Staged Low-Barrier and Mobile Care to Improve Retention and Viral Suppression in Hard-To-Reach Vulnerable People Living With HIV

分阶段进行低门槛和流动护理，以改善难以接触到的艾滋病毒感染者的保留和病毒抑制

• 批准号: 10462318
• 负责人: Katerina A Christopoulos
• 金额: $ 105.61万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-07-12 至 2027-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10462318
• 关键词: Address; Adoption; African American population; Appointment; Appointments and Schedules; Area; Black race; COVID-19 testing; COVID-19 vaccine; Caring; Case Management; Chronic; Clinic; Clinical; Clinical effectiveness; Communities; Complex; Consolidated Framework for Implementation Research; Control Groups; Cost Effectiveness Analysis; County; Criminal Justice; Data; Discipline of Nursing; Drops; Effectiveness; Eligibility Determination; Epidemic; Evaluation; Federally Qualified Health Center; Food; Goals; HIV; Heterogeneity; Hispanic Populations; Homeless persons; Homelessness; Hybrids; Individual; Intervention; Knowledge; Latino; Literature; Maintenance; Medical; Medicine; Mental disorders; Methods; Modeling; Needle-Exchange Programs; Outcome; Patients; Persons; Pharmacy facility; Pilot Projects; Population; Population Sciences; Primary Health Care; Process; Psychiatry; Public Health; Reach Effectiveness Adoption Implementation and Maintenance; Recording of previous events; Research; Safety; San Francisco; Schedule; Site; Social Work; Structural Racism; Substance Use Disorder; Sum; Syringes; System; Testing; Time; Treatment outcome; United States; Urban Population; Viral; Viral Load result; Visit; Vulnerable Populations; Work; addiction; antiretroviral therapy; barrier to care; base; care delivery; care systems; clinical effect; cohort; community burden; community clinic; cost; design; effectiveness evaluation; effectiveness implementation study; experience; flexibility; follow-up; health data; health equity; housing instability; implementation facilitators; implementation framework; implementation intervention; implementation outcomes; implementation research; implementation science; implementation strategy; improved; innovation; interdisciplinary treatment approach; multidisciplinary; novel strategies; outreach; primary outcome; programs; psychosocial; safety net; service delivery; severe mental illness; substance use; treatment as usual

Project Summary/Abstract Existing HIV care systems in the United States, usually based on scheduled appointments, are often inadequate for people living with HIV who have significant psychosocial and structural barriers to engagement in care (i.e. homelessness/unstable housing, substance use disorders, severe mental illness). Rather than connect these individuals to an incompatible system of HIV care, new approaches are needed that reduce barriers to care engagement and offer increased flexibility. In this study, we seek to implement an evidence- informed multicomponent clinical intervention that includes drop-in (i.e. no appointments) multidisciplinary HIV primary care, mobile HIV care, staged escalation/de-escalation of care intensity as needed, and active referral of patients from community-based clinical and non-clinical sites into this care model. This clinical intervention will be implemented at four diverse care sites in San Francisco and Alameda counties, both priority jurisdictions in the U.S. Ending the HIV Epidemic (EHE) strategy: an academic safety net HIV clinic, a needle exchange program, and two federally qualified health centers. Eligibility criteria include: 1) current HIV viral load ≥200 copies/mL or off antiretroviral therapy, 2) history of poor HIV care engagement, and 3) homelessness/ unstable housing, any mental health disorder, or any illicit substance. We use the Consolidated Framework for Implementation Research (CFIR) and RE-AIM implementation frameworks to guide implementation strategy selection and our implementation and clinical effectiveness evaluation. In Aim 1, we will use implementation mapping to assess barriers and facilitators of implementation and convene key stakeholders to contextually integrate the clinical intervention and finalize the implementation strategies. In Aim 2, we will conduct a hybrid type 2 implementation-effectiveness study to evaluate the effect of clinical intervention implementation on co-primary outcomes of Reach (any HIV primary care visit) and Effectiveness (any HIV viral load <200 copies/mL) among patients referred to the care model over 12 months of follow-up (n=400), comparing outcomes to two propensity score matched control groups (400 contemporaneous controls identified using Department of Public Health data and 400 historical controls identified at study sites). We will also assess clinic-level implementation outcomes. In Aim 3, we will evaluate and model the individual, clinic, and population-level impacts of the intervention approach using heterogeneity and health equity analysis, cost/ cost-effectiveness analysis, scenario modeling of optimal and reduced component scenarios and population- level impact. Our multidisciplinary study team has a strong track record of implementation research to improve HIV care engagement among vulnerable populations. The proposed study will provide robust evidence for a drop-in/mobile HIV care approach and strategies to support implementation at a diverse set of clinic sites. By codifying these implementation strategies to facilitate wider-scale implementation, we seek to contribute to improving EHE Treatment outcomes among those for whom traditional models of care are sub-optimal.

项目摘要/摘要 美国现有的艾滋病毒护理系统通常是基于预定的，通常是 对于患有艾滋病毒的人不足，他们的参与度有重大的社会心理和结构性障碍 在护理中（即无家可归/不稳定的住房，药物使用障碍，严重的精神疾病）。而不是 将这些人连接到不兼容的艾滋病毒护理系统，需要新的方法来减少 护理参与的障碍并提供了提高的灵活性。在这项研究中，我们试图实施证据 - 知情的多组分临床干预措施，其中包括撤离（即未任命）多学科艾滋病毒 初级保健，移动艾滋病毒护理，根据需要进行护理强度的升级/降级以及主动推荐 该护理模型的基于社区的临床和非临床部位的患者。这种临床干预 将在旧金山和阿拉米达县的四个潜水员护理网站上实施，这是优先的 美国的司法管辖区结束了艾滋病毒流行（EHE）策略：一项学术安全净艾滋病毒诊所，针头 交流计划和两个联邦资格的卫生中心。资格标准包括：1）当前的HIV病毒 负载≥200副本/mL或抗逆转录病毒疗法，2）艾滋病毒护理差的病史和3） 无家可归/不稳定的住房，任何精神健康障碍或任何非法物质。我们使用合并的 实施研究框架（CFIR）和RE-AIM实施框架以指导 实施策略选择以及我们的实施和临床有效性评估。在AIM 1中，我们 将使用实施映射来评估实施和便利密钥的障碍和促进者 利益相关者将上下文整合临床干预并确定实施策略。目标 2，我们将进行一项混合2型实施效应研究，以评估临床的影响 对涉及共同成果的干预实施（任何艾滋病毒初级保健访问）和有效性 （任何HIV病毒载荷<200拷贝/mL）在12个月内提及护理模型的患者中 （n = 400），将结果与两个承诺得分匹配的对照组进行比较（400个当代对照组 使用公共卫生数据和研究地点确定的400个历史控制识别）。我们将 还评估诊所级实施结果。在AIM 3中，我们将评估和建模个体，诊所， 使用异质性和健康公平分析，成本/ 成本效益分析，最佳和减少组件场景的场景建模以及种群 - 水平影响。我们的多学科研究团队具有实施研究的良好记录，以改善 脆弱人群中的艾滋病毒护理参与。拟议的研究将为A提供可靠的证据 下水/移动艾滋病毒护理方法和支持在一组诊所站点的实施的策略。经过 编纂这些实施策略以促进广泛实施，我们试图为 在传统的护理模型中，改善了EHE治疗结果。