South Africa's new Central Chronic Medicine Dispensing and Distribution program: assessing the clinic, patient, and community impact

项目摘要 到2020年在撒哈拉以南非洲实现联合国艾滋病规划署的90-90-90目标将需要创新的解决方案， 对公共卫生保健设施的需求日益增加。撒哈拉以南非洲抗逆转录病毒治疗覆盖率 徘徊在50%左右，卫生系统面临着增加艾滋病毒检测和ART登记的双重挑战， 那些尚未得到照顾的人，并继续为数百万已经接受抗逆转录病毒治疗的人提供治疗。 基于抗逆转录病毒疗法的治疗是维持长期病毒学抑制和HIV滞留的潜在策略 在乎南非新的中央慢性病药物分配和分配（CCMDD）计划允许 临床稳定的患者从社区接送点列表中选择（例如，私人药房，学校， 因此，有可能为患者提供更方便的服务， 卫生设施。目前的提案利用这一国家政策变化来评估影响 随着时间的推移，在病人、诊所和社区层面进行的这种大规模服务提供干预， 南非德班Umlazi高密度定居点。采用混合方法， 实用，稳健的实施和可持续发展模型（PRISM），我们将全面评估 通过以下具体目标，在乌姆拉齐的所有10个公共部门诊所实施CCMDD： 1)前瞻性评估患者对CCMDD的接受情况以及与有利的早期治疗相关的患者因素， CCMDD入组者的临床结局，并与非入组者的结局进行比较; 2）评价 患者、诊所工作人员和管理人员采用CCMDD的促进者和障碍， 方法，以及3）使用以下方法评估Umlazi所有10个公共部门诊所随时间推移的病毒学抑制 程序化电子健康记录数据 本提案的动机是PA-17-182，以更好地理解使用实施的系统级干预措施 科学，这可能会增加持续参与艾滋病毒护理的人数。我们已经扮演了一个主要的 在南非艾滋病毒护理连续体中沿着实施和评估干预措施的十多年来所发挥的作用 并有能力评估这一重要政策变化的影响。我们的研究结果将告知临床 艾滋病毒高流行率环境中的领导人和决策者制定社区抗逆转录病毒治疗提供系统， 将为数百万艾滋病毒感染者提供终身治疗。这项研究有可能改变 整个撒哈拉以南非洲的临床实践，在那里，创新和有效的方法，以长期 迫切需要以社区为基础提供艾滋病毒治疗。

Project Summary Achieving the UNAIDS 90-90-90 target by 2020 in sub-Saharan Africa will require innovative solutions to meet the increasing demands placed on public health care facilities. With ART coverage in sub-Saharan Africa hovering around 50%, health systems face the dual challenge of increasing HIV testing and ART enrollment for those not yet in care and continuing to provide treatment to the millions of people already on ART. Community- based ART delivery is a potential strategy for maintaining long-term virologic suppression and retention in HIV care. South Africa’s new Central Chronic Medicine Dispensing and Distribution (CCMDD) program allows clinically stable patients to choose from a list of community pick-up points (e.g., private pharmacies, schools, churches) to access ART and therefore has the potential to offer more convenient services to patients and to decompress health facilities. The current proposal leverages this national policy change to assess the impact of this large scale service delivery intervention at the patient-, clinic-, and community-level over time in the high-density settlement of Umlazi in Durban, South Africa. Using a mixed-methods approach that incorporates the Practical, Robust Implementation and Sustainability Model (PRISM), we will comprehensively evaluate the impact of CCMDD at all 10 public sector clinics in Umlazi through the following specific aims: 1) To prospectively assess patient uptake of CCMDD and patient factors associated with favorable early clinical outcomes for CCMDD enrollees and to compare outcomes with non-enrollees; 2) To evaluate facilitators of and barriers to adoption of CCMDD by patients, clinic staff, and administrators using qualitative methods, and 3) To evaluate virologic suppression over time across all 10 public sector clinics in Umlazi using programmatic electronic health record data. This proposal is motivated by PA-17-182 to better understand system-level interventions using implementation science, which may increase the number of people consistently engaged in HIV care. We have played a major role for over a decade implementing and evaluating interventions along the HIV care continuum in South Africa and are well-positioned to evaluate the impact of this important policy change. Our results will inform clinical leaders and policymakers in high HIV prevalence settings developing community ART delivery systems that will enable life-long therapy for millions of people living with HIV. This research has the potential to change clinical practice throughout sub-Saharan Africa, where innovative and efficient approaches to long-term community-based HIV treatment delivery are urgently needed.