Strengthening the continuity of HIV care in Tanzania with economic support

摘要 人们越来越认识到，如果不改进，就不可能实现艾滋病毒流行控制的全球目标 保留艾滋病毒护理和坚持抗逆转录病毒治疗(ART)。只有58%的艾滋病毒携带者 东部和南部非洲的艾滋病病毒(PLHIV)受到病毒抑制，并向这些人提供坚持咨询 病毒载量增加只会导致40%-50%的病毒抑制。财政奖励，最初用于 减贫，已被证明可以激励行为改变和提高对艾滋病毒相关疾病的参与度 服务。然而，关于以激励为基础的计划对人的有效性的数据很少 那些脱离了艾滋病毒护理以及积极利用激励措施应对艾滋病毒感染者的人 坚持不懈。这一研究差距限制了我们对财务激励计划是否值得的理解 投资支持终身护理，这对“作为艾滋病毒预防的治疗”(TasP)的成功至关重要。 拟议的研究将促进全球对财政激励的有效性的了解 加强艾滋病毒护理的连续性。我们将基于我们在坦桑尼亚进行的一项试点研究的数据 他们发现，为失业者提供一次性经济激励的干预措施是可行的， 在激励重新参与艾滋病毒护理方面是可以接受的，并且初步有效。利用我们已建立的 利用行为经济学的研究计划和专业知识，我们设计了一个为期5年的混合方法、混合 有效性--评价财务激励干预并描述其成功的实施研究 执行，最终目标是缩小实现艾滋病规划署“95-95-95”目标的差距。我们 将首先评估一次性经济激励是否会提高护理的重新参与度和持久的病毒抑制 在盖塔和卡盖拉地区脱离护理的640名艾滋病毒携带者中，有12个月(目标1)。我们 然后将衡量向692名处于护理阶段的PLHIV患者提供的短期经济激励的有效性 失去随访或依从性差的风险，以12个月的持久病毒抑制为结果(目标 2)。混合方法研究将描述实施的成功和挑战，并综合经验教训。 学会了为脆弱的艾滋病毒感染者提供激励方案的信息(目标3)。这个项目是由 加州大学伯克利分校，健康促进国家繁荣，拉塞罗，管理与发展 卫生部和坦桑尼亚卫生、社区发展、性别、老年人和儿童部。 在项目结束时，我们将对激励策略进行严格评估，并将理解 它是否可以缓解脱离艾滋病毒护理的长期挑战，与美国国立卫生研究院办公室一致 艾滋病研究的优先事项是实施关于保留护理和坚持抗逆转录病毒治疗的研究。这 信息与正在实施或正在实施的基于激励的计划的范围高度相关 考虑改善艾滋病病毒感染者的健康状况，并在联合国艾滋病规划署快车道国家优化TasP方案。 1

SUMMARY It is increasingly recognized that global goals for HIV epidemic control cannot be realized without improving retention in HIV care and adherence to antiretroviral therapy (ART). Only 58% of people living with HIV (PLHIV) in eastern and southern Africa are virally suppressed, and adherence counseling provided to those with elevated viral loads results in viral suppression only 40-50% of the time. Financial incentives, first used for poverty reduction, have been shown to motivate behavior change and improve engagement in HIV-related services. However, there is a paucity of data about the effectiveness of incentive-based programs for people who have disengaged from HIV care as well as the proactive use of incentives for PLHIV struggling with adherence. This research gap limits our understanding of whether financial incentive programs are worthwhile investments to support lifelong care, which is essential to the success of ‘treatment as HIV prevention’ (TasP). The proposed research will advance global knowledge about the effectiveness of financial incentives for strengthening the continuity of HIV care. We will build on data from a pilot study we conducted in Tanzania which found that an intervention offering a one-time financial incentive to out-of-care PLHIV was feasible, acceptable, and preliminarily efficacious at motivating re-engagement in HIV care. Leveraging our established research program and expertise with behavioral economics, we designed a 5-year, mixed-methods, hybrid effectiveness-implementation study to evaluate the financial incentive intervention and describe its successful implementation, with the ultimate goal of closing the gap towards achievement of UNAIDS’ ‘95-95-95’ goals. We will first assess if a one-time financial incentive improves re-engagement in care and durable viral suppression at 12 months among 640 PLHIV in Geita and Kagera Regions who have disengaged from care (Aim 1). We will then measure the effectiveness of short-term financial incentives offered to 692 in-care PLHIV who are at risk of loss to follow-up or poor adherence, with durable viral suppression at 12 months as the outcome (Aim 2). A mixed-methods study will describe implementation successes and challenges and synthesize lessons learned to inform adoption of incentive programs for vulnerable PLHIV (Aim 3). The project is a collaboration of the University of California, Berkeley, Health for a Prosperous Nation, Rasello, Management and Development for Health, and the Tanzania Ministry of Health, Community Development, Gender, Elderly, and Children. At the conclusion of the project, we will have rigorously evaluated the incentive strategy and will understand whether it can mitigate the persistent challenge of disengagement from HIV care, consistent with NIH Office of AIDS Research priorities for implementation research on retention in care and adherence to ART. This information is highly relevant to the spectrum of incentive-based programs being implemented or under consideration to improve the health of PLHIV and to optimize TasP programs in UNAIDS Fast Track countries. 1