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Kemp CG, Edwards AJ, White L, Kore G, Thurman PJ, Gaines T, King PT, Cole M, Orellana ER. Implementation Science for HIV Prevention and Treatment in Indigenous Communities: a Systematic Review and Commentary. Curr HIV/AIDS Rep 2024:10.1007/s11904-024-00706-z. [PMID: 39120668 DOI: 10.1007/s11904-024-00706-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE OF REVIEW We systematically reviewed implementation research conducted in Indigenous communities in the Americas and the Pacific that focused on improving delivery of HIV preventive or treatment services. We highlight strengths and opportunities in the literature and outline principles for Indigenous-led, HIV-related implementation science. RECENT FINDINGS We identified 31 studies, revealing a consistent emphasis on cultural tailoring of services to Indigenous communities. Common barriers to implementation included stigma, geographic limitations, confidentiality concerns, language barriers, and mistrust. Community involvement in intervention development and delivery emerged as a key facilitator, and nearly half of the studies used community-based participatory research methods. While behavioral HIV prevention, especially among Indigenous youth, was a major focus, there was limited research on biomedical HIV prevention and treatment. No randomized implementation trials were identified. The findings underscore the importance of community engagement, the need for interventions developed within Indigenous communities rather than merely adapted, and the value of addressing the social determinants of implementation success. Aligned to these principles, an indigenized implementation science could enhance the acceptability and reach of critical HIV preventive and treatment services in Indigenous communities while also honoring their knowledge, wisdom, and strength.
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Affiliation(s)
- Christopher G Kemp
- Center for Indigenous Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Abagail J Edwards
- Center for Indigenous Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lauren White
- Joint Program for Social Work and Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Gauri Kore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Tommi Gaines
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Paula Toko King
- Te Rōpū Rangahau Hauora a Eru Pōmare, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Marama Cole
- Te Rōpū Rangahau Hauora a Eru Pōmare, Department of Public Health, University of Otago, Wellington, New Zealand
| | - E Roberto Orellana
- Indigenous Wellness Research Institute, University of Washington, Seattle, WA, USA
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Kadota JL, Packel LJ, Mlowe M, Ulenga N, Mwenda N, Njau PF, Dow WH, Wang J, Sabasaba A, McCoy SI. Rudi Kundini, Pamoja Kundini (RKPK): study protocol for a hybrid type 1 randomized effectiveness-implementation trial using data science and economic incentive strategies to strengthen the continuity of care among people living with HIV in Tanzania. Trials 2024; 25:114. [PMID: 38336793 PMCID: PMC10858527 DOI: 10.1186/s13063-024-07960-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Economic incentives can improve clinical outcomes among in-care people living with HIV (PLHIV), but evidence is limited for their effectiveness among out-of-care PLHIV or those at risk of disengagement. We propose a type 1 hybrid effectiveness-implementation study to advance global knowledge about the use of economic incentives to strengthen the continuity of HIV care and accelerate global goals for HIV epidemic control. METHODS The Rudi Kundini, Pamoja Kundini study will evaluate two implementation models of an economic incentive strategy for supporting two groups of PLHIV in Tanzania. Phase 1 of the study consists of a two-arm, cluster randomized trial across 32 health facilities to assess the effectiveness of a home visit plus one-time economic incentive on the proportion of out-of-care PLHIV with viral load suppression (< 1000 copies/ml) 6 months after enrollment (n = 640). Phase 2 is an individual 1:1 randomized controlled trial designed to determine the effectiveness of a short-term counseling and economic incentive program offered to in-care PLHIV who are predicted through machine learning to be at risk of disengaging from care on the outcome of viral load suppression at 12 months (n = 692). The program includes up to three incentives conditional upon visit attendance coupled with adapted counselling sessions for this population of PLHIV. Consistent with a hybrid effectiveness-implementation study design, phase 3 is a mixed methods evaluation to explore barriers and facilitators to strategy implementation in phases 1 and 2. Results will be used to guide optimization and scale-up of the incentive strategies, if effective, to the larger population of Tanzanian PLHIV who struggle with continuity of HIV care. DISCUSSION Innovative strategies that recognize the dynamic process of lifelong retention in HIV care are urgently needed. Strategies such as conditional economic incentives are a simple and effective method for improving many health outcomes, including those on the HIV continuum. If coupled with other supportive services such as home visits (phase 1) or with tailored counselling (phase 2), economic incentives have the potential to strengthen engagement among the subpopulation of PLHIV who struggle with retention in care and could help to close the gap towards reaching global "95-95-95" goals for ending the AIDS epidemic. TRIAL REGISTRATION Phase 1: ClinicalTrials.gov, NCT05248100 , registered 2/21/2022. Phase 2: ClinicalTrials.gov, NCT05373095 , registered 5/13/2022.
