Implementation Research to Enhance Equity- Focused HIV Prevention in New York City

7.1.项目摘要/摘要--核心项目 有效实施艾滋病毒预防干预措施的根本挑战之一是 有资格获得并将从中受益最大的客户的参与。本核心项目的重点是 这个关键的实施问题：需要开发和测试新的实施战略，以增加 参与、吸收和维持经过验证的艾滋病毒预防干预措施，包括快速检测， 预科/PEP和IART。基于对研究文献和直接从社区收集的数据的回顾 纽约市卫生局(NYC HD)已确定，其EHE高优先级管辖区的成员 这一艾滋病毒预防实施问题的三个核心决定因素：(1)客户的预期和经验 污名和歧视限制了可接受性和接受度；(2)提供者的隐性和显性偏见限制和 传播；和(3)系统地强调孤立的服务和基于风险的资格限制获得和 可用性。为了应对这一问题，纽约市住房署选择了一种名为目标的实施战略 性健康方针，旨在：a)普及艾滋病毒预防对话并使之常态化 和干预措施；以及b)传播以客户为中心、肯定性别、不歧视、反对污名化的 以及性史和艾滋病毒预防对话的创伤信息方法。此核心项目使用 两阶段整群随机、阶梯式实施试验，以评估实施情况 由纽约市住房管理局资助的20家机构的战略。基于实施科学模型，我们将检查 三个级别的成果：a)执行成果(例如，艾滋病毒检测率、PrEP吸收率、直接联系 (B)服务成果(例如，公平分配艾滋病毒预防 对最优先人群的干预)；和c)患者结果(例如，对全市艾滋病毒发病率的影响， 参与护理和病毒抑制)。二次分析还将对假设的 程序逻辑模型中定义的机制(即，中介器)，包括提供者的维度 能力和病人的经验。将在制定目标方法时收集模型保真度数据 纽约市房屋署的实施战略，以及其在每个 个别机构。最后，将收集定性数据，以评估执行的障碍和促进者 在卫生部和机构两级为今后的适应和传播提供信息 实施战略。 7.2.项目摘要/摘要--协作项目 卫生保健提供方面最持久的挑战之一是质量。通常很容易确定是哪一种或 一个给定的机构或项目为客户提供了多少服务，但要想 确定这些服务的交付情况如何，或哪些方面的服务交付效果最好 对结果的影响。这个合作项目基于这样一个科学前提，即质量是可以定义的， 对卫生部门合同做法的重新设想进行了衡量和支持，并且 实施科学方法可以评估这一创新战略并确定其优势和 对于更广泛的传播来说，这是一个弱点。在这个协作项目中，我们解决了 通过：a)确定艾滋病毒预防服务质量的执行战略和 运作一种逻辑模型，通过该模型，更高质量的服务将解决已知的障碍和不平等 在社区、系统和客户一级；b)数据收集和质量改进及管理 (QIM)战略，侧重于将质量和质量指标作为艾滋病毒预防中基于激励的交付成果 合同；c)与各机构合作确定质量挑战的培训和技术支助系统 提供服务，并支持它们确定和颁布应对这些挑战的办法；以及d)a 协作研究设计，衡量以下各项的启动、采用和维护 实施策略，并应用编程逻辑模型来检查每个组件对 假设的决定因素、机制和结果。纽约市卫生局(NYC HD) 选择了基于质量的融资(QBF)模式来为其艾滋病毒预防合同提供资金(与 传统的按服务收费模式)作为一种实施战略，以减少在获取、使用 和艾滋病毒预防服务的成果，并公平地降低艾滋病毒发病率在纽约市最高的城市之一 优先人群。该协作项目有四个主要目标：(1)进行中断时间 系列(ITS)分析，以评估实施QBF模式的影响；(2)定性探讨影响因素 这可能解释了不同机构在成功实施QBF方面的差异；(3)确定 与纵向倍数QBF模型差异有效性显著相关的因素 回归分析；(4)测量模型的保真度，并在健康水平上监测QBF的实施 部门和资助机构。

7.1. PROJECT SUMMARY/ABSTRACT -- CORE Project One of the fundamental challenges to effective implementation of HIV prevention interventions is the engagement of clients who are eligible for and would benefit most from them. This Core Project is focused on this critical implementation problem: the need to develop and test novel implementation strategies that increase engagement, uptake, and sustainment of proven HIV prevention interventions, including rapid testing, PrEP/PEP, and iART. Based on a review of the research literature and data collected directly from community members in their EHE high priority jurisdictions, the New York City Health Department (NYC HD) has identified three core determinants of this HIV prevention implementation problem: (1) clients’ anticipated and experienced stigma and discrimination limit acceptability and uptake; (2) providers’ implicit and explicit bias limit offers and dissemination; and (3) systemic emphasis on siloed services and risk-based eligibility limits access and availability. In response to this problem, the NYC HD has chosen an implementation strategy called the GOALS Approach to Sexual Health, which is designed to: a) universalize and normalize HIV prevention conversations and interventions; and b) disseminate a client-centered, gender-affirming, non-discriminating, anti-stigmatizing and trauma-informed approach to sexual history and HIV prevention conversations. This Core Project uses a two-phase cluster-randomized, stepped-wedge implementation trial to evaluate adoption of the implementation strategy in 20 agencies funded by the NYC HD. Based on an implementation science model, we will examine outcomes at three levels: a) implementation outcomes (e.g., rates of HIV testing, PrEP uptake, immediate linkage of newly diagnosed patients to care); b) service outcomes (e.g., equitable distribution of HIV prevention