Hybrid implementation-effectiveness study to optimize HIV testing and PrEP in a southern jail (HOTSPOT)

项目摘要 2017年，美国超过一半的新艾滋病毒感染发生在48个高发县和农村州 这些区域被称为艾滋病毒“热点”，表明需要加强这些区域的艾滋病毒预防工作。暴露前 预防措施（PrEP）可以将新发艾滋病毒感染减少99%，但在南部的热点地区，PrEP的使用有限 艾滋病发病率最高的地方。刑事司法系统是让人们参与PrEP的主要场所， 许多在监狱中度过的人都有感染艾滋病毒的风险因素。在监狱中实施PrEP 特别是在医疗服务不足的黑人和拉丁裔人口比例过高的地方， 公共卫生的影响，因为快速周转回到社区。因为事实上南方的监狱 由于资源限制和相互竞争的优先事项，迫切需要实施战略 PrEP在这种情况下。我们的中心假设是，严格制定的PrEP实施策略可以 改善南部监狱释放人员与社区PrEP护理的联系。的目的 建议是制定，实施和评估达拉斯的多成分PrEP实施战略 县监狱，全国第八大监狱，位于艾滋病毒热点地区。我们将利用我们强大的 与监狱、公共卫生部门和社区的利益相关者建立伙伴关系， 建立了EPIS（勘探、准备、实施、维持）框架。执行 该战略将包括适合当地情况的、基于证据的工具，用于确定PrEP的候选人， 在关于PrEP的共同决策中，并在社区重返时将他们引导到PrEP护理中。我们将 使用第3类有效性-实施混合研究严格评估我们的实施策略， 其在收集临床结果的同时优先考虑实施结果。我们的具体目标是：1） 评估监狱中PrEP评估的促进者和障碍，以及监狱释放时PrEP的联系; 2） 达拉斯县监狱的多成分PrEP实施战略;以及3）实施和评估 PrEP实施战略。我们将使用混合方法来评估实施过程（可行性， 可接受性，渗透和维持）和临床结果的PrEP评价和联系，以及 中断的时间序列，以衡量艾滋病毒/性传播感染检测和诊断的变化。我们的研究团队包括专家 在艾滋病毒，PrEP，实施科学，定性研究和监禁人口的临床护理。这 该项目在影响艾滋病毒热点地区高度受影响人群的艾滋病毒发病率方面具有重要意义。 这项工作在利用实施科学来改善被监禁人群的PrEP方面具有创新性， 直接响应NOT-MH-20-024，“实施科学，以推进美国艾滋病毒预防 治疗目标”。我们的战略是可扩展的，在传播顾问的指导下， 作为其他刑事司法环境中未来公共卫生举措的典范，指导患者的PrEP- 以最有可能受益的人为中心，以最大限度地提高对艾滋病毒发病率的影响。

PROJECT SUMMARY Over half of all new HIV infections in the US in 2017 occurred in 48 high-incidence counties and rural states known as HIV “hotspots”, indicating a need to intensify HIV prevention efforts in these regions. Preexposure prophylaxis (PrEP) can reduce new HIV infections by 99%, but PrEP use is limited in hotspots in the South where HIV incidence is highest. The criminal justice system is a prime location to engage persons in PrEP, as many people who pass through jails and prisons have risk factors for acquiring HIV. Implementing PrEP in jails in particular, where medically underserved Black and Latinx populations are over-represented, can have a high public health impact given rapid turnover back to the community. Because virtually no jails in the South offer PrEP due to resource constraints and competing priorities, there is a critical need for strategies to implement PrEP in this setting. Our central hypothesis is that a rigorously-developed PrEP implementation strategy can improve linkage to community PrEP care for persons released from southern jails. The objective of this proposal is to develop, implement and evaluate a multicomponent PrEP implementation strategy for the Dallas County Jail, the 8th largest jail in the nation and located in an HIV hotspot. We will leverage our robust partnerships with stakeholders in the jail, public health department, and community as we follow a well- established EPIS (exploration, preparation, implementation, sustainment) framework. The implementation strategy will include locally-adapted, evidence-based tools for identifying candidates for PrEP, engaging them in shared decision-making about PrEP, and navigating them to PrEP care at community reentry. We will rigorously evaluate our implementation strategy using a type 3 effectiveness-implementation hybrid study, which prioritizes implementation outcomes while also collecting clinical outcomes. Our specific aims are to: 1) Assess facilitators and barriers to PrEP evaluations in jail and linkage to PrEP at jail release; 2) Refine a multicomponent PrEP implementation strategy for the Dallas County Jail; and 3) Implement and evaluate the PrEP implementation strategy. We will use mixed-methods to evaluate implementation processes (feasibility, acceptability, penetration and sustainment) and clinical outcomes for PrEP evaluations and linkage, and an interrupted time series to measure changes in HIV/STI testing and diagnoses. Our study team includes experts in HIV, PrEP, implementation science, qualitative research, and clinical care for incarcerated populations. This project is significant in its potential to impact HIV incidence in a highly affected population in an HIV hotspot. The work is innovative in using implementation science to improve PrEP for incarcerated populations and is directly responsive to NOT-MH-20-024, “Implementation Science to Advance the United States HIV Prevention and Treatment Goals.” Our strategy is scalable and with guidance from Dissemination Consultants, can serve as a model for future public health initiatives in other criminal justice settings, directing PrEP in a patient- centered manner to those most likely to benefit in order to maximize impact on HIV incidence.