Integrating Addiction Treatment and HIV Services into Primary Care Clinics in Ukraine

乌克兰变化无常的艾滋病毒疫情是欧洲最严重的，集中在注射毒品的人(PWID)中。最多的 乌克兰高性价比的艾滋病毒一级和二级预防和治疗战略是扩大美沙酮 维持治疗(MMT)，特别是对艾滋病毒携带者(PLH)，但覆盖率仍然很低(2.7%) 310,000个PWID。MMT的推广受到复杂的、多层次的患者、提供者、临床和社区因素的阻碍。 为了改革医疗保健，乌克兰已将加强初级保健列为优先事项。我们的试点研究，基于Collaborative 护理模式，肯定将MMT纳入PLH初级保健是可接受的、可行的、方便的、减少的 耻辱和管理的医疗合并症(艾滋病毒、结核病、丙型肝炎、抑郁症等)这在MMT中没有以其他方式处理 专科诊所。三个拟议的循证实践将加强协作护理模式的要素。项目 Echo使用协作学习环境持续培训、指导和强化专业护理实践 (例如，管理合并症)，用于使用远程教育技术的非专科医生。质量改进 (Q)技术改变临床和组织流程以实现预期结果，提供分析工具， 并确保利益相关者的参与。按绩效付费(P4P)激励鼓励医生实现核心设置 基于质量健康指标(QHI)的结果，QHI基于预先指定的流程措施 P4P效果最好。研究目的：1)比较初级(综合QHI评分)和次级(个体QHI) 来自15个地区(群)和45个地区的1350名HIV+PWID接受MMT治疗的结果 临床环境采用分层、分阶段、随机的整群对照设计，为期24个月。分层后 PWID根据目前接受MMT的情况，他们将被随机分配到专门的成瘾诊所接受MMT (n=450)或在Echo-IC/QI增强的初级保健诊所，有(N=450)或没有(N=450)P4P激励；2) 使用多层次实施科学框架，我们将检查客户、临床医生和 有助于在1,350名招募的PWID中获得最佳综合QHI分数的组织因素 目标1；和3)为生活在一起的人进行整合MMT的建模和成本效益分析(CEA) 将HIV纳入初级保健，无论是否有P4P，与接受MMT成瘾的PWID对照组进行比较 专业设置。其意义是基于乌克兰艾滋病病毒和其他共患疾病的高负担，其 在医疗改革中的区域领导作用及其加强初级保健的优先事项。创新体现在 通过整合MMT加强初级保健，使用与 实施科学框架，提供经验数据，向CEA通报其对ECHO、QI的创造性使用 技术和P4P，及其对综合护理的过程和结果(多重共病QHIS)的关注。可行性 基于试点测试，以及在综合护理、随机对照试验、实施科学、 耻辱、ECHO、QI、P4P和CEA，与众多坚定的国内和国际利益攸关方以及 在乌克兰进行成瘾、艾滋病毒和结核病研究的长期经验。

Ukraine's volatile HIV epidemic, the worst in Europe, is concentrated in people who inject drugs (PWIDs). The most cost-effective primary and secondary HIV prevention and treatment strategy for Ukraine is to expand methadone maintenance treatment (MMT), especially for people living with HIV (PLH), but coverage remains low (2.7%) for the 310,000 PWIDs. MMT scale-up is hampered by complex, multi-level patient, provider, clinic and community factors. To reform healthcare, Ukraine has prioritized strengthening primary care. Our pilot study, based on the Collaborative Care Model, affirmed that integrating MMT into primary care for PLH was acceptable, feasible, convenient, reduced stigma and managed medical comorbidities (HIV, TB, HCV, depression, etc.) that was not otherwise handled in MMT specialty clinics. Three proposed evidence-based practices will reinforce Collaborative Care Model elements. Project ECHO uses a collaborative learning environment to continuously train, coach, and reinforce specialty care practices (e.g., managing comorbidities) for non-specialist physicians using tele-education technology. Quality Improvement (QI) techniques change clinical and organizational processes to achieve desired outcomes, provide analytical tools, and ensure stakeholder engagement. Pay-for-performance (P4P) incentives encourage physicians to achieve a core set of outcomes based on quality health indicators (QHIs), which are based on pre-specified process measures that yield the best P4P results. Study aims: 1) To compare both primary (composite QHI score) and secondary (individual QHI scores, quality of life, and stigma) outcomes in 1,350 HIV+ PWIDs receiving MMT from 15 regions (clusters) and 45 clinical settings using a stratified, phase-in, randomized cluster-controlled design over 24 months. After stratifying PWIDs based on current receipt of MMT, they will be randomized to receive MMT in specialty addiction clinics (N=450) or in an ECHO-IC/QI-enhanced primary care clinic with (N=450) or without (N=450) P4P incentives; 2) Using a multi-level implementation science framework, we will examine the contribution of client, clinician, and organizational factors that contribute to attaining optimal comprehensive QHI scores in the 1,350 recruited PWIDs in aim 1; and 3) To conduct modeling and cost-effectiveness analyses (CEA) of integrating MMT for people living with HIV into primary care, with or without P4P, compared to a control group of PWIDs receiving MMT in addiction specialty settings. Significance is based on Ukraine's high burden of HIV and other comorbidities in PWIDs, its regional leadership role in healthcare reform, and its priority to strengthen primary care. Innovation is reflected in strengthening of primary care through MMT integration using a nationwide RCT cluster design linked to an implementation science framework that provides empiric data to inform the CEA, its creative use of ECHO, QI techniques, and P4P, and its focus on processes and outcomes (multi-comorbidity QHIs) of integrated care. Feasibility is based on pilot testing, and extensive co-investigator experience with integrated care, RCTs, implementation science, stigma, ECHO, QI, P4P, and CEA, combined with numerous committed national and international stakeholders and a longstanding experience of conducting research on addiction, HIV, and TB in Ukraine.