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Affiliation(s)
- Jillian L Kadota
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA.
| | - Laura J Packel
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Matilda Mlowe
- Health for a Prosperous Nation, Dar Es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar Es Salaam, Tanzania
| | | | | | - William H Dow
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, USA
| | - Jingshen Wang
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Amon Sabasaba
- Health for a Prosperous Nation, Dar Es Salaam, Tanzania
| | - Sandra I McCoy
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
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Wexler C, Maloba M, Sliefert M, Babu S, Maosa N, Maliski E, Nicolay Z, Were F, Mbithi Y, Mugendi G, Thomas G, Acharya H, Finocchario-Kessler S. Assessing user preferences for design characteristics of oral dissolvable strips for pediatric HIV medication: a qualitative study. BMC Health Serv Res 2023; 23:1103. [PMID: 37845699 PMCID: PMC10580521 DOI: 10.1186/s12913-023-10078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Current infant antiretroviral therapy formulations pose barriers to daily adherence due to complex weight-based dosing, conspicuous preparation, and poor palatability. These adherence barriers jeopardize adherence, making patients vulnerable to virologic failure, development of drug resistance, and preventable mortality. Our team has previously established proof-of-principle for multi-drug oral dissolvable strips as alternative pediatric antiretroviral formulations with the potential to overcome these challenges and improve pediatric ART adherence and outcomes. The objective of this study was to assess caregiver and provider preferences for oral dissolvable strips and its packaging to inform its development. METHODS Guided by concepts of user-centered design, we conducted key informant interviews with 30 HIV care providers and focus group discussions targeting caregivers of children < 10 years of age living with HIV at 3 Kenyan hospitals. Key informant interviews and focus group discussions were audio recorded, translated/transcribed verbatim, and hand coded for a-priori and emergent themes. RESULTS A total of 30 providers and 72 caregivers (caring for 83 children, aged 5 months to 18 years) participated in the study. Caregivers and providers expressed a strong desire for an easier way to administer medication, especially among children too young to swallow tablets whole, and expressed enthusiasm around the idea of oral dissolvable strips. Key preferences included a pleasant taste; one strip per dose; small size with rapid dissolution; clear markings and instructions; and no special storage requirements. For packaging, stakeholders preferred individually wrapped strips within a dispenser. The individual packaging should be durable, waterproof, and easy to dispose of in communal spaces. They should also be easy to open, with clear indications where to open. The packaging holding the strips should be durable, re-usable, accommodating of various refill frequencies, and easy to use for children as young as 6. DISCUSSION The concept of oral dissolvable strips was highly acceptable to caregivers of children living with HIV and HIV care providers. By engaging stakeholders in an iterative design process starting from the early phases of design and development, we will maximize the likelihood of developing a product that is acceptable to the caregiver and infant, therefore leading to sustainable adherence.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Michala Sliefert
- School of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | | | | | | | | | - Gregory Thomas
- School of Architecture and Design, University of Kansas, Lawrence, KS, USA
| | - Harshdeep Acharya
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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McBride CM, Roberts JS, Knerr S, Guan Y. Public Health Genomics: Time to Sharpen the Focus. Public Health Genomics 2023; 26:171-176. [PMID: 37729876 PMCID: PMC10614505 DOI: 10.1159/000533985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/01/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
- Colleen M. McBride
- Department of Behavioral, Social and Health Education Sciences, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - J. Scott Roberts
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Sarah Knerr
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Yue Guan
- Department of Behavioral, Social and Health Education Sciences, Emory Rollins School of Public Health, Atlanta, GA, USA
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Garner BR, Burrus O, Ortiz A, Tueller SJ, Peinado S, Hedrick H, Harshbarger C, Galindo C, Courtenay-Quirk C, Lewis MA. A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial. J Acquir Immune Defic Syndr 2022; 91:47-57. [PMID: 35583962 PMCID: PMC9377502 DOI: 10.1097/qai.0000000000003018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Positive Health Check is an evidence-based video doctor intervention developed for improving the medication adherence, retention in care, and viral load suppression of people with HIV receiving clinical care. SETTING Four HIV primary care clinics within the United States. METHODS As part of a type 1 hybrid trial, a mixed-methods approach was used to longitudinally assess the following 3 key implementation constructs over a 23-month period: innovation-values fit (ie, the extent to which staff perceive innovation use will foster the fulfillment of their values), organizational readiness for change (ie, the extent to which organizational members are psychologically and behaviorally prepared to implement organizational change), and implementation climate (ie, the extent to which implementation is expected, supported, and rewarded). Quantitative mixed-effects regression analyses were conducted to assess changes over time in these constructs. Qualitative analyses were integrated to help provide validation and understanding. RESULTS Innovation-values fit and organizational readiness for change were found to be high and relatively stable. However, significant curvilinear change over time was found for implementation climate. Based on the qualitative data, implementation climate declined toward the end of implementation because of decreased engagement from clinic champions and differences in priorities between research and clinic staff. CONCLUSIONS The Positive Health Check intervention was found to fit within HIV primary care service settings, but there were some logistical challenges that needed to be addressed. Additionally, even within the context of an effectiveness trial, significant and nonlinear change in implementation climate should be expected over time.
