Adaptive Strategies to Prevent and Treat Lapses of Retention in HIV Care for Adolescents (A4A)

摘要 非洲14-24岁感染艾滋病毒的青少年和年轻人（AYA） 与成人相比，病毒失败率和艾滋病毒相关死亡率较高。因此，有效的公共 迫切需要针对这一年龄组制定并在其中检验的保健战略。身体状况， AYA所面临的心理和社会转型创造了独特的适应性， 强大的结构（例如，运输费用），社会心理（例如，渴望融入同龄人， 污名）和基于诊所的（例如，提供者不友好，等待时间长） 公共卫生艾滋病毒治疗机构。障碍的强度和性质的可变性， 然而，这带来了一个关键的挑战：如果障碍是高度可变的， 所有人都需要，但它们也不能帮助所有需要帮助的人。适应性策略代表了一种新的 没有“银弹”解决方案的方法来解决这些问题，我们假设 特别是在艾滋病毒治疗的AYA参与相关性。适应性策略通常从开始 先进行不太密集的干预，然后只在那些 做得不好在那些做得好的人中保持较低强度的干预措施可以节省资源 在不需要额外服务的大部分AYA中， 为有需要的人提供大力支持。序贯多重分配随机试验 （SMART），用于比较不同的干预序列，已被用于 研究精神疾病，癌症治疗和艾滋病毒治疗，这项建议是第一个应用SMART 解决非洲青年协会参与非洲艾滋病毒治疗的问题。在此设计中，我们将使用 适合发展的干预措施，具有很高的效力潜力， AYA预执行。具体来说，我们将在肯尼亚随机抽取880名艾滋病毒感染者， (1)以青年为中心的教育和咨询（护理标准）vs.（2）添加SMS和同伴 通过电话提供支持、信息和咨询的电子导航员。者 参与度下降的患者将再次随机分配至三种更高强度的再治疗中的一种， 参与干预：（1）护理外展标准和强化咨询，（2） 有条件的现金转移和（3）亲自同行导航。主要结果将是 访视依从性和病毒载量抑制的组合。这项研究将量化相对 有效性（和成本效益）的几个战略组成的有前途的个人 干预措施。我们将评估提供者和患者的体验以及对 采用混合方法进行干预。这项创新的研究将为公众提供相关证据 卫生规划，以结束艾滋病流行病与艾滋病毒的AYA。

Abstract Adolescents and young adults (AYA) aged 14-24 years with HIV in Africa experience substantially higher rates of viral failure and HIV-related mortality as compared to adults. Thus, effective public health strategies tailored for and tested in this age group are urgently needed. The physical, psychological and social transitions faced by AYA create unique susceptibilities to prevalent and formidable structural (e.g., transport costs), psychosocial (e.g., the desire to fit in with peers, stigma) and clinic-based (e.g., unfriendly providers, long waiting times) barriers to engagement in public health HIV treatment settings. The variability in the intensity and the nature of barriers, however, poses a critical challenge: if barriers are highly variable, then no individual interventions are needed by all, while they also fail to help all in need. Adaptive strategies represent a novel approach to such problems with no “silver-bullet” solutions, and which we hypothesize have particular relevance for engagement of AYA in HIV treatment. Adaptive strategies typically begin with a less intensive intervention, and then escalate to a more intensive intervention only in those not doing well. Maintaining lower-intensity interventions in those doing well conserves resources in the substantial fraction of AYA who do not need additional services, thereby enabling more intensive support for those in need. While sequential multiple assignment randomized trials (SMARTs), which are used to compare different sequences of interventions, have been used to study mental illness, cancer therapy and HIV treatment, this proposal is the first to apply a SMART to address engagement of AYA in HIV treatment in Africa. Within this design, we will use developmentally appropriate interventions with high potential for effectiveness that will be tailored by AYA pre-implementation. Specifically, we will randomize 880 AYA with HIV in Kenya to either (1) youth-centered education & counseling (standard of care) vs. (2) addition of a SMS and peer electronic navigator who provides support, information and counseling via phone. Those with a lapse in engagement will be re-randomized a second time to one of three higher-intensity re- engagement interventions: (1) standard of care outreach and intensified counseling, (2) conditional cash transfers and (3) in-person peer navigation. The primary outcome will be a combination of visit adherence and viral load suppression. This study will quantify the relative effectiveness (and cost effectiveness) of several strategies composed of promising individual interventions. We will assess provider and patient experiences and satisfaction with the interventions using mixed methods. This innovative study will offer relevant evidence for public health programming to end the AIDS epidemic for AYA with HIV.