A sequential, adaptive model of differentiated service delivery to reach persons living with HIV who are lost-to-follow-up or who have detectable viral load

一种连续的、适应性的差异化服务提供模式，旨在覆盖失访或病毒载量可检测的艾滋病毒感染者

• 批准号: 10321966
• 负责人: Ruanne Vanessa Barnabas
• 金额: $ 55.87万
• 依托单位: UNIVERSITY OF WASHINGTON
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-01-01 至 2022-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10321966
• 关键词: Address; Adherence; Back; Behavior; Caring; Cessation of life; Characteristics; Client; Clinic; Clinic Visits; Communities; Cost Savings; Disease; Enrollment; Evaluation; Frequencies; Goals; HIV; HIV Infections; HIV Seronegativity; HIV Seropositivity; Health Benefit; Home; Incentives; Intervention; Interview; Life; Measures; Modeling; Morbidity - disease rate; Participant; Persons; Population; Provider; Randomized; Sampling; Sequential Multiple Assignment Randomized Trial; Service provision; Services; South Africa; Subgroup; System; Testing; Viral; Viral Load result; Wages; Wait Time; antiretroviral therapy; arm; barrier to care; base; budget impact; care delivery; cost; cost effectiveness; cost estimate; experience; follow-up; improved; incentive strategies; intervention delivery; intervention participants; microcosting; mortality; patient-level barriers; peer; preference; prevent; primary outcome; randomized trial; recruit; service delivery; success; transmission process; treatment strategy; trial design

ABSTRACT Globally, more than half of the world's 37 million people living with HIV are on antiretroviral therapy (ART) representing immense and encouraging success with access to HIV care. ART prevents disease, death and HIV transmission and HIV-positive persons can expect to live as long as their HIV-negative peers when their viral load is undetectable. However, treatment success still lags behind goals. In South Africa alone, 8 million HIV- positive persons require ART for life and only 4.5 million are currently on ART. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load, the hallmark of struggling to access and take ART. HIV differentiated service delivery (DSD) has simplified ART delivery: incentives, multi-month scripts, fast-track ART, and community or home ART delivery motivate clients, reduce the frequency of clinic visits, and decongest clinics. DSD is standard for clients who achieve viral suppression and engage in care; however, DSD needs adaptation to serve clients who are not succeeding. Indeed, persons who are not engaged in care arguably need simplified, client-centered approaches even more than those who can successfully engage. A suite of adaptive DSD strategies, including community-based ART, have been tested among stable clients with viral suppression. Lottery incentives effectively change short-term behavior, increasing ART initiation. Community and home ART delivery increases ART coverage and simplify ART access overcoming clinic barriers. For stable clients, these DSD activities are as effective as clinic-based care in terms of achieving and maintaining viral suppression, although among stable clients they have not shown superiority in viral suppression or cost savings. In contrast, DSD has the potential to improve rates of viral suppression and retention in care and save costs among more hard-to-reach groups. There is great potential that DSD systems can be client- responsive and system-efficient for subgroups requiring additional services, matching services with client needs. A sequential, comprehensive package of DSD approaches, with each step increasing the intensity of service provision – adaptive DSD – has not been tested to determine the proportion and characteristics of persons who would achieve viral suppression and retention in care and to estimate the cost-effectiveness and budget impact. To increase population level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates evaluation of a stepped, adaptive approach to achieving viral suppression with `right-sized' interventions. We are an experienced team and propose to build on our strong partnerships to sequentially test adaptive DSD strategies for persons with detectable viral load: lottery incentives, community-based ART, and home ART delivery. Our aim is to identify the most effective and efficient HIV care delivery strategies for South Africa.

抽象的 在全球范围内，全球3,700万人中有一半以上的艾滋病毒患者正在接受抗逆转录病毒疗法（ART） 在获得艾滋病毒护理方面，代表巨大的成功。艺术预防疾病，死亡和艾滋病毒 传播和艾滋病毒阳性的人可以期望生活在艾滋病毒的同龄人的情况下 负载是不可察觉的。但是，治疗成功仍然落后于目标。仅在南非，有800万名艾滋病毒 - 积极的人需要一生的艺术，目前只有450万。患者护理障碍，例如 遗漏的工资，运输成本以及长时间的诊所就诊和艺术补充的时间与可检测 病毒载荷，这是为了获得和采取艺术而奋斗的标志。 HIV差异化服务交付（DSD）具有 简化的艺术品交付：激励措施，多个月脚本，快速轨道艺术以及社区或家庭艺术品交付 激励客户，降低诊所就诊的频率以及降解诊所。 DSD是标准的客户 实现病毒抑制并从事护理；但是，DSD需要适应以服务于不属于的客户 成功。实际上，不从事护理的人可以说是简化的，以客户为中心的人 与能够成功参与的人相比，方法还要多。 稳定的客户已经测试了一套适应性DSD策略，包括基于社区的艺术 抑制病毒。彩票激励措施有效地改变了短期行为，增加了艺术启动。 社区和家庭艺术品分娩增加艺术覆盖范围，并简化艺术访问克服诊所 障碍。对于稳定的客户，就实现和 保持病毒抑制，尽管在稳定的客户中，他们尚未表现出在病毒抑制中的优势 或节省成本。相比之下，DSD有可能提高病毒抑制和保留率 并节省更多难以触及的小组的成本。 DSD系统可以是客户端的巨大潜力 - 需要其他服务的子组响应且系统效率，将服务与客户需求匹配。 DSD方法的顺序，全面的包装，每一步都会增加服务的强度 提供 - 自适应DSD - 尚未进行测试以确定那些人的比例和特征 将在护理中实现病毒抑制和保留率，并估算成本效益和预算影响。 为了增加人口水平的病毒抑制，患有可检测的病毒负荷的人需要响应DSD 干预措施。顺序多次分配随机试验（智能）设计有助于评估 通过“右尺寸”干预措施实现病毒抑制的阶梯式自适应方法。我们是一个经验丰富的 团队和提议以我们的强大合作伙伴关系为基础，以对人进行顺序测试自适应DSD策略 具有可检测的病毒载荷：彩票激励措施，基于社区的艺术和家庭艺术品。我们的目标是 确定南非最有效，最有效的艾滋病毒护理提供策略。