Improving HIV Service Delivery for People who Inject Drugs in Kazakhstan

 描述（由申请人提供）：受注射毒品使用的驱动，哈萨克斯坦和其他中亚国家目前正在经历世界上增长最快的艾滋病毒发病率，并继续报告艾滋病毒护理的巨大差距。根据2014年的国家数据，在哈萨克斯坦估计的19，000名艾滋病毒阳性的PWID中，只有三分之一与艾滋病毒护理有关，只有10%开始抗逆转录病毒治疗，4%达到病毒抑制。由于哈萨克斯坦在2015年将抗逆转录病毒疗法的资格从<350 CD 4扩大到<500 CD 4，迫切需要招募以前不合格的艾滋病毒感染者-积极的艾滋病毒感染者在抗逆转录病毒治疗中的作用。哈萨克斯坦对艾滋病毒感染者的持续护理中存在的巨大差距反映了其他国家的差距，在这些国家中，只有一小部分艾滋病毒感染者开始抗逆转录病毒治疗。越来越多的研究表明，提高艾滋病毒感染者的抗逆转录病毒治疗率可能是一种有效的战略，预防艾滋病毒传播，降低死亡率，改善生活质量，减少毒品和性危险行为。迫切需要进行有效性和执行情况研究，以确定如何最好地改善艾滋病毒服务的提供，缩小连续护理中关键的“治疗”差距。这将通过识别艾滋病毒阳性的PWID并将其与艾滋病毒护理联系起来，并接触那些从未接受过艾滋病毒护理、间歇性使用护理或退出治疗的人来实现。拟议的研究旨在评估一个增强的艾滋病毒服务整合包（BRIDGE）的实施和有效性，该包可能在哈萨克斯坦庞大的针-注射器计划网络中扩大规模。该方案包括由艾滋病护理诊所护士在NSP中开展的同伴驱动招聘、艾滋病咨询和快速检测（HCT）的低门槛战略，以及疾病预防控制中心将PWID与艾滋病护理联系起来的高效病例管理战略ARTAS。BRIDGE的系统设计旨在解决艾滋病毒检测PWID的具体服务障碍，将其与艾滋病毒护理联系起来，并促进ART的启动。本研究将采用创新的阶梯式楔形设计，利用从国家艾滋病规划署和艾滋病诊所收集的站点级数据，在哈萨克斯坦4个地理位置不同的城市的24个国家艾滋病规划署中，评估BRIDGE在改善与艾滋病毒护理和启动抗逆转录病毒治疗的联系方面的实施情况和有效性。我们还将进行一项纵向小组研究，在基线、6个月和12个月随访时对来自哈萨克斯坦4个城市的HIV阳性PWID（N=600）进行重复评估。本研究将采用混合方法，以确定多层次的结构，社区和组织因素，影响的实施和有效性的桥梁和桥梁的成本，审查的成本效益，扩展的可行性和可持续性的影响。这项研究建立在调查小组在过去十年中与共和国艾滋病中心合作在哈萨克斯坦PWID中进行的广泛的艾滋病毒干预研究的基础上。它解决了实施研究问题，以改善和整合艾滋病毒服务提供系统的PWID不仅是重要的区域，但有相关的其他国家，同时注射吸毒和艾滋病毒流行病。

 DESCRIPTION (provided by applicant): Driven by injection drug use, Kazakhstan and other Central Asian nations are currently experiencing the fastest growing HIV incidence in the world and continue to report huge gaps in the continuum of HIV care for PWID. According to 2014 national data, only one-third of the estimated 19,000 HIV-positive PWID in Kazakhstan are ever linked to HIV care and only 10% initiate ART with 4% achieving viral suppression. As Kazakhstan is expanding eligibility for ART from <350 CD4 to <500 CD4 in 2015, there is an urgency to enroll previously ineligible HIV-positive PWID in ART. Large gaps in Kazakhstan's continuum of care for PWID mirror gaps found in other countries in which only a small proportion of PWID initiate ART. Mounting research demonstrates that improving rates of ART among PWID may be an effective strategy to prevent HIV transmission, lower mortality, improve quality of life, and reduce drug and sexual risk behaviors. There is a critical need for effectiveness and implementation research to identify how best to improve HIV service delivery to close the critical "Treat" gap in the continuum of care. This will occur by identifying and linkng HIV-positive PWID to HIV care, and reaching out to those who have never been in HIV care, are intermittent users of care, or have dropped out of treatment. The proposed study is designed to evaluate the implementation and effectiveness of an enhanced HIV service integration package (BRIDGE) that may be scaled up in Kazakhstan's vast network of needle-syringe programs (NSPs) for PWID. This package includes low threshold strategies of peer-driven recruitment, HIV counseling and rapid testing (HCT) in NSPs conducted by HIV care clinic nurses, and ARTAS, CDC's highly effective case management strategies for linking PWID to HIV care. BRIDGE is systematically designed to address specific service barriers to testing PWID for HIV, linking them to HIV care, and promoting ART initiation. This study will employ an innovative stepped wedge design to evaluate implementation and effectiveness of BRIDGE on improving linkage to HIV care and initiation of ART in 24 NSPs located in 4 geographically disparate Kazakhstani cities using site-level data collected from NSPs and HIV clinics. We will also conduct a longitudinal panel study with a random sample of HIV-positive PWID (N=600) from four cities in Kazakhstan using repeated assessments at baseline, 6-, and 12-months follow-up. This study will employ mixed methods to identify multi-level structural, community, and organizational factors that influence the implementation and effectiveness of BRIDGE and the cost of BRIDGE, examining implications for cost-effectiveness, feasibility of expansion, and sustainability. The study builds on the investigative team's extensive HIV intervention research among PWID in Kazakhstan in collaboration with the Republican AIDS Center over the past decade. It addresses implementation research questions to improve and integrate HIV service delivery systems for PWID that are not only important to the region, but have relevance to other countries that have concurrent injection drug use and HIV epidemics.