Innovations in Implementing Decentralized HIV Services in Peru

秘鲁实施分散式艾滋病毒服务的创新

• 批准号: 10762842
• 负责人: FREDERICK LEWIS ALTICE
• 金额: $ 72.36万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-06 至 2028-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10762842
• 关键词: Acceleration; Address; Adopted; Adoption; Affect; Age; Caring; Chronic; Clinic; Clinical; Clinical Competence; Clinical Skills; Clinical Trials; Collaborations; Country; Decentralization; Detection; Diagnosis; Education; Epidemic; Evidence based practice; Flowcharts; Geography; Goals; Guidelines; HIV; Health; Health Benefit; Healthcare; Healthcare Systems; Hybrids; Incidence; Income; Individual; Laboratories; Learning; Measures; Methods; Modeling; Outcome; Patient Care; Patient Transfer; Patients; Performance; Persons; Peru; Peruvian; Politics; Population; Populations at Risk; Primary Care; Public Health; Randomized; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Recommendation; Reproducibility; Research Support; Services; Site; South America; South American; System; Time; Traction; Training; Viral; Work; addiction; antiretroviral therapy; barrier to care; clinical practice; design; effectiveness outcome; evidence base; experience; health goals; implementation framework; implementation outcomes; implementation science; implementation strategy; implementation tool; implementation trial; improved; innovation; low and middle-income countries; medical specialties; member; men who have sex with men; metropolitan; mortality; primary care provider; primary health center; professional atmosphere; scale up; secondary outcome; service delivery; skills; social stigma; success; tool; urban setting; Acceleration; Address; Adopted; Adoption; Affect; Age; Caring; Chronic; Clinic; Clinical; Clinical Competence; Clinical Skills; Clinical Trials; Collaborations; Country; Decentralization; Detection; Diagnosis; Education; Epidemic; Evidence based practice; Flowcharts; Geography; Goals; Guidelines; HIV; Health; Health Benefit; Healthcare; Healthcare Systems; Hybrids; Incidence; Income; Individual; Laboratories; Learning; Measures; Methods; Modeling; Outcome; Patient Care; Patient Transfer; Patients; Performance; Persons; Peru; Peruvian; Politics; Population; Populations at Risk; Primary Care; Public Health; Randomized; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Recommendation; Reproducibility; Research Support; Services; Site; South America; South American; System; Time; Traction; Training; Viral; Work; addiction; antiretroviral therapy; barrier to care; clinical practice; design; effectiveness outcome; evidence base; experience; health goals; implementation framework; implementation outcomes; implementation science; implementation strategy; implementation tool; implementation trial; improved; innovation; low and middle-income countries; medical specialties; member; men who have sex with men; metropolitan; mortality; primary care provider; primary health center; professional atmosphere; scale up; secondary outcome; service delivery; skills; social stigma; success; tool; urban setting

