Assessment of a Community Support Worker Intervention for PLWH in Rural Ethiopia

 描述(由申请人提供)：作为撒哈拉以南非洲和其他地区艾滋病毒护理级联的一个严重缺口，许多进入艾滋病毒护理的患者失去了后续(LTFU)，特别是在最初的1-2年内。许多这样的患者在没有接受治疗的情况下死亡，或者在高级免疫抑制下返回。我们在埃塞俄比亚的研究表明，农村环境中的艾滋病毒患者(艾滋病毒在那里得到越来越多的治疗)面临着多种挑战，这些挑战可能会影响到对艾滋病毒治疗的保留和健康状况，包括缺乏关于艾滋病毒治疗的知识、内部和被认为的耻辱、社会孤立以及难以获得医疗保健系统。尽管艾滋病毒项目使用社区支持工作者(CSW)来应对这些和其他挑战，但CSW项目有效性的证据主要基于观察性和单点研究，与积极结果相关的因素尚不清楚。在2011-2012年间，我们成功地实施了一项试点社区干预，以支持埃塞俄比亚农村的艾滋病毒患者，使用的是本身也是艾滋病毒阳性的性服务工作者。在新加入护理的艾滋病毒患者中，LTFU微乎其微，受助者在艾滋病毒知识、精神和身体生活质量以及感受到的社会支持方面有显著改善，慢性症状和内部污名减少。使用基于社会支持概念框架的干预措施来缓冲应激事件的负面影响，我们建议在一项大型多地点社区随机试验中严格评估CSW干预措施。在埃塞俄比亚南部国家、民族和人民地区，8家医院和32家卫生中心将随机接受干预或控制武器。对于每个干预地点，将雇用、培训该地区的CSW，并将其分配给艾滋病毒阳性患者，在社区环境中提供：信息支持(教育/咨询)；情感支持(解决内部和感知的耻辱)、陪伴支持(以减少社会隔离)和工具性支持(增加获得艾滋病毒临床护理系统的机会)。来自这些地点的2640名新诊断的艾滋病毒患者将接受基线评估，并将接受36个月的跟踪，并每年进行后续评估。健康调查将评估有关艾滋病毒治疗、内部和感知的外部耻辱、社会支持的感觉以及身心健康(生活质量)的知识。从客户的艾滋病毒诊所记录中提取的数据将包括去诊所就诊的日期(以评估正在接受护理的情况)、艾滋病毒临床状态、CD4+计数和体重指数。我们假设，与对照组的HIV患者相比，干预组的患者在36个月的随访中将减少HIV临床护理的LTFU(目标1)，以及增加知识、社会支持感觉和健康状况，并减少内部/感知的耻辱和社会孤立的感觉(目标2)。我们还将评估目标2中的因素对保留在护理中的预测程度(目标3)。这项研究对未来以社区为基础的项目具有很强的研究意义，这些项目使用支持人员来加强艾滋病毒护理的连续体，并支持分散的艾滋病毒护理。

 DESCRIPTION (provided by applicant): As a critical gap in the HIV cascade of care in sub-Saharan Africa and elsewhere, many patients entering HIV care are lost to follow-up (LTFU), especially within the first 1-2 years. Many such patients die without treatment or return with advanced immune suppression. Our studies in Ethiopia indicate that HIV patients in rural settings (where HIV is increasingly treated) face multiple challenges that may impact retention in care and health status, including lack of knowledge about HIV treatment, internal and perceived stigma, social isolation, and poor access to the medical care system. Although HIV programs have used community support workers (CSWs) to address these and other challenges, evidence for efficacy of CSW programs is largely based on observational and single site studies, and factors associated with positive outcomes are not well understood. During 2011-2012, we successfully implemented a pilot community intervention to support HIV patients in rural Ethiopia, using CSWs who were themselves HIV positive. Among HIV patients newly enrolled in care, LTFU was minimal, and clients had significant improvement in HIV knowledge, mental and physical quality of life, and perceived social support, with reduction in chronic symptoms and internal stigma. Using an intervention grounded in the conceptual framework of social support as buffering against the negative effects of stressful events, we propose to rigorously evaluate a CSW intervention in a large multi-site community randomized trial. In Ethiopia's Southern Nations, Nationalities and Peoples' Region, 8 hospitals and 32 health centers will be randomized to intervention or control arms. For each intervention site, CSWs from that local area will be hired, trained, and assigned to HIV positive clients to provide in community settings: informational support (education/counseling); emotional support (to addressed internal and perceived stigma), companionship support (to reduce social isolation), and instrumental support (with increased access to the HIV clinical care system). 2,640 newly diagnosed HIV patients from these sites will receive a baseline assessment and will be followed for 36 months with yearly follow-up assessments. Health surveys will assess knowledge about HIV treatment, internal and perceived external stigma, feelings of social support, and physical and mental health (quality of life). Data abstracted from the clients' HIV Clinic record will inclue dates of clinic visits (to assess ongoing retention in care), HIV clinical status, CD4+ count and body mass index. We hypothesize that compared to HIV patients in the control arm, those in the intervention arm will have reduced LTFU from HIV clinical care over 36 months of follow-up (Aim 1), as well as increased knowledge, feelings of social support, and health status, and decreased feelings of internal/perceived stigma and social isolation (Aim 2). We will also evaluate the extent to which factors in Aim 2 are predictive of retention in care (Aim 3). This study has strong research implications for future community-based programs using support workers to strengthen the HIV care continuum and to support decentralized HIV care.