Training CHWs to Support Re-Engagement in TB/HIV Care in the Context of Depression and Substance Use

项目摘要。南非（SA）是艾滋病毒/艾滋病感染者人数最多的国家（PLWH; 7.7 它是全球结核病发病率最高的国家之一。护理参与度差 导致南非艾滋病毒和结核病发病率和死亡率。社区卫生工作者是第一线 工作人员在重新吸引失去随访（LTFU）的患者参与SA的TB/HIV护理方面发挥着核心作用。 尽管现有的CHW项目专注于重新吸引LTFU患者，抑郁症患者， 危险的酒精使用或其他物质使用（SU）特别容易受到结核病/艾滋病的不良影响 关心并有更大的可能性成为LTFU。此外，我们的试验数据显示，CHW具有高水平的 对抑郁症患者的耻辱，危险的酒精使用和其他SU，这可能进一步破坏 在这一脆弱人群中开展结核病/艾滋病毒护理。减少CHW对抑郁症和SU的污名 为社区卫生工作者提供技能，使他们重新参与护理，这可能是一个独特的机会， 结核病/艾滋病毒护理级联并改善结核病/艾滋病毒结果。在“联系”和“消除歧视”框架以及 情境信息动机行为技能护理启动和维护模型（sIMB-CIM），这 建议建立在我们以前的工作，通过开发和调整一种新的CHW培训计划，以减少CHW 对抑郁症和SU的污名，并评估理论驱动的实施科学成果， 患者重新参与结核病/艾滋病护理。我们正在利用一个强大的，现有的基础设施的CHW做家庭 对结核病/艾滋病毒合并感染的长期未治愈患者进行访问，从而促进拟议的 模型我们建议（1）确定实施CHW导向培训的多层次障碍和促进因素， 减少对抑郁症和药物使用患者的羞辱，促进重新参与结核病/艾滋病毒护理， 对社区卫生工作者、提供者和结核病/艾滋病毒和抑郁症患者进行半结构化访谈，和/或 SU（n=30）和CHW对TB/HIV患者进行家访（n=10）的观察评估， 是LTFU。利用这些反馈，我们将（2）调整拟议的CHW培训和实施策略 并从五名社区卫生工作者及其病人（各四名病人; n=20）。然后，我们将（3）评估适应CHW培训的实施情况和初步效果 计划减少CHW对抑郁症和SU的污名，并促进重新参与结核病/艾滋病毒护理， 一项2型，在普罗克特实施模型指导下的混合有效性-实施研究。我们提出了一个 阶梯楔形设计，6个诊所（每个诊所10个CHW），以评价：1）可行性、可接受性和保真度 CHW培训（初级;实施）; 2）结核/艾滋病毒共同感染者对抑郁症和SU的CHW耻辱感， 感染患者（主要;有效性）; 3）患者重新参与结核病/艾滋病毒护理超过六个月（次要）。 该提案响应了FOA和NIMH的优先事项，作为一项实施科学研究，以优化 CHW项目的覆盖范围和影响，以减少抑郁症和SU患者获得结核病/艾滋病护理的障碍。

Project Summary. South Africa (SA) is home to the largest number of people living HIV/AIDS (PLWH; 7.7 million) and one of the highest incidence rates of tuberculosis (TB) globally. Poor engagement in care contributes to HIV and TB morbidity and mortality in SA. Community health workers (CHWs) are frontline workers who play a central role in re-engaging patients who are lost to follow-up (LTFU) in TB/HIV care in SA. Despite existing CHW programs focused on re-engaging patients who are LTFU, people with depression, hazardous alcohol use, or other substance use (SU) are particularly susceptible to poor engagement in TB/HIV care and have a greater likelihood of being LTFU. Further, our pilot data shows that CHWs have high levels of stigma towards patients with depression, hazardous alcohol use, and other SU, which can further undermine engagement in TB/HIV care in this vulnerable population. Reducing CHW stigma towards depression and SU and providing CHWs skills to re-engage this population in care may be a unique opportunity to strengthen the TB/HIV care cascades and improve TB/HIV outcomes. Guided by the Link and Phelan stigma framework and the Situated Information Motivation Behavioral Skills Model of Care Initiation and Maintenance (sIMB-CIM), this proposal builds upon our prior work by developing and adapting a novel CHW training program to reduce CHW stigma towards depression and SU, and evaluating theoretically-driven implementation science outcomes and patient re-engagement in TB/HIV care. We are leveraging a robust, existing infrastructure of CHWs doing home visits with patients with TB/HIV co-infection who are LTFU, thus promoting the sustainability of the proposed model. We propose to (1) identify multi-level barriers and facilitators to implementing a CHW-oriented training to reduce stigma towards patients with depression and substance use to promote re-engagement in TB/HIV care by conducting semi-structured interviews with CHWs, providers, and patients with TB/HIV and depression and/or SU (n=30) and observational assessments of CHWs making home visits (n=10) to individuals with TB/HIV who were LTFU. Using this feedback, we will (2) adapt the proposed CHW training and implementation strategy and obtain feedback on the feasibility and acceptability from five CHWs and their patients (four patients each; n=20). We will then (3) evaluate the implementation and preliminary effectiveness of the adapted CHW training program to reduce CHW stigma towards depression and SU and promote re-engagement in TB/HIV care using a Type 2, hybrid effectiveness-implementation study guided by Proctor’s implementation model. We propose a stepped wedge design with six clinics (10 CHWs in each), to evaluate: 1) Feasibility, acceptability and fidelity of the CHW training (primary; implementation); 2) CHW stigma towards depression and SU among TB/HIV co- infected patients (primary; effectiveness); 3) Patient re-engagement in TB/HIV care over six months (secondary). This proposal is responsive to the FOA and NIMH priorities as an implementation science study to optimize the reach and impact of CHW programs to reduce barriers to TB/HIV care for patients with depression and SU.