Despite successes in diagnosing and initiating antiretroviral therapy (ART) in people with HIV (PWH) in Peru, a LMIC with an HIV epidemic concentrated in key at-risk populations, the implementation gap is highest for retention in care (RIC), resulting in low levels of viral suppression (43%) and increasing HIV incidence. HIV care in Peru is currently concentrated in large secondary health centers (SHCs). Based on WHO recommendations to decentralize healthcare, an evidence-based practice that increases RIC, the Peruvian Ministry of Health recommended in 2019 to decentralize HIV services to primary health centers (PHCs). We propose to work in the 4 largest regions in urban Lima that manages 37% of all PWH in care. Currently, <15% of PWH in Lima receive care in PHCs, supporting the need for more effective implementation of decentralized services. Using the RE- AIM implementation framework, we propose to accelerate decentralization by combining NIATx, an evidence- informed implementation strategy with a bundle of implementation tools to scale up evidence-based practices, with Project ECHO, an evidence-informed tele-educational strategy to increase clinical skills in primary care providers to competently provide specialty (i.e., HIV) services. We will first use the Delphi method to establish guidelines to safely decentralize PWH using a hub (SHC) and spoke (PHC) model and to establish the minimal number of quality health indicators that are needed to safely keep patients in PHCs. These guidelines can be used to create clinical checklists that can be used to support guideline concordance in clinical practice. We will then conduct a rapid, multi-level (patients, clinicians, healthcare system) assessment of barriers and facilitators to decentralizing HIV care, which will be assessed just before each of the four hub and spoke regions will be randomized to 24 months of implementation using NIATx and ECHO in a stepped wedge design. The primary effectiveness outcome will be proportionate change of PWH receiving HIV care in PHCs. Secondary outcomes include RIC and VS with exploratory analyses for mortality. The primary implementation outcomes are confidence in managing PWH at PHCs. Collaboration, workplace climate and adoption of HIV care at new PHC sites will be measured within each hub and spoke. Adoption of HIV care at new PHCs in each region will be assessed. Importance is high due to the MoH’s goal to decentralize HIV care in an urban, low/middle income setting where HIV is concentrated in key populations with low levels of RIC and VS levels. Innovation is high due to combining NIATx and ECHO in an urban South American context and using them beyond addiction treatment. Feasibility is high due to the longstanding relationships between team members alongside the strong commitment by the Ministry of Health. The team brings expertise in HIV care (Sanchez, Altice), Public Health (Konda, Altice), implementation science (Altice, Madden, Konda) and service integration (Altice, Madden). Public Health benefit is high not only in terms of systems-, clinician- and patient-level benefits through implementing decentralized care in Peru, but also serves as a template for other urban, low/middle income settings.

尽管在秘鲁患有艾滋病毒（PWH）的患者的诊断和抗逆转录病毒疗法（ART）方面取得了成功，但 LMIC患有HIV流行的LMIC集中在关键高危人群中，实施差距最高 保留护理（RIC），导致病毒抑制水平较低（43％）和HIV入口增加。艾滋病毒护理 目前，秘鲁集中在大型中学中心（SHC）中。根据谁的建议 为了分散医疗保健，这是一种基于证据的实践，以增加秘鲁卫生部RIC 推荐于2019年将艾滋病毒服务分散到初级卫生中心（PHCS）。我们建议在 城市利马市的4个最大地区，管理着所有PWH的37％。目前，利马的PWH <15％接受 PHC的护理，支持更有效地实施分散服务。使用重新 AIM实施框架，我们建议通过结合Niatx（证据）来加速权力下放化。 通过一系列实施工具来扩展基于证据的实践的知情实施策略， 通过Project Echo，一种有证据的电信教育策略来提高初级保健的临床技能 提供者能够有能力提供专业（即艾滋病毒）服务。我们将首先使用Delphi方法来建立 使用轮毂（SHC）和辐条（PHC）模型安全分散PWH的准则，并建立最小的 确保将患者保留在PHC中所需的质量健康指标数量。这些准则可能是 用于创建可用于支持临床实践中的指南协和的临床清单。我们将 然后对障碍和促进者进行快速的多层次（患者，临床医生，医疗系统）评估 分散艾滋病毒护理，将在四个枢纽和辐条区域中的每个枢纽之前进行评估 在阶梯楔形设计中，使用Niatx和Echo随机分配到24个月的实施。主要 有效性结果将是PHC中接受HIV护理的PWH的比例变化。次要结果 包括RIC和VS具有探索性分析的死亡率。主要实现结果是 对在PHCS管理PWH的信心。在新的PHC上的合作，工作场所气氛和采用艾滋病毒护理 站点将在每个集线器中测量并发言。在每个地区的新PHC中采用艾滋病毒护理将是 评估。重要性很高，因为卫生部的目标是在城市，低/中间收入中分散艾滋病毒护理 艾滋病毒集中在RIC和VS水平较低的关键种群中。创新很高 在南美城市的环境中结合Niatx和Echo，并使用它们不仅成瘾治疗。 由于团队成员之间的长期关系以及强大的强大关系，可行性很高 卫生部的承诺。该团队带来了艾滋病毒护理（Sanchez，Altice），公共卫生的专业知识 （Konda，Altice），实施科学（Altice，Madden，Konda）和服务整合（Altice，Madden）。民众 健康益处不仅在系统，临床和患者水平的福利方面都很高 秘鲁的分散护理，但也是其他城市，低/中收入环境的模板。