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Affiliation(s)
| | | | - Alexa Ortiz
- RTI International, Research Triangle Park, NC; and
| | | | | | | | - Camilla Harshbarger
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
| | - Carla Galindo
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
| | - Cari Courtenay-Quirk
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
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Drabo EF, Moucheraud C, Nguyen A, Garland WH, Holloway IW, Leibowitz A, Suen SC. Using Microsimulation Modeling to Inform EHE Implementation Strategies in Los Angeles County. J Acquir Immune Defic Syndr 2022; 90:S167-S176. [PMID: 35703769 PMCID: PMC9216245 DOI: 10.1097/qai.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is essential to ending HIV. Yet, uptake remains uneven across racial and ethnic groups. We aimed to estimate the impacts of alternative PrEP implementation strategies in Los Angeles County. SETTING Men who have sex with men, residing in Los Angeles County. METHODS We developed a microsimulation model of HIV transmission, with inputs from key local stakeholders. With this model, we estimated the 15-year (2021-2035) health and racial and ethnic equity impacts of 3 PrEP implementation strategies involving coverage with 9000 additional PrEP units annually, above the Status-quo coverage level. Strategies included PrEP allocation equally (strategy 1), proportionally to HIV prevalence (strategy 2), and proportionally to HIV diagnosis rates (strategy 3), across racial and ethnic groups. We measured the degree of relative equalities in the distribution of the health impacts using the Gini index (G) which ranges from 0 (perfect equality, with all individuals across all groups receiving equal health benefits) to 1 (total inequality). RESULTS HIV prevalence was 21.3% in 2021 [Black (BMSM), 31.1%; Latino (LMSM), 18.3%, and White (WMSM), 20.7%] with relatively equal to reasonable distribution across groups (G, 0.28; 95% confidence interval [CI], 0.26 to 0.34). During 2021-2035, cumulative incident infections were highest under Status-quo (n = 24,584) and lowest under strategy 3 (n = 22,080). Status-quo infection risk declined over time among all groups but remained higher in 2035 for BMSM (incidence rate ratio, 4.76; 95% CI: 4.58 to 4.95), and LMSM (incidence rate ratio, 1.74; 95% CI: 1.69 to 1.80), with the health benefits equally to reasonably distributed across groups (G, 0.32; 95% CI: 0.28 to 0.35). Relative to Status-quo, all other strategies reduced BMSM-WMSM and BMSM-LMSM disparities, but none reduced LMSM-WMSM disparities by 2035. Compared to Status-quo, strategy 3 reduced the most both incident infections (% infections averted: overall, 10.2%; BMSM, 32.4%; LMSM, 3.8%; WMSM, 3.5%) and HIV racial inequalities (G reduction, 0.08; 95% CI: 0.02 to 0.14). CONCLUSIONS Microsimulation models developed with early, continuous stakeholder engagement and inputs yield powerful tools to guide policy implementation.
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Affiliation(s)
- Emmanuel F. Drabo
- Department of Health Policy and Management, John Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of Los Angeles, CA
| | - Anthony Nguyen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, CA
| | - Wendy H. Garland
- Los Angeles County Department of Public Health, Division of HIV and STD Programs, Los Angeles, CA
| | - Ian W. Holloway
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of Los Angeles, CA
- Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, CA
| | - Arleen Leibowitz
- UCLA Center for HIV Identification, Prevention and Treatment Services, University of Los Angeles, CA
- Department of Public Policy, Luskin School of Public Affairs, University of California, Los Angeles, CA
| | - Sze-chuan Suen
- Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, CA
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Stump T, Ethier K, Hirschhorn L, Dakin A, Bouacha N, Freeman A, Bannon J, Gómez W, Moskowitz J, Bouris A. Development of an Implementation Facilitation Strategy to Link Mental Health Screening and eHealth Intervention for Clients in Ryan White-Funded Clinics in Chicago. J Acquir Immune Defic Syndr 2022; 90:S197-S205. [PMID: 35703772 PMCID: PMC9204837 DOI: 10.1097/qai.0000000000002980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To reduce the impact of depression on people living with HIV, we are implementing a clinic-based behavioral health screener and referral to Optimizing Resilience and Coping with HIV through Internet Delivery, an evidenced-based intervention. We used the Consolidated Framework for Implementation Research to identify contextual barriers and facilitators in advance of implementation. SETTING Sixteen Chicagoland area Ryan White Medical Case Management sites. METHODS We conducted a sequential mixed-methods study with medical case managers and supervisors. Participants completed an online survey assessing Consolidated Framework for Implementation Research domains, scored on a 1 (strongly disagree) to 5 (strongly agree) scale. Survey results informed a purposive sampling frame and interview protocol. Interviews were analyzed by rapid qualitative analysis. RESULTS On average, survey respondents (n = 58) slightly agreed with positive views of team culture, learning climate, and implementation readiness (mean = 3.80-3.87). Potential barriers included intervention complexity (mean = 3.47), needed human resources (mean = 2.71-3.33), and only slight agreement with relative advantage over existing screening/referral systems (mean = 3.09-3.71). Qualitative results (n = 15) identified low advantage for clinics with robust behavioral health systems but strong advantage in clinics without these services. Respondents identified system-wide training and monitoring strategies to facilitate implementation. CONCLUSIONS Ryan White Medical Case Management sites are a generally favorable context for the implementation of the interventions. As illustrated in an implementation research logic model, barriers will be addressed through deploying strategies proposed to impact clinic- and individual-level outcomes, including electronic prompts (reduce complexity), training on Optimizing Resilience and Coping with HIV through Internet Delivery as a complement to other behavioral health services (increase relative advantage), and feedback during implementation (strengthen rewards/incentives).
