PWID Opportunities to Improve TrEat and Retain (POINTER)

7.项目摘要/摘要 注射毒品(PWID)的人感染艾滋病毒的风险很高，治疗结果更差 特别是在低收入和中等收入国家(LMIC)。阿片类药物的使用在 年，印度北部和中部地区出现了新的注射毒品疫情。 最近5-10年。在这些地区，我们记录了高共用针头的比率、高艾滋病毒流行率和 艾滋病毒发病率低，艾滋病毒检测和治疗的机会低。我们的团队展示了应答者的潜力- 驱动抽样(RDS)，以利用社交网络，识别不知情和已出院的HIV阳性PWID。在……里面 响应RFA-DA-18-017，我们建议以RDS的经验为基础 “寻求和测试”，通过严格评估旨在改善“治疗和测试”的三个可扩展战略 在LMIC环境中保留在PWID中的HIV护理连续体的步骤。目标1是进行阶乘分析 评估政策干预的单独和综合影响的随机对照试验(同一天 ART)、结构性干预(以社区为基础的护理)和个人层面的干预(心理社会/ 导航)，以改善HIV阳性PWID患者的治疗结果。析因设计可以同时评估 多种干预措施的主要效果以及干预措施之间的相互作用，为试验提供了可能性 效率(有效地以一次试验的价格获得三次试验)，以及关于不同干预措施如何 各种机制可能会影响彼此的有效性。我们将检验3个假设：假设1A- 在HIV阳性的PWID患者中，当天开始抗逆转录病毒治疗将增加12个月的存活率， 与标准的艺术启蒙相比。当天的艺术在非洲被发现是有效的，但从来没有 以PWID进行评估。假设1B-基于社区的护理将增加病毒感染者的12个月存活率 与基于政府的护理相比，艾滋病毒阳性PWID中的抑制。在之前的工作中，我们发现 以PWID为中心的综合护理中心(ICCs)在吸引人群方面非常有效，提供阿片类药物 治疗和增加艾滋病毒检测的摄取率。在此，我们建议扩展ICC模型以提供 在无障碍和无歧视的环境中以社区为基础的艾滋病毒护理。假设1C-A 心理社会/导航干预(加强支持)将在病毒抑制的情况下提高12个月存活率 在HIV阳性的PWID中，与标准支持相比。患者导航器将提供以PWID为重点的 激励性面谈、技能培养以及基于外地的系统导航和保留。我们建议 适应和加强以证据为基础的PWID干预措施。将评估干预效果的持久性 18个月的时候。目标2是说明执行拟议方案的障碍和促进因素 干预措施，并确定干预成本和潜在成本效益。我们将描述 在Curran类型-1之后进行专门的实施科学评估的实施路径 这是一个成效-执行混合研究的模式，并将进行正式的成本效益分析。

7. PROJECT SUMMARY/ABSTRACT People who inject drugs (PWID) are at high risk for HIV infection and experience worse treatment outcomes than other key populations, particularly in low to middle income countries (LMIC). Opioid use is common in India and new injection drug epidemics have emerged in the North and Central regions of the country in the last 5-10 years. In these regions, we have documented high rates of needle sharing, high HIV prevalence and incidence, and low access to HIV testing and treatment. Our team demonstrated the potential of respondent- driven sampling (RDS) to leverage social networks and identify unaware and out-of-care HIV-positive PWID. In response to RFA-DA-18-017, we propose to build on our experience with RDS as the foundation of “seek and test”, by rigorously assessing three scalable strategies aimed at improving the “treat and retain” steps of the HIV care continuum among PWID in a LMIC setting. Aim 1 is to conduct a factorial randomized controlled trial to evaluate the individual and combined effects of a policy intervention (same-day ART), a structural intervention (community-based care) and an individual-level intervention (psychosocial/ navigation) to improve treatment outcomes among HIV-positive PWID. A factorial design can assess both the main effects of multiple interventions and interactions between the interventions, offering the potential for trial efficiency (effectively getting 3 trials for the price of one) and novel insights on how interventions with different mechanisms may influence the effectiveness of one another. We will test 3 hypotheses: Hypothesis 1A - Same-day ART initiation will increase 12-month survival with viral suppression among HIV-positive PWID, compared with standard ART initiation. Same-day ART has been found effective in Africa, but has never been evaluated in PWID. Hypothesis 1B - Community-based care will increase 12-month survival with viral suppression among HIV-positive PWID, compared with government-based care. In prior work, we found that PWID-centric integrated care centers (ICCs) were highly effective at engaging the population, providing opioid treatment and increasing HIV testing uptake. Here we propose to scale-up the ICC model to provide community-based HIV care in an accessible and non-discriminatory setting. Hypothesis 1C - A psychosocial/navigation intervention (enhanced support) will increase 12-month survival with viral suppression among HIV-positive PWID, compared with standard support. Patient navigators will provide PWID-focused motivational interviewing, skills building, and field-based systems navigation and retention. We propose to adapt and build upon evidence-based interventions for PWID. Durability of intervention effects will be assessed at 18 months. Aim 2 is to characterize the barriers and facilitators to implementation of the proposed interventions, and determine the intervention costs and potential cost-effectiveness. We will characterize implementation pathways with a dedicated implementation science evaluation following the Curran type-1 model of an effectiveness-implementation hybrid study and will conduct formal cost-effectiveness analyses.