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来说，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，需要及时诊断并与护理联系起来，及时开始抗逆转录病毒治疗并进入护理，参与护理，支持抗逆转录病毒治疗依从性，并保留以促进持久的病毒学抑制。解决这种通常被称为“寻找、检测、治疗和保留（STTR）”模式的级联护理实施中的失败问题，对于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，围绕这一战略的许多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。对护理的联系、参与和保留的关注较少。具体而言，很少注意查明艾滋病毒感染者，这些人尽管知道自己的诊断，但从未接受过艾滋病毒护理，是间歇性护理的使用者，或已退出护理。特别难以与感染艾滋病毒的吸毒者建立联系并将其留在艾滋病毒护理中。在波多黎各，吸毒，特别是注射吸毒，继续助长迅速蔓延的艾滋病毒流行病。在此背景下，我们提议的项目的总体目标是实施和评估社区一级的结构化方法，以提高波多黎各圣胡安吸毒者获得艾滋病毒护理的机会和保留。建议的干预措施将是：1)识别不知道自己的艾滋病毒状况和/或未参与艾滋病毒护理的艾滋病毒感染者；2)通过流动保健车提供直接艾滋病毒护理服务；3)支持通过患者导航员确定感染艾滋病毒的吸毒者，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其治疗方案的能力。我们建议通过随机推出设计来评估我们的结构增强护理方法，这是对楔形设计的改进。社区层面干预的成功将通过评估病毒学抑制（主要生物学结果）、艾滋病毒护理就诊人数的增加、抗逆转录病毒治疗的接受情况、对艾滋病毒治疗方案的依从性和药物使用的减少（作为次要行为结果）来评估，这些研究对象来自干预所包括的每个社区的艾滋病毒阳性个体的独立队列。我们还将评估强化护理方法的实施过程和成本，包括对成本效益、扩展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.