Enhanced Access to HIV Care for Drug Users in San Juan, Puerto Rico

描述（由申请人提供）：最近的科学进展表明，对于艾滋病毒感染者，抗逆转录病毒治疗（ART）是改善免疫功能、降低发病率、提高生活质量、延长生存期和预防艾滋病毒传播的最有效策略。然而，将这一知识转化为实践，需要及时诊断和联系到护理，进入护理与及时的抗逆转录病毒治疗开始，并参与护理，支持抗逆转录病毒治疗的坚持，并保留，以促进持久的病毒学抑制。解决在实施这一系列护理中的失败，通常被称为“寻求，测试，治疗和保留（STTR）”模式，对实现美国国家艾滋病毒/艾滋病战略的目标至关重要。迄今为止，围绕这一战略的大部分研究和讨论都集中在扩大艾滋病毒检测，以改善新病例的早期发现。对与照料的联系、参与照料和保留照料的关注较少。具体而言，很少有人关注识别艾滋病毒感染者，尽管知道他们的诊断，但从未接受过艾滋病毒护理，只是间歇性的护理使用者，或者已经退出护理。感染艾滋病毒的吸毒者是一个特别难以与艾滋病毒护理联系并留住他们的亚群。在波多黎各，吸毒，特别是注射吸毒，继续助长艾滋病毒的迅速蔓延。在此背景下，我们拟议项目的总体目标是实施和评估社区一级的结构化方法，以加强波多黎各圣胡安吸毒者获得和保留艾滋病毒护理的机会。拟议的干预措施将是：1）查明不知道自己艾滋病毒状况和（或）没有参与艾滋病毒护理的感染艾滋病毒的吸毒者; 2）通过移动的保健货车提供直接的艾滋病毒护理服务; 3）为查明的感染艾滋病毒的吸毒者提供患者导航员，以提高他们参与艾滋病毒护理、开始抗逆转录病毒治疗和坚持治疗方案的能力。我们建议通过随机展开设计（一种改进的阶梯楔形设计）来评估我们的结构性增强护理方法。社区一级的干预措施的成功将通过评估病毒学抑制（主要生物学结果），增加出席艾滋病毒护理访问，抗逆转录病毒治疗的吸收，坚持艾滋病毒治疗方案，并减少物质使用（作为次要行为结果）在一个独立的队列的艾滋病毒阳性个体从每个社区包括在干预措施。我们亦会评估加强护理模式的推行过程和成本，包括对成本效益、扩展的可行性和可持续性的影响。

DESCRIPTION (provided by applicant): Recent scientific advances demonstrate that for people living with HIV, antiretroviral therapy (ART) is the most effective strategy to improve immune function, reduce morbidity, improve quality of life, prolong survival, and prevent HIV transmission. Translating this knowledge into practice, however, requires prompt diagnosis and linkage to care, entry into care with timely ART initiation, and engagement in care, support for ART adherence, and retention to promote durable virologic suppression. Addressing failures in the implementation of this cascade of care, often referred to as the "Seek, Test, Treat, and Retain (STTR)" paradigm, is vital to achieving the goals of the National HIV/AIDS strategy in the United States. To date, much of the research and discussion surrounding this strategy has focused on expanding HIV testing to improve the early identification of new cases. There has been less attention focused on linkage to, engagement in, and retention in care. Specifically, little attention has focused on identifying HIV-infected individuals who, despite being aware of their diagnosis, have never been in HIV care, are intermittent users of care, or have dropped out of care. A particularly difficult subpopulation to link to and retain in HIV care are HIV-infected drug users. In Puerto Rico, drug use, especially injection drug use, continues to fuel a fast-growing HIV epidemic. Within this context, the overall goal of our proposed project is to implement and evaluate a community-level, structured approach to enhance HIV care access and retention for drug users in San Juan, Puerto Rico. The proposed intervention will be to: 1) identify drug users living with HIV who either do not know their HIV status and/or are not engaged in HIV care; 2) provide direct HIV care services through a mobile health van; and 3) support identified HIV-infected drug users with patient navigators to enhance their ability to engage in HIV care, to initiate antiretroviral therapy, and maintain adherence to their treatment regimens. We are proposing to evaluate our structural enhanced care approach through a randomized roll-out design, a refinement of the stepped-wedge design. The community-level success of the intervention will be assessed by evaluating virologic suppression (primary biological outcome), increased attendance to HIV care visits, uptake of antiretroviral therapy, adherence to HIV treatment regimens, and decreased substance use (as secondary behavioral outcomes) in an independent cohort of HIV-positive individuals drawn from each of the neighborhoods included in the intervention. We will also evaluate the implementation process and cost of the enhanced care approach including implications for cost-effectiveness, feasibility of expansion, and sustainability.