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Principal Investigator: Aaloke Mody
Organization: WASHINGTON UNIVERSITY
Fiscal Year: 2024
Award: $193,511
Funding agency: National Institute of Mental Health
ABSTRACT
Sustained retention in HIV care is critical for viral suppression, but people living with HIV (PLWH) frequently
transition in and out of care over time, putting them at high risk for ongoing viremia and drug resistance. Even
when PLWH return to care after loss to follow-up (LTFU), rates of becoming LTFU again in the future are very
high. Our preliminary data from Zambia suggests that 30% become LTFU again within 6 months, and that 50%
of those who are currently LTFU have previously cycled in and out of care. The time of reengagement in care is
thus a critical period to intervene in this high-risk population, and strategies to improve post-return care delivery
are urgently needed to break ongoing cycles of disengagement. After returning to care, PLWH often report being
scolded, health care workers (HCW) delay ART re-initiation due to adherence concerns and do not consistently
monitor virologic response, and PLWH likely still experience the life situations (e.g., competing obligations, travel
away from home, or psychosocial factors) that led to their initial LTFU. Strategies to 1) target HCW behaviors
(i.e., welcoming returning patients, prompt ART re-initiation) using implementation strategies such as practice
facilitation and audit and feedback and 2) offer PLWH support services tailored to their initial reasons for LTFU
(e.g., extended refills, transfer coordination, peer-navigation) may be promising. To be successful, however, we
need to understand how to effectively implement these approaches into existing care, including 1) how to engage
HCWs in attitude- and behavior-change strategies, 2) what support services to prioritize for different barriers,
and 3) how to integrate activities into existing workflows. This R34 proposal will build the necessary foundation
for implementing a multicomponent reengagement strategy to support sustained reengagement after returning
to HIV care. In Aim 1a, we assess patient and HCW needs and preferences for reengagement strategies with
patient semi-structured interviews (n=20) and focus group discussions with HCWs and clinic leadership (4 FGDs,
n=8-10 each). In Aim 1b, we conduct discrete choice experiments (200 PLWH, 100 HCWs) to quantify relative
preferences for the contents and attributes for our reengagement strategy. In Aim 2, we undertake a human-
centered design process that engages key stakeholders (PLWH, HCWs, clinic leadership, Ministry of Health) in
co-developing the content and features of a multicomponent reengagement strategy focused on 1) improving
the patient reengagement experience, 2) optimizing ART re-initiation and viral load monitoring post-return, and
3) providing tailored services that target individuals’ specific reasons for LTFU. In Aim 3, we will pilot the
developed strategy at one urban and one rural clinic in Lusaka, Zambia. We will use a mixed-methods approach
to assess the implementation (e.g., acceptability, appropriateness), service delivery (e.g., time to ART re-
initiation, viral load monitoring), and clinical outcomes (e.g., retention and viral suppression at 6 months post-
return). Results from this proposal will directly inform a future R01 to formally test this health-system intervention
for patients reengaging in HIV care in a Type II hybrid implementation-effectiveness cluster randomized trial.
Terms: <AIDS Virus><Acquired Immune Deficiency Syndrome Virus><Acquired Immunodeficiency Syndrome Virus><Active Follow-up><Address><Adherence><Africa South of the Sahara><After Care><After-Treatment><Aftercare><Assess implementation><Attitude><Back><Behavior><Caring><Clinic><Clinical><Cluster randomization trial><Cluster randomized trial><Collaborations><Consolidated Framework for Implementation Research><Consolidated Framework for Implementation Science><Consolidated Framework for Implementing Change><Counseling><Data><Development><Dorsum><Drug resistance><Effectiveness><Ensure><Feedback><Focus Groups><Foundations><Future><HIV><Health><Health Care Providers><Health Personnel><Health system><Healthcare Providers><Healthcare worker><Home><Human><Human Immunodeficiency Viruses><Implementation assessment><Individual><Infectious Diseases / Laboratory><Infectious Diseases Research><Interruption><Intervention><Intervention Strategies><Interview><Investigators><LAV-HTLV-III><Lead><Leadership><Life Experience><Lymphadenopathy-Associated Virus><Methods><Modeling><Modern Man><Monitor><Morbidity><Morbidity - disease rate><Northern Rhodesia><Nurses><Outcome><Patient outcome><Patient-Centered Outcomes><Patient-Focused Outcomes><Patients><Pb element><Persons><Physicians><Population><Process><Protocol><Protocols documentation><Provider><Psychosocial Factor><Qualitative Methods><Reporting><Research><Research Infrastructure><Research Personnel><Researchers><Services><Structure><Sub-Saharan Africa><Subsaharan Africa><Testing><Time><Training><Transmission><Travel><Universities><Viral><Viral Burden><Viral Load><Viral Load result><Viremia><Virus-HIV><Washington><Zambia><active followup><behavior change><care delivery><critical period><design><designing><developmental><drug resistant><effectiveness/implementation hybrid><evaluate implementation><evaluation of implementation><evidence base><experience><experiment><experimental research><experimental study><experiments><follow up><follow-up><followed up><followup><health care personnel><health care worker><health provider><health workforce><healthcare personnel><heavy metal Pb><heavy metal lead><high risk><high risk group><high risk individual><high risk people><high risk population><homes><human centered design><implementation evaluation><implementation strategy><improved><improved outcome><intervention mapping><interventional strategy><medical personnel><mortality><nurse><patient oriented outcomes><patient population><peer><post treatment><preference><prevent><preventing><programs><prototype><psychosocial variables><public health priorities><qualitative reasoning><resistance to Drug><resistant to Drug><response><rural clinic><rural health clinic><service delivery><strategies for implementation><transmission process><treatment provider><viraemia><viral sepsis><virusemia>