Reaching the hardest of the hard-to-reach

 联合国艾滋病规划署制定了一个雄心勃勃的目标，到2020年达到90 -90-90，以帮助结束艾滋病的流行，其中90%的艾滋病毒感染者将知道他们的状况，90%的人知道他们的状况将接受联合抗逆转录病毒治疗（cART），90%的治疗将实现病毒学抑制。然而，为了实现这一愿景，需要在所有人群中实现90-90-90，特别是那些最难接触到的人群，如中低收入国家的注射毒品者。低收入国家的艾滋病毒感染者是艾滋病毒流行病增长最快的国家之一，这至少可归因于两个因素：（1）获得艾滋病毒预防服务的机会不足，包括艾滋病毒咨询和检测（HCT）;因此，（2）与护理、开始抗逆转录病毒治疗和病毒治疗的联系程度较低。 镇压虽然病毒抑制是最终目标，但有几个步骤可以导致病毒抑制-前两个步骤可能是最具挑战性的步骤是识别不知道自己状态的感染PWID并将其与护理联系起来。有几种策略专注于提高护理保留率和正在评估的病毒抑制，但很少有试验正在进行中，以确定不知情和脱离护理的个人，并将他们与护理联系起来，特别是在中低收入国家的PWID中。除了艾滋病毒，PWID还承担着不成比例的高负担，丙型肝炎病毒感染的知识水平和护理连续性远远低于对艾滋病毒的观察。因此，本申请的重点是制定和评估两种战略的成本效益，以确定艾滋病毒感染者和不从事护理在社区和他们的护理中心。战略1，基于时间的响应者驱动抽样（tRDS），专门侧重于网络连接，以确定社区中的感染者，提供艾滋病毒/丙型肝炎病毒检测，并将感染者与护理中心联系起来。战略2，响应者驱动的抽样加上有针对性的实地艾滋病毒检测（RDS+），利用网络连接和空间有针对性的实地检测相结合，以确定感染者，并将他们与护理联系起来。这两种策略将使用 在艾滋病毒/艾滋病流行的不同阶段，在六个印度城市进行的群集随机试验方法（例如，历史与新兴）和不同的地理大小（小城市与大城市）。将在两种策略之间进行比较的主要终点将是与护理相关的每个HIV病毒血症（HIV RNA>1000拷贝/ml）个体的成本。次要结果包括每个HIV感染者（以前不知道状态）个体的成本和每个HCV感染者（以前不知道状态）个体的成本。此应用程序的另一个目标是微调这两种策略，以最大限度地提高每种方法的成本效益。这些干预措施如果具有成本效益，可以在其他高收入、中等收入和低收入环境中复制，以确定社区中的艾滋病毒/丙型肝炎病毒感染者，并将其与护理联系起来。

 DESCRIPTION (provided by applicant): UNAIDS has set an ambitious target of 90-90-90 by 2020 to help end the AIDS epidemic wherein 90% of all HIV-infected people will know their status, 90% of those aware of their status will receive combination antiretroviral therapy (cART) and 90% of those on therapy will achieve virologic suppression. However, for this vision to be realized, 90-90-90 needs to be achieved in all populations especially those that are hardest to reach such as people who inject drugs (PWID) in low- and middle-income countries (LMICs). PWID in LMICs account for some of the fastest growing HIV epidemics that can be attributed to at least two factors: (1) inadequate access to HIV prevention services including HIV counseling and testing (HCT); and consequently, (2) low levels of linkage to care, initiation of ART and viral suppression. While viral suppression is the ultimate goal, there are several steps that lead to viral suppression - the first two steps and probably the most challenging steps are identifying infected PWID who are unaware of their status and linking them to care. There are several strategies focused on improving rates of retention in care and viral suppression being evaluated, but there are few trials underway to identify unaware and out-of-care individuals and link them to care particularly among PWID in LMICs. Beyond HIV, PWID also bear a disproportionately high burden of HCV infection with poor levels of knowledge and a care continuum far worse than what has been observed for HIV. Accordingly, this application is focused on developing and evaluating the cost-effectiveness of two strategies to identify PWID who are HIV-infected and not engaged in care in the community and link them to care centers. Strategy 1, time-based respondent-driven sampling (tRDS), focuses exclusively on network connections to identify infected individuals in the community, provide HIV/HCV testing and link infected persons to care centers. Strategy 2, respondent-driven sampling plus targeted field-based HIV testing (RDS+), utilizes a combination of network connections and spatially targeted field-based testing to identify infected individuals and link them to care. These two strategies will be evaluated using a cluster randomized trial approach across six Indian cities at varying stages of the HIV/PWID epidemic (e.g., historical vs. emerging) and differing geographic sizes (small cites vs. large cities). The primary endpoint of interest that will be compared across the two strategies will be the cost per HIV viremic (HIV RNA>1000 copies/ml) individual linked to care. Secondary outcomes include the cost per HIV-infected (previously unaware of status) individual identified and the cost per HCV-infected (previously unaware of status) individual identified. An additional objective of this application is to fine-tune these two strategies to maximize the cost-effectiveness of each approach. These interventions if cost-effective could be replicated in other high-, middle- and low-income settings to identify out-of-care HIV/HCV infected PWID in the community and link them to care.