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Affiliation(s)
- Tammy Stump
- Northwestern University Feinberg School of Medicine, University of Illinois – Chicago
| | - Kristen Ethier
- University of Chicago Crown Family School of Social Work, Policy and Practice, University of Illinois – Chicago
| | - Lisa Hirschhorn
- Northwestern University Feinberg School of Medicine, University of Illinois – Chicago
| | - Andrea Dakin
- AIDS Foundation Chicago, University of Illinois – Chicago
| | - Nora Bouacha
- AIDS Foundation Chicago, University of Illinois – Chicago
| | - Angela Freeman
- Northwestern University Feinberg School of Medicine, University of Illinois – Chicago
| | - Jacqueline Bannon
- Northwestern University Feinberg School of Medicine, University of Illinois – Chicago
| | - Walter Gómez
- Jane Addams College of Social Work, University of Illinois – Chicago
| | - Judith Moskowitz
- Northwestern University Feinberg School of Medicine, University of Illinois – Chicago
| | - Alida Bouris
- University of Chicago Crown Family School of Social Work, Policy and Practice, University of Illinois – Chicago
- Chicago Center for HIV Elimination
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Queiroz A, Mongrella M, Keiser B, Li DH, Benbow N, Mustanski B. Profile of the Portfolio of NIH-Funded HIV Implementation Research Projects to Inform Ending the HIV Epidemic Strategies. J Acquir Immune Defic Syndr 2022; 90:S23-S31. [PMID: 35703752 PMCID: PMC10204808 DOI: 10.1097/qai.0000000000002962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The US government created an initiative to end the HIV epidemic in the United States by the year 2030 (EHE). This multiagency initiative was structured around four pillars: Prevent, Diagnose, Treat, and Respond to improve HIV programs, resources, and service delivery infrastructure. In support of its research mission, the National Institutes of Health (NIH) has funded implementation research (IR) projects by addressing the four pillars and encouraging investigators to collaborate with local partners and Health and Human Services (HHS) grantees in 57 priority jurisdictions. METHODS This paper analyzed data from the NIH funded CFAR/ARC supplement projects from 2019 to 2021. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to characterize projects by stage of implementation. RESULTS The Prevent pillar was most frequently studied, with Pre-Exposure Prophylaxis (PrEP) being the most studied intervention. The most common partners were health departments, community-based organizations (CBOs), and Federally Qualified Health Centers (FQHCs). The Consolidated Framework for Implementation Research (CFIR) framework was the most utilized to investigate implementation determinants, followed by the RE-AIM framework and Proctor model to assess implementation outcomes. CONCLUSION Monitoring the projects resulting from NIH investments is fundamental to understanding the response to EHE, and achieving these results requires systematic and continuous effort that can support the generalizable implementation knowledge emerging from individual studies. There are some remaining gaps in the project portfolio, including geographical coverage, range of implementation outcomes being measured, and interventions still requiring further research to ensure equitable scale-up of evidence based interventions and achieve EHE goals.
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Affiliation(s)
- Artur Queiroz
- Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, Chicago, IL
| | - Melissa Mongrella
- Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, Chicago, IL
| | - Brennan Keiser
- Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, Chicago, IL
| | - Dennis H Li
- Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, Chicago, IL
- Third Coast Center for AIDS Research, Chicago, IL
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nanette Benbow
- Third Coast Center for AIDS Research, Chicago, IL
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brian Mustanski
- Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, Chicago, IL
- Third Coast Center for AIDS Research, Chicago, IL
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
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Beres LK, Schwartz S, Mody A, Geng E, Baral S. Five Common Myths Limiting Engagement in HIV-Related Implementation Research. J Acquir Immune Defic Syndr 2022; 90:S41-S45. [PMID: 35703754 PMCID: PMC9204845 DOI: 10.1097/qai.0000000000002964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT HIV-related implementation research holds great promise in achieving the potential of efficacious prevention and treatment tools in reducing the incidence of HIV and improving HIV treatment outcomes among people living with HIV. From the perspectives of HIV-related implementation research training and academia and through consultations with funders and investigators new to implementation research, we identified 5 myths that act as barriers to engagement in implementation research among new investigators. Prevailing myths broadly include (1) one must rigidly apply all aspects of an implementation framework for it to be valid, (2) implementation research limits the type of designs available to researchers, (3) implementation strategies cannot be patient-level or client-level approaches, (4) only studies prioritizing implementation outcomes are "true" implementation research, and (5) if not explicitly labeled implementation research, it may have limited impact on implementation. We offer pragmatic approaches to negotiate these myths with the goal of encouraging dialog, ensuring high-quality research, and fostering a more inclusive and dynamic field of implementation research. Ultimately, the goal of dispelling these myths was to lower the perceived bar to engagement in HIV-related implementation research while still ensuring quality in the methods and measures used.
