Integrating Addiction and Infectious Diseases Services into Primary Care in Rural Settings

摘要 美国结束艾滋病毒流行的战略呼吁扩大对新感染的预防， 应对艾滋病毒爆发。这些疫情经常发生在县和州， 艾滋病毒的负担，但与阿片类药物使用障碍（OUD）的共同发生和共同流行的性质， 增加了对新的艾滋病毒（和HCV）疫情高度敏感的县和地区。西弗吉尼亚州（WV） 这种主要是农村地区的爆炸性阿片类药物流行病表现为人均过量率最高， 以及最近爆发艾滋病毒疫情的5个县。在临床环境中预防和控制艾滋病毒的循证实践 包括治疗OUD（MOUD）、ART预防治疗（TasP）和暴露前预防 （PrEP）。然而，这些药物的治疗首先需要筛查和评估，然后是 治疗（SET）。采用科学、技术和工程进程，如果适当， 方便。大多数农村地区提供艾滋病毒/丙型肝炎病毒/OUD专业服务的设备不足-这是一个重要的挑战， 来自印第安纳州斯科特县的教训。然而，农村地区主要依赖初级保健诊所（PCC）， 提供这些服务的专业知识。为了克服艾滋病毒/丙型肝炎病毒/OUD的SET过程的采用障碍， 有效的促进是关键，NIATx治疗改善策略结合正在进行的临床 ECHO项目提供的教育和支持有可能增加采用整合专业 将艾滋病毒/丙型肝炎病毒/OUD服务纳入方案合作中心。使用i-PARiHS实施框架，我们建议解决这个问题 通过首先确定采用和扩大艾滋病毒/丙肝病毒/OUD服务的障碍，那我们就 通过在电子健康记录（EHR）中整合临床提示来筛选 HIV/HCV/OUD，然后是治疗提示。治疗将得到ECHO项目的支持， 持续的临床支持，以激发对治疗的信心，以及嵌入在 电子健康记录作为质量绩效改进活动的一部分，以持续将艾滋病毒/丙肝病毒/OUD服务纳入 PCC。然后，我们建议进行一个阶梯式楔形，第3类，混合实施试验，以评估程度 临床医生采用并维持SET流程，以在20个PCC中整合护理， 使用NIATx更改项目。SET过程的采用是主要成果和综合质量 健康指标（QHI）结合了初级保健、HIV、HCV和MOUD的QHI，是次要疗效 结果。组织和临床医生因素，沿着参与促进活动（NIATx，ECHO 会议）将探讨作为潜在的调解人和主持人。对于西弗吉尼亚州农村背景来说意义重大 阿片类药物的流行引发了HIV/HCV的爆发。通过整合HIV/HCV/OUD实现高创新 利用我们在城市国际环境中成功使用的框架和战略，将服务纳入PCCs。公共 由于缺乏关于将服务纳入农村初级保健中心的知识，保健效益很高。可行性 基于具有跨学科专业知识和WV之前经验丰富的团队的跟踪记录，

Abstract The US strategy to End the HIV Epidemic calls for expanded prevention of new infections and more effective responses to HIV outbreaks. These outbreaks often occur in counties and states that share a disproportional burden of HIV, but the co-occurring and syndemic nature with opioid use disorder (OUD) leaves hundreds of additional counties and regions highly susceptible to new HIV (and HCV) outbreaks. West Virginia (WV) is one such mostly rural setting with an explosive opioid epidemic manifest by the highest per capita rate of overdoses and 5 counties with recent HIV outbreaks. Evidence-based practices to prevent and control HIV in clinical settings include medications for OUD (MOUD), ART treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). Treatment with these medications, however, first requires screening and evaluation, followed by treatment (SET). Adoption of SET processes may in turn translate to better health outcomes if adequately facilitated. Most rural settings are poorly equipped to provide specialty HIV/HCV/OUD services – an important lesson from Scott County, Indiana. Yet rural settings rely mostly on primary care clinics (PCC) with inadequate expertise to provide these services. To overcome adoption barriers of SET processes for HIV/HCV/OUD, effective facilitation is key and the NIATx treatment improvement strategy combined with ongoing clinical education and support provided by Project ECHO has the potential to increase adoption to integrate specialty HIV/HCV/OUD services into PCCs. Using the i-PARiHS implementation framework, we propose to address this unmet need by first identifying barriers to adoption and scale-up of HIV/HCV/OUD services. Then we will facilitate practice transformation by integrating clinical prompts in the electronic health record (EHR) to screen for HIV/HCV/OUD, followed by treatment prompts. Treatment will be supported by Project ECHO that provides ongoing clinical support to inspire confidence in treatment, alongside a clinical dashboard embedded within the EHR as part of the quality performance improvement activities to sustain integrating HIV/HCV/OUD services into PCCs. We then propose to conduct a stepped wedge, Type 3, hybrid implementation trial to assess the extent to which clinicians adopt and sustain SET processes to integrate care at 20 PCCs that is facilitated by rapid cycle change projects using NIATx. Adoption of SET processes are the primary outcome and a composite quality health indicator (QHI) that combines QHIs for primary care, HIV, HCV and MOUD are secondary efficacy outcomes. Organizational and clinician factors, along with engagement in facilitation activities (NIATx, ECHO sessions) will be explored as potential mediators and moderators. Significance is high for the rural WV context where a volatile opioid epidemic has ignited HIV/HCV outbreaks. Innovation is high by integrating HIV/HCV/OUD services into PCCs using a framework and strategy we successfully used in urban international settings. Public health benefits are high given the lack of knowledge known about integrating services into rural PCCs. Feasibility is high based on the track record of an experienced team with interdisciplinary expertise and prior in WV.