IMPLEMENTING ASSISTED PARTNER SERVICES TO HIV TEST AND TREAT MEN IN WESTERN KENYA

具体目标 增加艾滋病毒携带者知道自己血清状态的比例是控制艾滋病毒的关键 撒哈拉以南非洲的流行病。在肯尼亚，大约有160万人携带艾滋病毒，据估计 53%的感染艾滋病毒的肯尼亚人不知道自己的状况1。尽管接受艾滋病毒检测的成年人数量 2008年至2010年，肯尼亚的检测率增长了6倍多，自2010年以来一直保持稳定， 正在发现测试中的重大差距。虽然这并不令人惊讶，关键人群的成员 通常无法达到标准测试策略，令人惊讶的是，25-50岁的男性明显较少 可能会检测并链接到护理是否感染。这项提议将重点放在后一种人群上。2014年，仅有45%的 男性报告说，他们在去年进行了检测，而女性的这一比例超过53%。这是必不可少的 如果肯尼亚要达到联合国艾滋病规划署的第一个“90名”，就必须采用缩小现有差距的新测试战略 90-90-90到20203。具体地说，如果肯尼亚要从大约一半的艾滋病毒携带者(PLWH)知道 要使他们的比例上升到90%，需要在艾滋病毒检测男子和将他们与护理联系起来方面取得更大进展。在那里的时候 一旦与护理挂钩，将是额外的挑战，级联中的第一步是至关重要的，一步是 所有其他人都依赖于此才能取得成功。 去年，我们成功完成了协助合作伙伴服务的整群随机临床试验(RCT (APS)促进对艾滋病毒感染高危人群的检测，他们中的许多人并不知道他们 4-6 APS干预包括通知性伴侣的个人 被诊断出感染了艾滋病毒，并提供检测和联系护理。作为一项公共卫生战略，防止 通过检测和治疗性伴侣感染HIV的指标性病例，APS广泛传播 在美国和欧洲被采用，但尚未在撒哈拉以南非洲地区推广。我们的审判是在中环进行的 和肯尼亚西部，我们在那里雇佣和培训研究人员，在18个不同的设施提供APS，以及 确定APS对于艾滋病毒病例的发现和与这些护理的联系是安全和高效的 情况。4，5尽管这项试验显示了疗效，世界卫生组织在 2016年11月推广合作伙伴服务7，大规模推出APS将是一项挑战。An的有效性 整合到现有卫生系统中的干预措施通常低于#年确定的疗效 由于卫生系统薄弱和干预措施提供方面的差异而进行的对照试验。实施 科学倡导更多的现实生活研究，利用现有系统提供大规模和 这就是这个项目的目标。我们建议在荷马湾研究APS的成效和可行性。 和基苏木，这两个肯尼亚艾滋病毒感染率最高的县，并产生证据表明 将确保在整个区域迅速和可持续地执行。我们将实现这些目标 通过以下具体目标： 目标1.评估协助伙伴服务(APS)在融入现有肯尼亚时的效力 卫生部(MOH)卫生倡议APHIAplus，通过以下方式加强肯尼亚西部的艾滋病毒服务 确定APS提高了男性的艾滋病毒检测率，确定了男性中新的艾滋病毒感染，以及 将这些男子与艾滋病毒护理和治疗联系起来，以诊断后12个月的病毒抑制来衡量。 利用完成的区域风险评估，我们处于独特的地位，可以评估以下结果： 1)对从未做过检测的男性进行艾滋病毒检测 2)新的男性艾滋病毒感染者和艾滋病毒不和谐的夫妇 3)将APS确定的艾滋病毒感染者的护理联系缩短6周，并在6个月前开始抗逆转录病毒治疗 4)这些感染艾滋病毒的男性在12个月时血浆艾滋病毒RNA水平受到抑制 目标2.确定实施综合APS服务的保真度、可行性、成本和成本效益 通过现有的艾滋病毒服务，在感染艾滋病毒的少女和妇女中传播艾滋病毒。我们将生成证据来 告知APS的有效扩大和可持续性，重点是肯尼亚的资源和能力 政府和当地机构调整这一测试战略，以适应新的人口和成本限制。 具体地说，我们将评估以下内容： 1)与高度接受艾滋病毒检测、与护理和治疗挂钩的执行要素 2)影响APS干预保真度的卫生设施和个人因素 3)影响可行性的可接受性、需求和卫生系统要求 4)将APS纳入现有艾滋病毒检测服务期间和之后对健康结果的影响 5)将APS纳入现有艾滋病毒检测服务的成本和成本效益 影响：肯尼亚卫生部和国家艾滋病和性传播感染控制计划(NASCOP)已经确定 协助合作伙伴服务作为实现国家90-90-90目标的关键战略，最近举行了一次会议 确认他们致力于在艾滋病毒检测项目中扩大APS。拟议中的项目将架起 临床研究结果、日常实践和公共卫生之间的差距，并提供亟需的指导 关于如何在保持其效力和确保可持续性的同时整合这一战略。

Specific Aims Increasing the proportion of people living with HIV who know their serostatus is critical to containing the HIV epidemic in sub-Saharan Africa. In Kenya, approximately 1.6 million people are living with HIV and it is estimated that 53% of HIV-infected Kenyans are unaware of their status1. Although numbers of adults tested for HIV increased more than 6-fold between 2008 and 2010 in Kenya, testing rates have been stable since 2010 and significant gaps in testing are being identified. While it is not surprising that members of key populations are often not reached with standard testing strategies, it is surprising that 25-50 year old men are significantly less likely to test and link to care if infected. This proposal will focus on this latter demographic. In 2014 only 45% of men reported that they had tested in the last year compared to more than 53% of women 2, and it is essential that new testing strategies that narrow existing gaps be adopted if Kenya is to reach the first “90” in the UNAIDS 90-90-90 by 20203. Specifically, if Kenya is to move from about half of persons living with HIV (PLWH) knowing their status to 90%, greater progress needs to be made in HIV testing men and linking them to care. While there will be additional challenges once linked to care, the first step in the cascade is critically important, a step upon which all others are dependent for success. Last year we successfully completed a cluster randomized clinical trial (RCT) of assisted partner services (aPS) to promote testing of individuals at high risk for HIV infection, many of whom were unaware of their status and had not previously tested.4-6 The aPS intervention involves notifying sexual partners of individuals diagnosed with HIV and offering testing and linkage