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Affiliation(s)
- Laura K. Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aaloke Mody
- University of Washington, St. Louis, St. Louis, MO, USA
| | - Elvin Geng
- University of Washington, St. Louis, St. Louis, MO, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Cardoso-Weinberg A, Alley C, Kupfer LE, Aslanyan G, Makanga M, Zicker F, Olesen OF. Funders' Perspectives on Supporting Implementation Research in Low- and Middle-Income Countries. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00497. [PMID: 35487544 PMCID: PMC9053148 DOI: 10.9745/ghsp-d-21-00497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/01/2022] [Indexed: 11/23/2022]
Abstract
We identify and discuss 7 approaches for funders to contemplate when considering support for implementation research in low- and middle-income countries.
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Affiliation(s)
- Ana Cardoso-Weinberg
- European & Developing Countries Clinical Trials Partnership, EDCTP, The Hague, The Netherlands.
| | - Chris Alley
- Hunter College, City University of New York, New York, NY, USA
| | - Linda E Kupfer
- Fogarty International Center - National Institutes of Health (NIH), Bethesda, MD, USA
| | - Garry Aslanyan
- TDR, the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland
| | - Michael Makanga
- European & Developing Countries Clinical Trials Partnership, EDCTP, The Hague, Netherlands
| | - Fabio Zicker
- Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | - Ole F Olesen
- European Vaccine Initiative (EVI), Heidelberg, Germany & Global Health Section, Department of Public Health, University of Copenhagen, Denmark
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Liu C, Lee JH, Gupta AJ, Tucker A, Larkin C, Turimumahoro P, Katamba A, Davis JL, Dowdy D. Cost-effectiveness analysis of human-centred design for global health interventions: a quantitative framework. BMJ Glob Health 2022; 7:bmjgh-2021-007912. [PMID: 35346954 PMCID: PMC8961136 DOI: 10.1136/bmjgh-2021-007912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/26/2022] [Indexed: 11/04/2022] Open
Abstract
Introduction Human-centred design (HCD) is a problem-solving approach that is increasingly used to develop new global health interventions. However, there is often a large initial cost associated with HCD, and global health decision-makers would benefit from an improved understanding of the cost-effectiveness of HCD, particularly the trade-offs between the up-front costs of design and the long-term costs of delivering health interventions. Methods We developed a quantitative framework from a health systems perspective to illustrate the conditions under which HCD-informed interventions are likely to be cost-effective, taking into consideration five elements: cost of HCD, per-client intervention cost, anticipated number of clients reached, anticipated incremental per-client health benefit (ie, disability-adjusted life years (DALYs) averted) and willingness-to-pay. We evaluated several combinations of fixed and implementation cost scenarios based on the estimated costs of an HCD-informed approach to tuberculosis (TB) contact investigation in Uganda over a 2-year period to illustrate the use of this framework. Results The cost-effectiveness of HCD-informed TB contact investigation in Uganda was estimated to vary from US$8400 (2400 clients reached, lower HCD cost estimate) to US$306 000 per DALY averted (120 clients reached, baseline HCD cost estimate). In our model, cost-effectiveness was improved further when the interventions were expected to have wider reach or higher per-client health benefits. Conclusion HCD can be cost-effective when used to inform interventions that are anticipated to reach a large number of clients, or in which the cost of HCD is smaller relative to the cost of delivering the intervention itself.
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Affiliation(s)
- Chen Liu
- Department of Division of Pulmonary & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jae Hyoung Lee
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda J Gupta
- Department of Health Equity and Social Justice, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Austin Tucker
- Department of Population Health Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Patricia Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - J Lucian Davis
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
- Department of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Central, Uganda
- Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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12
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Harmonizing Implementation and Outcome Data Across HIV Prevention and Care Studies in Resource-Constrained Settings. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2022; 2:166-177. [PMID: 35411334 PMCID: PMC8987520 DOI: 10.1007/s43477-022-00042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/25/2022] [Indexed: 12/15/2022]
Abstract
Harmonizing measures across studies can facilitate comparisons and strengthen the science, but procedures for establishing common data elements are rarely documented. We detail a rigorous, 2-year process to harmonize measures across the Prevention And Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) consortium, consisting of eight federally-funded studies. We created a repository of measured constructs from each study, classified and selected constructs for harmonization, and identified survey instruments. Measures were harmonized for implementation science, HIV prevention and care, demographics and sexual behavior, mental health and substance use, and economic assessment. Importantly, we present our harmonized implementation science constructs. A common set of implementation science constructs have yet to be recommended in the literature for low-to-middle-income countries despite increasing recognition of their importance to delivering and scaling up effective interventions. Drawing on RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) and the Implementation Outcomes Framework, items were harmonized for staff/administrators and study participants to measure reach, adoption, implementation, maintenance, feasibility, acceptability, appropriateness, and fidelity. The process undertaken to harmonize measures and the codified set of implementation science measures developed by our consortium can inform future data harmonization efforts, critical to strengthening the replication and generalizability of findings while facilitating collaborative research-especially in resource-limited settings. We conclude with recommendations for research consortia, namely ensuring representation from all study teams and research priorities; adopting a flexible, transparent, and systematic approach; strengthening the literature on implementation science harmonization; and being responsive to life events (e.g., COVID-19). Supplementary Information The online version contains supplementary material available at 10.1007/s43477-022-00042-7.
