Innovations in Implementing Decentralized HIV Services in Peru

尽管秘鲁在艾滋病毒感染者（PWH）的诊断和抗逆转录病毒治疗（ART）方面取得了成功， 艾滋病毒流行病集中在主要高危人群的低收入中等收入国家， 继续护理（RIC），导致病毒抑制水平低（43%）和艾滋病毒发病率增加。艾滋病毒护理 在秘鲁，目前主要集中在大型二级保健中心。根据世卫组织的建议 分散医疗保健，这是一种以证据为基础的做法， 建议在2019年将艾滋病毒服务下放到初级卫生中心（PHCs）。我们建议在 利马市4个最大的地区，管理着37%的PWH护理。目前，利马不到15%的公共卫生机构接受 在初级保健中心的护理，支持需要更有效地实施分散的服务。使用RE- AIM实施框架，我们建议通过结合NIATx，一个证据， 知情的实施战略，包括一系列实施工具，以扩大循证做法， ECHO项目，这是一项以证据为依据的远程教育战略，旨在提高初级保健的临床技能 提供者能够胜任地提供专业（即，艾滋病毒）服务。我们将首先使用德尔菲方法建立 使用中心（SHC）和辐射（PHC）模型安全分散PWH的指南，并建立最小的 安全地将患者留在初级保健中心所需的质量健康指标数量。这些指导方针可以是 用于创建可用于支持临床实践中指南一致性的临床检查表。我们将 然后对障碍和促进者进行快速、多层次（患者、临床医生、医疗保健系统）评估 分散艾滋病毒护理，这将在四个中心辐射区域中的每一个之前进行评估， 采用NIATx和ECHO在阶梯楔形设计中随机分配24个月。主 成效结果将是威尔斯亲王医院在初级保健中心接受爱滋病护理的比例改变。次要结局 包括RIC和VS以及对死亡率探索性分析。主要实施成果是 对在诊所管理威尔斯亲王医院的信心。在新的初级保健中心开展协作、工作场所气氛和采用艾滋病毒护理 将在每个中心和辐射内测量站点。在每个区域的新初级保健中心采用艾滋病毒护理， 评估。由于卫生部的目标是将艾滋病毒护理分散到城市、低/中等收入地区， 艾滋病毒集中在RIC和VS水平较低的关键人群中。创新是高度应有的 将NIATx和ECHO结合在南美城市环境中，并将其用于成瘾治疗之外。 可行性很高，因为团队成员之间的长期关系以及强大的 卫生部的承诺。该团队带来了艾滋病毒护理（桑切斯，阿尔蒂斯），公共卫生 （Konda，Altice），实施科学（Altice，Madden，Konda）和服务集成（Altice，Madden）。公共 健康效益高，不仅在系统方面，临床医生和患者层面的好处，通过实施 这不仅是秘鲁分散式护理的一个范例，而且也是其他城市、低/中等收入环境的一个模板。

Despite successes in diagnosing and initiating antiretroviral therapy (ART) in people with HIV (PWH) in Peru, a LMIC with an HIV epidemic concentrated in key at-risk populations, the implementation gap is highest for retention in care (RIC), resulting in low levels of viral suppression (43%) and increasing HIV incidence. HIV care in Peru is currently concentrated in large secondary health centers (SHCs). Based on WHO recommendations to decentralize healthcare, an evidence-based practice that increases RIC, the Peruvian Ministry of Health recommended in 2019 to decentralize HIV services to primary health centers (PHCs). We propose to work in the 4 largest regions in urban Lima that manages 37% of all PWH in care. Currently, <15% of PWH in Lima receive care in PHCs, supporting the need for more effective implementation of decentralized services. Using the RE- AIM implementation framework, we propose to accelerate decentralization by combining NIATx, an evidence- informed implementation strategy with a bundle of implementation tools to scale up evidence-based practices, with Project ECHO, an evidence-informed tele-educational strategy to increase clinical skills in primary care providers to competently provide specialty (i.e., HIV) services. We will first use the Delphi method to establish guidelines to safely decentralize PWH using a hub (SHC) and spoke (PHC) model and to establish the minimal number of quality health indicators that are needed to safely keep patients in PHCs. These guidelines can be used to create clinical checklists that can be used to support guideline concordance in clinical practice. We will then conduct a rapid, multi-level (patients, clinicians, healthcare system) assessment of barriers and facilitators to decentralizing HIV care, which will be assessed just before each of the four hub and spoke regions will be randomized to 24 months of implementation using NIATx and ECHO in a stepped wedge design. The primary effectiveness outcome will be proportionate change of PWH receiving HIV care in PHCs. Secondary outcomes include RIC and VS with exploratory analyses for mortality. The primary implementation outcomes are confidence in managing PWH at PHCs. Collaboration, workplace climate and adoption of HIV care at new PHC sites will be measured within each hub and spoke. Adoption of HIV care at new PHCs in each region will be assessed. Importance is high due to the MoH’s goal to decentralize HIV care in an urban, low/middle income setting where HIV is concentrated in key populations with low levels of RIC and VS levels. Innovation is high due to combining NIATx and ECHO in an urban South American context and using them beyond addiction treatment. Feasibility is high due to the longstanding relationships between team members alongside the strong commitment by the Ministry of Health. The team brings expertise in HIV care (Sanchez, Altice), Public Health (Konda, Altice), implementation science (Altice, Madden, Konda) and service integration (Altice, Madden). Public Health benefit is high not only in terms of systems-, clinician- and patient-level benefits through implementing decentralized care in Peru, but also serves as a template for other urban, low/middle income settings.