碍威胁艾滋病毒感染患者的健康。如果在艾滋病诊所常规提供针对烟草、酒精和阿片类药物使用障碍的循证咨询和药物治疗（本文称为成瘾治疗），情况会怎样？实施促进是一个既定的和可重复的战略，以增加循证治疗的吸收。这是一个多组件的干预，评估关键利益相关者（管理员，供应商，患者）的需求，并提供了一个定制的实施策略，使用外部的促进者，当地的冠军，供应商教育，学术细节，利益相关者参与，性能监测和反馈，形成性评估，学习协作和计划营销，以实施循证治疗。我们的目标是评估实施促进对四个大型艾滋病诊所使用成瘾治疗的影响。我们将在混合型3研究中使用PARiHS（促进卫生服务研究实施行动）实施科学框架，该框架允许同时评估实施情况及其有效性。我们将使用阶梯式楔形设计，随机分配诊所接受实施促进的顺序。我们的目标是：目标1-在主要利益相关者中，使用混合方法来识别成瘾治疗整合的证据，背景和促进相关障碍和促进因素，以帮助为每个诊所量身定制实施促进：目标2-评估实施促进对以下方面的影响：a）组织和提供者准备提供成瘾治疗，B）提供成瘾治疗，目标3-评估实施便利对符合戒毒条件的患者接受抗逆转录病毒治疗、病毒抑制、VACS指数（一种经验证的死亡风险衡量标准）和艾滋病毒护理保留率的影响。这项建议的新方面包括：1）使用实施促进来解决一系列障碍，而不是艾滋病毒诊所中的单一物质使用障碍，2）将管理员，提供者和患者的投入纳入艾滋病毒诊所成瘾治疗的实施中，3）用于评估艾滋病毒诊所短期和长期接受成瘾治疗的混合实施-有效性设计，4）关注组织模式，确保在诊所层面整合成瘾治疗，但允许根据利益相关者的投入和滥用的物质灵活决定由谁提供这些治疗，以及5）使用VACS指数，该指数更好地反映了禁欲的健康益处，而不是关注病毒载量，尽管患者正在吸烟，但抗逆转录病毒治疗可能会受到抑制，酒精或阿片类药物使用。与艾滋病毒诊所合作，采用实施促进成瘾治疗（如果？）这项研究为确定一项有效的战略提供了特殊的希望，以增加艾滋病毒诊所对成瘾治疗的接受，从而扭转其对发病率和死亡率的破坏性影响。

 DESCRIPTION (provided by applicant): Tobacco, alcohol and opioid use disorders threaten the health of HIV-infected patients. What if evidence-based counseling and medication treatments for tobacco, alcohol and opioid use disorders (herein referred to as addiction treatments) were routinely provided in HIV clinics? Implementation Facilitation is an established and reproducible strategy to increase the uptake of evidence-based treatments. It is a multi-component intervention that assesses key stakeholder's (administrators, providers, patients) needs and provides a tailored implementation strategy using an external facilitator, local champions, provider education, academic detailing, stakeholder engagement, performance monitoring and feedback, formative evaluations, learning collaborative and program marketing to implement evidence-based treatments. Our goal is to evaluate the impact of Implementation Facilitation on the use of addiction treatments in four large HIV clinics. We will use the PARiHS (Promoting Action on Research Implementation in Health Services) Implementation Science framework in a Hybrid Type 3 study that allows for simultaneous evaluation of the implementation and its effectiveness. We will use a stepped wedge design that randomly assigns the order in which the clinics receive Implementation Facilitation. Our aims are: Aim 1-Among key stakeholders, to use mixed methods to identify evidence, context and facilitation-related barriers and facilitators to the integration of addiction treatments to help tailor an Implementation Facilitation for each clinic: Aim 2-To assess the impact of Implementation Facilitation on: a) organizational and provider readiness to deliver addiction treatments, b) the provision of addiction treatments, c) changes in organizational models used to deliver addiction treatments; and Aim 3- To evaluate the impact of Implementation Facilitation on antiretroviral receipt, viral suppression, VACS Index (a validated measure of mortality risk) and retention in HIV care among patients eligible for addiction treatment. The novel aspects of this proposal include: 1) the use of Implementation Facilitation to address a range of disorders, rather than a single substance use disorder in HIV clinics, 2) incorporation of administrator, provider and patient input into the implementation of addiction treatment in HIV clinics, 3) a hybrid implementation- effectiveness design for assessing short and long-term uptake of addiction treatments in HIV clinics, 4) a focus on organizational models that ensure that there is integration of addiction treatments at the clinic level but allows flexibility as to who provides these treatments based on stakeholder input and the abused substance, and 5) the use of the VACS Index that better reflects the health benefits of abstinence than a focus on viral load which may be suppressed in patients on antiretroviral treatment despite ongoing tobacco, alcohol or opioid use. The Working with HIV Clinics to adopt Addiction Treatments using Implementation Facilitation (WHAT IF?) study holds exceptional promise of identifying an effective strategy to increasing the uptake of addiction treatments into HIV clinics thereby reversing their devastating impact on morbidity and mortality.