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Lunze K, Kiriazova T, Blokhina E, Bushara N, Bridden C, Gnatienko N, Bendiks S, Quinn E, Krupitsky E, Raj A, Samet JH. Linking HIV-positive people in addiction care to HIV services in St. Petersburg, Russia - Mixed-methods implementation study of strengths-based case management. Glob Public Health 2021; 16:1711-1723. [PMID: 33091311 PMCID: PMC8634803 DOI: 10.1080/17441692.2020.1834599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
Abstract
Access to HIV services for HIV-positive patients in addiction care is challenging in Russia, because both care systems are organised independently from each other. Strengths-based case management is an effective strategy to connect people with HIV (PHIV) to HIV care. This mixed-methods study's objective was to investigate implementation of a case management intervention in St. Petersburg, Russia, designed to connect PHIV who inject drugs to HIV care. We analysed survey data from 118 HIV-positive patients in addiction care and conducted six focus groups (n=38). Quantitative analyses of fidelity and satisfaction outcomes and qualitative text analysis assessed intervention implementation. Participants who linked to HIV services embraced empowerment and motivation resulting from case management as supporting self-efficacy and linkage to services. Among participants who did not link to care, drug use impeded their care engagement. Main levers to implementation were empowerment to cope with challenges of a fragmented health system and persistent stigma. Those who connected to HIV services credited case managers for facilitating linkage; those who did not link attributed it to personal issues. Implementation of case management for HIV care in Russia should focus on effective substance use treatment and empowerment, motivation and support in addressing personal and system factors.
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Affiliation(s)
- Karsten Lunze
- Boston University School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA
| | | | - Elena Blokhina
- First Pavlov State Medical University, St. Petersburg, Russia
| | - Natalia Bushara
- First Pavlov State Medical University, St. Petersburg, Russia
| | - Carly Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Natalia Gnatienko
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Sally Bendiks
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Emily Quinn
- Boston University School of Public Health, Boston, MA, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical University, St. Petersburg, Russia
- Bekhterev National Medical Research Center for Psychiatry and Neurology, St. Petersburg, Russia
| | - Anita Raj
- Department of Medicine, Center on Gender Equity and Health, University of California - San Diego School of Medicine, La Jolla, California, USA
| | - Jeffrey H Samet
- Boston University School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA
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14
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Varallyay NI, Bennett SC, Kennedy C, Ghaffar A, Peters DH. How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean. Health Policy Plan 2021; 35:ii98-ii111. [PMID: 33156937 PMCID: PMC7646734 DOI: 10.1093/heapol/czaa126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 01/04/2023] Open
Abstract
Innovative strategies are needed to improve the delivery of evidence-informed health interventions. Embedded implementation research (EIR) seeks to enhance the generation and use of evidence for programme improvement through four core features: (1) central involvement of programme/policy decision-makers in the research cycle; (2) collaborative research partnerships; (3) positioning research within programme processes and (4) research focused on implementation. This paper examines how these features influence evidence-to-action processes and explores how they are operationalized, their effects and supporting conditions needed. We used a qualitative, comparative case study approach, drawing on document analysis and semi-structured interviews across multiple informant groups, to examine three EIR projects in Bolivia, Colombia and the Dominican Republic. Our findings are presented according to the four core EIR features. The central involvement of decision-makers in EIR was enhanced by decision-maker authority over the programme studied, professional networks and critical reflection. Strong research-practice partnerships were facilitated by commitment, a clear and shared purpose and representation of diverse perspectives. Evidence around positioning research within programme processes was less conclusive; however, as all three cases made significant advances in research use and programme improvement, this feature of EIR may be less critical than others, depending on specific circumstances. Finally, a research focus on implementation demanded proactive engagement by decision-makers in conceptualizing the research and identifying opportunities for direct action by decision-makers. As the EIR approach is a novel approach in these low-resource settings, key supports are needed to build capacity of health sector stakeholders and create an enabling environment through system-level strategies. Key implications for such supports include: promoting EIR and creating incentives for decision-makers to engage in it, establishing structures or mechanisms to facilitate decision-maker involvement, allocating funds for EIR, and developing guidance for EIR practitioners.
