Linking Russian Narcology & HIV Care to Enhance Treatment, Retention, & Outcomes

描述（由申请人提供）：俄罗斯和东欧是世界上艾滋病毒流行增长最快的国家之一，其传播风险主要来自注射吸毒。俄罗斯和该区域其他国家已在已建立的成瘾治疗系统（即麻醉科医院）内实施了常规艾滋病毒检测。然而，麻醉科系统在很大程度上独立于其他医疗保健系统，并没有采取将艾滋病毒感染患者与艾滋病毒护理联系起来的策略。这是一个错失的机会：在接受麻醉科治疗的俄罗斯注射吸毒者（IDUs）中，高达45%的人感染了艾滋病毒，但只有20%的感染者在接受治疗。为了留住那些接受艾滋病毒治疗的人，俄罗斯艾滋病治疗系统已经开始使用病例管理人员；然而，这些努力没有考虑到注射吸毒者所面临的独特挑战，这些挑战可能会影响留用，也没有解决开始治疗的问题。本研究的目的是“连接传染病和麻醉科护理（LINC）”，旨在改善东欧“寻找、测试、治疗和保留”范式的治疗和保留维度。我们将在俄罗斯实施和评估一项行为和结构干预措施，旨在支持和激励感染艾滋病毒的麻醉品海洛因依赖患者（即注射吸毒者）参与（即发起和保留）艾滋病毒医疗护理，并最终改善其艾滋病毒治疗结果。LINC是一种临床模式，旨在协调麻醉学和艾滋病毒护理系统，使用有助于参与医疗护理的元素：艾滋病毒病例管理和护士家访。该研究的核心假设是，通过以下途径进行干预，包括麻醉科和艾滋病毒系统之间的协调：a)由同行提供的艾滋病毒病例管理，以帮助激励和减少艾滋病毒护理的障碍；b)加强成瘾护士的门诊麻醉科治疗；c)这些提供者之间的沟通，将导致参与艾滋病毒护理。实施研究认识到，有效的干预措施可能无法在不同的背景和系统之间成功转化。因此，我们将评估推动俄罗斯以及另一个前苏联国家乌克兰开展艾滋病毒护理的组织和业务问题。该项目将由一个在俄罗斯处理艾滋病毒、药物使用和临床干预方面经验丰富的国际研究小组承担。本提案的具体目的是评估LINC干预与标准护理相比在4个不同结果上的有效性：1)在入组后6个月内开始艾滋病毒护理（bbb10次艾滋病毒医疗护理）；2)在12个月内继续接受艾滋病毒护理（连续2个6个月期间接受1次医疗护理）；3)适当的艾滋病毒治疗（如果CD4细胞计数<350，或如果12个月内CD4细胞计数低于350，进行第二次CD4计数）；4)改善艾滋病毒健康结果（12个月时CD4细胞计数）。最后的具体目标是确定影响LINC干预在俄罗斯和另一个东欧国家的采用和可持续性的背景因素。如果LINC能够有效地嵌入东欧医疗系统，那么它就有可能在世界该地区广泛实施，并对注射吸毒者中的艾滋病毒流行产生重大影响。

DESCRIPTION (provided by applicant): Russia and Eastern Europe have one of the fastest growing HIV epidemics in the world, with transmission risk primarily from injection drug use. Russia and other countries in the region have implemented routine HIV testing within established addiction treatment systems (i.e. narcology hospitals). The narcology system, however, works largely independent of other medical care systems and has not adopted strategies to link HIV- infected patients to HIV care. This is a missed opportunity: up to 45% of Russian injection drug users (IDUs) in narcology treatment have HIV, yet as few as 20% of those infected are in care. To retain those in HIV care the Russian AIDS treatment system has begun using case managers; however these efforts do not consider the unique challenges faced by IDUs that can impact retention nor do they address care initiation. The objective of this study "Linking Infectious and Narcology Care (LINC)" is to improve upon the treat and retain dimensions of the "seek, test, treat, and retain" paradigm in Eastern Europe. We will implement and assess a behavioral and structural intervention in Russia designed to support and motivate HIV-infected narcology heroin dependent patients (i.e., IDUs) to engage (i.e., initiate and retain) in HIV medical care and ultimately improve their HIV outcomes. LINC is a clinical model designed to coordinate narcology and HIV systems of care using elements shown to facilitate engagement in medical care: HIV case management and nurse home visits. The central hypothesis is that an intervention that involves coordination between the narcology and HIV systems via a) HIV case management delivered by a peer to help motivate and reduce barriers to HIV care, b) enhanced outpatient narcology treatment by addiction nurses and c) communication between these providers will lead to engagement in HIV care. Implementation research recognizes that effective interventions may not translate successfully across different contexts and systems. Hence, we will assess the organizational and operational issues that drive engagement in HIV care in Russia as well as a comparable setting in another former Soviet Union country, Ukraine. The project will be undertaken by an international research team experienced in addressing HIV, substance use, and clinical interventions in Russia. This proposal's Specific Aims are to assess the effectiveness of the LINC intervention compared to standard of care on 4 distinct outcomes:1) initiation of HIV care (> 1 visit to HIV medical care) within 6 months of enrollment; 2) retention in HIV care (> 1 visit to medical care in 2 consecutive 6 month periods) within 12 months; 3) appropriate HIV care (prescribed ART if CD4 cell count is <350 or having a second CD4 count if CD4 >350 within 12 months; and 4) improved HIV health outcomes (CD4 cell count at 12 months). The final Specific Aim is to establish the contextual factors that influence adoption and sustainability of the LINC intervention in Russia and another Eastern European country. If LINC can embed effectively within Eastern European medical systems, then it has the potential to be widely implemented in this region of the world and have a major impact on the HIV epidemic among IDUs.