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来实现 日益增长的需求对公共卫生保健设施提出了要求。在撒哈拉以南非洲地区进行ART报道 在50%左右徘徊，卫生系统面临着增加艾滋病毒检测和抗逆转录病毒治疗的双重挑战 那些尚未接受治疗的人，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。社区- 基于ART的给药是维持HIV病毒长期抑制和滞留的潜在策略 关心。南非新的中央慢性药物分发和分发(CCMDD)计划允许 临床稳定的患者可以从社区接待点列表中选择(例如，私人药房，学校， 教堂)获得艺术，因此有可能为患者提供更方便的服务 为卫生设施减压。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，这种在患者、诊所和社区层面的大规模服务提供干预 南非德班的乌姆拉齐高密度聚居地。使用结合了以下内容的混合方法 实用、稳健的实施和可持续发展模型(PRISM)，我们将全面评估 CCMDD通过以下具体目标对乌姆拉齐所有10个公共部门诊所产生影响： 1)前瞻性地评估患者对CCMDD的摄取和与有利早期相关的患者因素 CCMDD参与者的临床结果并与非参与者的结果进行比较；2)评估 患者、诊所工作人员和管理人员使用定性方法采用CCMDD的促进者和障碍 方法，以及3)评估乌姆拉齐所有10家公共部门诊所随时间的病毒学抑制情况 程序化电子健康记录数据。 这项建议是由PA-17-182推动的，目的是更好地了解使用实施的系统级干预 科学，这可能会增加持续从事艾滋病毒护理的人数。我们打了一场大满贯 十多年来在南非实施和评估艾滋病毒护理连续干预措施的作用 并处于有利地位，可以评估这一重要政策变化的影响。我们的结果将通知临床 在艾滋病毒高流行环境中开发社区ART交付系统的领导人和政策制定者 将使数百万艾滋病毒携带者能够接受终身治疗。这项研究有可能改变 整个撒哈拉以南非洲的临床实践，在那里创新和有效地治疗长期 迫切需要以社区为基础的艾滋病毒治疗服务。

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.