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Affiliation(s)
- N Ilona Varallyay
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
- Corresponding author. Malabia 1970, Buenos Aires CABA 1414,
Argentina. E-mail:
| | - Sara C Bennett
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
| | - Caitlin Kennedy
- Social and Behavioral Interventions Program, Department of
International Health, Johns Hopkins School of Public Health, 615 N Wolfe St,
Baltimore, MD 21205, United States
| | - Abdul Ghaffar
- The Alliance for Health Policy and Systems Research at the
World Health Organization, 20 avenue Appia, 1211 Geneva, Switzerland
| | - David H Peters
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
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van den Berg JJ, O'Keefe E, Davidson D, Fiellin DA, Kershaw T, Barbour RC, Cu-Uvin S, Cleary PD. The development and evaluation of an HIV implementation science network in New England: lessons learned. Implement Sci Commun 2021; 2:64. [PMID: 34112269 PMCID: PMC8192037 DOI: 10.1186/s43058-021-00165-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 05/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Describe and evaluate an implementation science network focused on HIV prevention and treatment in New England. METHODS In 2014, we established a partnership among university researchers and community stakeholders to stimulate and support HIV-related implementation research. We solicited information from Network members through surveys, interviews at Network events, and dialog with participants. In 2017, we conducted a sociocentric network assessment of collaborations on research projects, grants, manuscripts, and consultations. RESULTS We identified 988 connections made through the Network that resulted in 185 manuscripts published and 15 grants funded. Our experience indicated that eight factors were instrumental in building and sustaining the Network: (1) acknowledging different perspectives, (2) balancing content and expertise, (3) encouraging consistent engagement, (4) providing seed funding, (5) membership flexibility, (6) maintenance of Network interactions, (7) supporting local HIV prevention and treatment efforts, and (8) maintaining productive relationships with health departments and community-based organizations. CONCLUSIONS Developing and maintaining a regional network on implementation science for HIV prevention and treatment is feasible and can facilitate new and productive partnerships among researchers and community organizations and members.
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Affiliation(s)
- Jacob J van den Berg
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, RI, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elaine O'Keefe
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA
| | - Daniel Davidson
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA
| | - David A Fiellin
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA.,Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Trace Kershaw
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA.,Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College Street, New Haven, CT, 06520-8034, USA
| | - Russell C Barbour
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA
| | - Susan Cu-Uvin
- Department of Ob-Gyn and Medicine, Alpert School of Medicine, Brown University, Providence, USA.,Division of Infectious Diseases, The Miriam Hospital, Providence, RI, USA
| | - Paul D Cleary
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA. .,Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT, 06520-8034, USA.
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16
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Implementing Implementation Research: Teaching Implementation Research to HIV Researchers. Curr HIV/AIDS Rep 2021; 18:186-197. [PMID: 33709323 DOI: 10.1007/s11904-021-00551-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Given the growth in HIV-related implementation research, there is a need to expand the workforce and rigor through implementation science (IS) training and mentorship. Our objective is to review IS training opportunities for HIV-focused researchers and describe the approach and lessons learned from a recent HIV-related implementation research training initiative. RECENT FINDINGS IS training opportunities range from degree programs to short- and longer-term professional development institutes and community-focused institutional trainings. Until recently, there have not been extensive dedicated opportunities for implementation research training for HIV-focused investigators. To meet this gap, an inter-Center for AIDS Research IS Fellowship for early-stage investigators was launched in 2019, building on lessons learned from dissemination and implementation training programs. Key components of the HIV-focused IS fellowship include didactic training, mentorship, grant-writing, and development of HIV-IS collaborative networks. Fellows to-date were two-thirds junior faculty and one-third post-doctoral fellows, the majority (69%) with prior public health training. Perceived value of the program was high, with a median rating of 9 [IQR 8-9] on a 10-point scale. Overall, 22/27 (81%) Fellows from the first cohort submitted IS-related grants within 12 months of Fellowship completion, and by 1 year 13 grants had been funded among 10 investigators, 37% overall among Fellows. Mentors identified framing of IS questions as the top-ranked training priority for HIV-investigators. Increasing knowledge of the utility of IS may support more grants focused on optimal implementation of HIV treatment and prevention strategies. Experiences from mentors and trainees engaged in an IS-focused fellowship for HIV investigators demonstrate the demand and value of a dedicated training program and reinforce the importance of mentorship.
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Nnaji CA, Wiysonge CS, Okeibunor JC, Malinga T, Adamu AA, Tumusiime P, Karamagi H. Implementation research approaches to promoting universal health coverage in Africa: a scoping review. BMC Health Serv Res 2021; 21:414. [PMID: 33941178 PMCID: PMC8094606 DOI: 10.1186/s12913-021-06449-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/27/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa. METHODS The review protocol was developed based on the methodological framework proposed by Arksey and O'Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion. RESULTS The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers. CONCLUSIONS This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region.