to care. As a public health strategy to prevent the transmission of HIV through testing and treating the sexual partners of infected index cases, aPS is widely adopted in the US and Europe but has not been scaled up in sub-Saharan Africa. Our trial took place in central and western Kenya where we employed and trained study staff to deliver aPS in 18 different facilities, and determined that aPS is safe and highly effective for HIV case finding and linkage to care under these conditions.4,5 Despite this trial showing efficacy and the World Health Organization releasing guidelines in November 2016 promoting partner services7, rolling out aPS at scale will be challenging. Effectiveness of an intervention when integrated into existing health systems is usually lower than the efficacy determined in controlled trials due to weaknesses in health systems and differences in intervention delivery. Implementation science advocates for more real life research that utilizes existing systems to deliver interventions at scale and this is what this project aims to do. We propose to study the effectiveness and feasibility of aPS in Homa Bay and Kisumu, two Kenyan counties with the highest HIV prevalence in the country, and generate evidence that will ensure rapid and sustainable implementation across the region. We will accomplish these objectives through the following Specific Aims: AIM 1. Evaluate effectiveness of assisted partner services (aPS) when integrated within an existing Kenya Ministry of Health (MOH) health initiative, APHIAplus, to strengthen HIV services in western Kenya by determining that aPS improves HIV testing rates among men, identifies new HIV infections among men, and links these men to HIV care and treatment, as measured by viral suppression 12 months after diagnosis. Leveraging the completed RCT, we are in a unique position to assess the following outcomes: 1)HIV testing among men who have never tested 2) New male HIV infections and HIV-discordant couples 3) Linkage to care by 6 weeks and initiation of ART by 6 months for HIV-infected men identified by aPS 4) Suppression of plasma HIV RNA levels at 12 months among these HIV-infected men AIM 2. Determine fidelity, feasibility, cost and cost-effectiveness of implementing integrated aPS services among HIV-infected adolescent girls and women through existing HIV services. We will generate evidence to inform effective scale-up and sustainability of aPS, focusing on the resources and capacity of the Kenyan government and local institutions to adapt this testing strategy to new populations and cost constraints. Specifically, we will evaluate the following: 1) Implementation elements associated with high uptake of HIV testing, linkage to care and treatment 2) Health facility and individual-level factors that influence fidelity to the aPS intervention 3) Acceptability, demand, and health system requirements influencing feasibility 4) Impact on health outcomes during and after integration of aPS into existing HIV testing services 5) Costs and cost-effectiveness of aPS when integrated into existing HIV testing services Impact: The Kenya Ministry of Health and National AIDS and STI Control Program (NASCOP) have identified assisted partner services as a key strategy for achieving national 90-90-90 goals and recently held a meeting affirming their commitment to scaling up aPS within HIV testing programs. The proposed project will bridge the gap between clinical research findings, everyday practice and public health, and provide much-needed guidance on how to integrate this strategy while retaining its efficacy and ensuring sustainability.