interventions to highest priority populations); and c) patient outcomes (e.g., impact on city-wide HIV incidence, engagement in care, and viral suppression). Secondary analysis will also be conducted on hypothesized mechanisms (i.e., mediators) as defined in the program’s logic model, including dimensions of provider competence and patients’ experience. Model fidelity data will be collected on enactment of the GOALS Approach implementation strategy by the NYC HD, and its ability to successfully implement the strategy at each of the individual agencies. Finally, qualitative data will be collected to assess barriers and facilitators to implementation at both the health department and agency levels to inform future adaptation and dissemination of the implementation strategy. 7.2. PROJECT SUMMARY/ABSTRACT -- COLLABORATIVE Project One of the most persistent challenges in health care provision is quality. It is often easy to determine which or how many services are being provided to clients by a given agency or program, but it is far more difficult to determine how well these services are being delivered, or what aspects of service delivery have the greatest impact on outcomes. This Collaborative Project is based on the scientific premise that quality can be defined, measured, and supported by a re-envisioning of health department contract practices, and that an implementation science approach can evaluate this innovative strategy and identify its strengths and weaknesses for broader dissemination. In this Collaborative Project, we address the persistent problem of quality through: a) an implementation strategy that defines quality in HIV prevention services and operationalizes a logic model through which higher quality services will address known barriers and inequities at the community-, system-, and client-levels; b) a data collection and quality improvement and management (QIM) strategy that focuses on quality and quality metrics as incentive-based deliverables in HIV prevention contracts; c) a training and technical support system that works with agencies to identify challenges to quality service provision and supports them to identify and enact approaches to address those challenges; and d) a collaborative research design that measures initiation, adoption, and sustainment of each component of this implementation strategy, and applies a programmatic logic model to examine the impact of each component on hypothesized determinants, mechanisms, and outcomes. The New York City Health Department (NYC HD) has selected a Quality-Based Financing (QBF) model to fund its HIV prevention contracts (in contrast to a traditional fee-for-service model) as an implementation strategy to decrease inequities in access, utilization, and outcomes for HIV prevention services, and to equitably decrease the HIV incidence among NYC’s highest priority populations. This Collaborative Project has four main objectives: (1) conduct an interrupted time series (ITS) analysis to evaluate the impact of implementing the QBF model; (2) qualitatively explore factors that potentially explain differences in successful implementation of QBF across different agencies; (3) Identify factors significantly associated with differential effectiveness of the QBF model using longitudinal multiple regression analysis; and (4) Measure model fidelity and monitor QBF implementation at the level of the health department and funded agencies.