Systems analysis and improvement approach to optimize the pediatric HIV diagnosis and care cascade (SAIA-PEDS)

摘要 这一实施研究项目旨在调整和评估卫生系统干预措施 减少儿童HIV级联(检测、与护理的联系、治疗启动和病毒感染)的下降 抑制)。儿童艾滋病毒感染的发病率和死亡率很高；及时诊断，与护理挂钩，以及 治疗是至关重要的。然而，儿科艾滋病毒级联的所有步骤完成率很低，限制了潜力 为感染艾滋病毒的儿童提供健康福利。提供商发起的测试和咨询(PITC)和索引案例 检测(检测感染艾滋病毒的成年人的孩子)是潜在的高收益病例发现策略，但 使用可变覆盖率不一致地实施。虽然与关怀和艺术启蒙的及时联系是迫切的 对于儿童来说，在诊断后促进和记录联系的系统很弱，儿科治疗 水平落后于成年人。最后，病毒载量监测优于CD4检测，特别是对儿童来说，但 用于及时和一致的病毒载量检测和结果返回的系统薄弱。 儿童艾滋病毒级联类似于防止母婴传播的级联，既有复杂的人群，也有复杂的 系统。在防止母婴传播级联中有效减少下降的干预措施可能是有效的 在优化儿科艾滋病毒级联方面。在这项研究中，我们的目标是适应和测试系统分析和 改进方法(SAIA)干预，结合了经典的系统工程方法，包括 级联分析、过程映射和持续质量改进，并在 改善防止母婴传播梯级的流动。在目前的R34提案中，我们的目标是1)修改SAIA 对儿童艾滋病毒级联的干预(SAIA-PEDS干预)，2)试点和完善SAIA-PEDS 使用混合方法进行干预，以及3)准备未来分组所需的材料 确定SAIA-PEDS疗效和成本效益的随机试验。在这款R34飞行员和 未来R01的应用，我们的主要改进成果是a)采用儿科艾滋病毒检测，b)联系 对于艾滋病毒护理，c)抗逆转录病毒疗法的启动，以及d)病毒载量的监测和抑制。 该项目利用了内罗毕大学和华盛顿大学之间长达25年的合作 与肯尼亚国家艾滋病和性传播感染控制方案(NASCOP)的合作者以及伙伴关系。 学术界和政策制定者之间的这种独特的伙伴关系使严谨和有影响力的研究能够 解决与地方优先事项相一致的问题，为国家政策提供信息。

ABSTRACT This implementation research project aims to adapt and evaluate a health systems intervention designed to reduce drop-offs in the pediatric HIV cascade (testing, linkage to care, treatment initiation, and viral suppression). Pediatric HIV infection has high morbidity and mortality; prompt diagnosis, linkage to care, and treatment are critical. However, completion of all steps of the pediatric HIV cascade is low, limiting the potential health benefits for HIV-infected children. Provider initiated testing and counseling (PITC) and index-case testing (testing children of HIV-infected adults) are potentially high yield case-detection strategies but are inconsistently implemented with variable coverage. While timely linkage to care and ART initiation are urgent for children, systems to promote and document linkage following diagnosis are weak and pediatric treatment levels lag behind adults. Finally, viral load monitoring is superior to CD4 testing, particularly for children, but systems for prompt and consistent viral load testing and return of results are weak. The pediatric HIV cascade is similar to the PMTCT cascade, having both complex populations and complex systems. Interventions that have been effective at decreasing drop-off in the PMTCT cascade may be effective in optimizing the pediatric HIV cascade. In this study, we aim to adapt and test the Systems Analysis and Improvement Approach (SAIA) intervention which joins classical systems engineering methods including cascade analysis, process mapping, and continuous quality improvement, and which has been effective in improving flow through the PMTCT cascade. In the current R34 proposal, we aim to 1) adapt the SAIA intervention for the pediatric HIV cascade (SAIA-PEDS intervention), 2) pilot and refine the SAIA-PEDS intervention using a mixed-methods approach, and 3) prepare the materials required for a future cluster randomized trial to determine SAIA-PEDS effectiveness and cost-effectiveness. In both this R34 pilot and the future R01 application, our primary outcomes for improvement are a) uptake of pediatric HIV testing, b) linkage to HIV care, c) ART initiation, and d) viral load monitoring and suppression. This project leverages a >25 year collaboration between University of Nairobi and University of Washington collaborators as well as partnerships with the Kenyan National AIDS and STI Control Programme (NASCOP). This unique partnership between academia and policymakers allows rigorous and impactful research to address questions aligned with local priorities that inform national policy.