Positive Connections: COPA2

抽象的。“具有挑战性”的艾滋病毒感染患者，即那些没有保留在治疗中的患者，代表着对 积极预防，因为保留护理也与总体社区水平病毒的减少有关 负担。与护理挂钩，及早开始抗逆转录病毒治疗(ART)，在治疗中坚持和保留 使艾滋病毒感染者能够实现并保持病毒抑制到无法检测的水平，优化 健康和减少艾滋病毒传播。阿根廷是拉美国家中首批保证 艾滋病毒预防、诊断和综合护理服务，包括抗逆转录病毒药物， 消除了费用和可获得性作为护理艾滋病毒感染患者的障碍。然而，就像在美国一样，辍学发生在 艾滋病毒连续体的每个阶段。据估计，阿根廷有11万人感染艾滋病毒；其中， 已确诊77,000人(70%)，60,000人(54%)与护理有关。然而，只有36%的人实现了 病毒抑制和31%的确诊患者推迟进入护理。我们的试点研究估计了 护理的比例从65%到90%不等。在普遍获得护理的情况下，艾滋病毒感染者构成了一个紧迫的问题 由于病毒耐药性、治疗失败和艾滋病毒的可能性增加而造成的公共卫生问题 变速箱。在社区层面实现有意义的减少艾滋病毒感染，新的和创新的 必须制定战略，使未保留在护理中的患者重新参与进来。 动机访谈(MI)是一种广泛使用的以患者为中心的协作式方法，并已被使用 由中美洲和南美洲的治疗师加强药物使用和风险方面的动机和承诺 还原。我们最近完成的试点可行性研究针对的是没有保留在治疗中的具有挑战性的患者 在阿根廷布宜诺斯艾利斯的公立和私立诊所。这项先导研究利用了MI，并在文化上 根据当地情况量身定做的，是可行的，并为患者、医生和诊所工作人员所接受。结果 证明了以医生为基础的心肌梗死干预在让患者重新参与护理方面是有效的，即， 增强和持续的患者依从性、病毒抑制和医患沟通以及 这些患者在基线后6个月和9个月对治疗的态度。 拟议的临床试验旨在将这些发现推广到4个城市人口的公立和私立诊所。 在阿根廷的中心，诊所(N=6个诊所，每个站点6个MD)被随机分配到实验(医生) MI干预)(n=3)或对照(医生护理标准)(n=3)，比例为3：3。使用集群 随机临床试验设计，拟议的研究将测试以医生为基础的动机的有效性 访谈干预以改善和维持保持、依从性、持久性和病毒抑制 在超过24个月的“挑战”患者中(n=360)。结果将对公众健康产生重要影响 用于实施MI，以重新吸引和留住艾滋病毒患者的治疗和护理，并改善病毒 通过高水平的药物依从性进行抑制。

Abstract. “Challenging” HIV-infected patients, those not retained in treatment, represent a critical focus for positive prevention, as retention in care is also associated with reduction in overall community-level viral burden. Linkage to care, early initiation of antiretroviral therapy (ART), adherence and retention in treatment enables HIV-infected individuals to achieve and maintain viral suppression to non-detectable levels, optimizing health and reducing HIV transmission. Argentina was one of the first Latin American countries to guarantee HIV prevention, diagnosis and comprehensive care services, including antiretroviral (ARV) medication, which removed cost and access as barriers to care for HIV-infected patients. Yet, as in the USA, drop out occurs at every stage of the HIV continuum. An estimated 110,000 individuals are HIV-infected in Argentina; of these, 77,000 (70%) have been diagnosed and 60,000 (54%) were linked to care. However, only 36% have achieved viral suppression and 31% of those diagnosed delayed entry to care. Our pilot study estimated retention in care ranged from 65-90%. Given universal access to care, patients with uncontrolled HIV constitute an urgent public health problem due to the increased likelihood of viral resistance, treatment failure and HIV transmission. To achieve meaningful reductions in HIV infection at the community level, new and innovative strategies must be developed to re-engage patients not retained in care. Motivational Interviewing (MI) is a widely used collaborative patient-centered approach and has been used by therapists in Central and South America to enhance motivation and commitment in substance use and risk reduction. Our recently completed pilot feasibility study targeted challenging patients not retained in treatment in public and private clinics in Buenos Aires, Argentina. The pilot study, which utilized MI and was culturally tailored to the local setting, was feasible and acceptable to patients, physicians and clinic staff. Results demonstrated that a physician-based MI intervention was effective in re-engaging patients in care, i.e., enhanced and sustained patient adherence, viral suppression and patient-physician communication and attitudes about treatment among these patients at 6 and 9 months post baseline. The proposed clinical trial seeks to extend these findings in public and private clinics in 4 urban population centers in Argentina, in which clinics (N = 6 clinics, 6 MDs per site) are randomized to experimental (physician MI Intervention) (n = 3) or control (physician Standard of Care) (n = 3) conditions in a 3:3 ratio. Using a cluster randomized clinical trial design, the proposed study will test the effectiveness of a physician-based Motivational Interviewing intervention to improve and sustain retention, adherence, persistence and viral suppression among “challenging” patients (n = 360) over 24 months. Results will have important public health implications for the implementation of MI to re-engage and retain patients in HIV treatment and care and improve viral suppression through high levels of medication adherence.