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

描述(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，传播风险主要来自注射毒品。俄罗斯和该区域其他国家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，麻醉系统在很大程度上独立于其他医疗保健系统，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战略。这是一个错失的机会：在麻醉治疗中，高达45%的俄罗斯注射吸毒者(IDU)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护理的人，俄罗斯艾滋病治疗系统已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面临的可能影响留住的独特挑战，也没有解决护理启动问题。这项名为“将传染病和肿瘤学护理(LINC)联系起来”的研究的目的是在东欧改进治疗和保留“寻找、测试、治疗和保留”范例的各个方面。我们将在俄罗斯实施和评估旨在支持和激励艾滋病毒感染的麻醉学海洛因依赖者(即注射吸毒者)从事(即启动和保留)艾滋病毒医疗并最终改善他们的艾滋病毒结果的行为和结构性干预措施。LINC是一种临床模式，旨在协调麻醉学和艾滋病毒护理系统，使用所显示的促进参与医疗护理的要素：艾滋病毒病例管理和护士家访。中心假设是，涉及麻醉学和艾滋病毒系统之间协调的干预措施，通过a)由同伴提供艾滋病毒病例管理，以帮助激励和减少艾滋病毒护理的障碍，b)由成瘾护士加强门诊麻醉治疗，以及c)这些提供者之间的沟通将导致参与艾滋病毒护理。执行情况研究认识到，有效的干预措施可能不会成功地在不同的背景和系统之间转化。因此，我们将评估推动俄罗斯参与艾滋病毒护理的组织和业务问题，以及另一个前苏联国家乌克兰的类似情况。该项目将由一个在解决艾滋病毒、药物使用和俄罗斯临床干预方面经验丰富的国际研究团队承担。这项建议的具体目标是评估LINC干预措施与标准护理在4个不同结果方面的有效性：1)在登记后6个月内开始艾滋病毒护理(&gt；1次艾滋病毒医疗护理)；2)在12个月内保留艾滋病毒护理(连续2个6个月期间1次就诊)；3)适当的艾滋病毒护理(如果CD4细胞计数为&lt；350或在12个月内进行第二次CD4计数)；以及4)改善艾滋病毒健康结果(CD4细胞计数为12个月)。最终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纳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，那么它有可能在世界这一地区得到广泛实施，并对注射吸毒者中的艾滋病毒流行产生重大影响。 公共卫生相关性：LINC的研究将测试一项干预措施，以协调俄罗斯成瘾(即麻醉学)和艾滋病毒/艾滋病治疗系统之间的护理，并建立可能影响其在东欧采用和可持续性的背景因素。LINC干预旨在支持和激励感染艾滋病毒的海洛因依赖麻醉学患者(即注射吸毒者)从事(即启动和保留)艾滋病毒医疗护理，以改善艾滋病毒结果。如果有效，其影响将是巨大的，因为干预措施有可能在这一由注射吸毒者驱动的艾滋病毒流行的区域广泛实施，减少艾滋病毒/艾滋病的传播和并发症。

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. PUBLIC HEALTH RELEVANCE: The LINC study will test an intervention to coordinate care between the addiction (i.e., narcology) and HIV/AIDS treatment systems in Russia and establish the contextual factors that might influence its adoption and sustainability in Eastern Europe. The LINC intervention is designed to support and motivate HIV-infected heroin dependent narcology patients (i.e., IDUs) to engage (i.e., initiate and retain) in HIV medical care to improve HIV outcomes. If effective, its impact would be substantial as the intervention has the potential to be widely implemented in this region with an IDU-driven HIV epidemic, reducing HIV/AIDS spread and complications.