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Affiliation(s)
- Chukwudi A Nnaji
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Joseph C Okeibunor
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Thobile Malinga
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Abdu A Adamu
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Prosper Tumusiime
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Humphrey Karamagi
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
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Nnaji CA, Wiysonge CS, Okeibunor J, Malinga T, Adamu AA, Tumusiime P, Karamagi H. Protocol for a scoping review of implementation research approaches to universal health coverage in Africa. BMJ Open 2021; 11:e041721. [PMID: 33589452 PMCID: PMC7887369 DOI: 10.1136/bmjopen-2020-041721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of institutions and initiatives promoting the uptake of implementation research in Africa, their role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). This review aims to extensively identify and characterise the nature, facilitators and barriers to the use of implementation research for assessing or evaluating UHC-related interventions or programmes in Africa. METHODS AND ANALYSIS This scoping review will be developed based on the methodological framework proposed by Arksey and O'Malley and enhanced by the Joanna Briggs Institute. It will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive search of the following electronic databases will be conducted: Medline (via PubMed), Scopus and the Cochrane Library. Relevant grey literature and reference lists will also be searched. All publications describing the application of implementation research in the context of UHC will be considered for inclusion. Findings will be narratively synthesised and analysed using a predefined conceptual framework. Where applicable, quantitative evidence will be aggregated using summary statistics. There will be consultation of stakeholders, including UHC-oriented health professionals, programme managers, implementation researchers and policy-makers; to provide methodological, conceptual and practical insights. ETHICS AND DISSEMINATION The data used in this review will be sourced from publicly available literature; hence, this study will not require ethical approval. Findings and recommendations will be disseminated to reach a diverse audience, including UHC advocates, implementation researchers and key health system stakeholders within the African region. Additionally, findings will be disseminated through an open-access publication in a relevant peer-reviewed journal.
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Affiliation(s)
- Chukwudi A Nnaji
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Charles S Wiysonge
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Joseph Okeibunor
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Thobile Malinga
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Abdu A Adamu
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Prosper Tumusiime
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Humphrey Karamagi
- Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
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Shangani S, Bhaskar N, Richmond N, Operario D, van den Berg JJ. A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States. AIDS 2021; 35:177-191. [PMID: 33048881 DOI: 10.1097/qad.0000000000002713] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions. METHODS We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions. RESULTS A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world. CONCLUSION HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.
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Affiliation(s)
- Sylvia Shangani
- College of Health Sciences, Department of Community & Environmental Health, Old Dominion University, Norfolk, Virginia
| | - Nidhi Bhaskar
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Natasha Richmond
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Don Operario
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Jacob J van den Berg
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
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Understanding HIV Program Effects: A Structural Approach to Context Using the Transportability Framework. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S199-S205. [PMID: 31764255 DOI: 10.1097/qai.0000000000002202] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implementation science focuses on evaluating strategies for delivering evidence-based interventions to improve HIV prevention and treatment. The effectiveness of these implementation strategies is often context-dependent and reconciling the desire to produce generalizable knowledge in the face of these contextual interventions is a central challenge for implementation science researchers. METHODS We provide an overview of the causal transportability theory and conceptualize context under this framework. We review how causal graphs can be used to illustrate the assumptions necessary to apply the results of a study to a new context, and we illustrate this approach using an example of a community adherence group intervention that aims to improve retention in HIV care. Finally, we discuss several key insights highlighted by the transportability theory that are relevant to implementation science researchers. RESULTS By adopting causal transportability to consider how context may affect the success of an implementation strategy, researchers can formally diagnose when the results of a study are likely to generalize to a given setting. Moreover, selection diagrams can highlight what additional measurements would be needed in a target population to estimate the effect of an implementation strategy in that target population without having to repeat the initial study. CONCLUSIONS Transportability translates intuition about context-dependent interventions and external validity into actionable and testable insight.
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Integrating Economic Evaluation and Implementation Science to Advance the Global HIV Response. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S314-S321. [PMID: 31764269 DOI: 10.1097/qai.0000000000002219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous cost-effectiveness analyses have indicated good value for money from a wide array of interventions for treatment and prevention of HIV/AIDS. There is limited evidence, however, regarding how cost-effectiveness information contributes to better decision-making around investment and action in the global HIV response. METHODS We review challenges for economic evaluation relevant to the global HIV response and consider how the practice of cost-effectiveness analysis could integrate approaches and insights from implementation science to enhance the impact and efficiency of HIV investments. RESULTS In light of signals that cost-effectiveness analyses may be vulnerable to systematic bias toward overly optimistic conclusions, we emphasize two priorities for advancing the field of economic evaluation in HIV/AIDS and more broadly in global health: (1) systematic reevaluation of the cost-effectiveness literature with reference to ex-post empirical evidence on costs and effects in real-world programs and (2) development and adoption of good-practice guidelines for incorporating implementation and delivery aspects into economic evaluations. Toward the latter aim, we propose an integrative approach that focuses on comparative evaluation of strategies, which specify both technologies/interventions as well as the delivery platforms, complementary interventions, and actions needed to increase coverage, quality, and uptake of those technologies/interventions. Specific recommendations draw on several existing implementation science models that provide systematic frameworks for understanding implementation barriers and enablers, designing and choosing specific implementation and policy actions, and evaluating outcomes. DISCUSSION These preliminary steps aimed at bridging the divide between economic evaluation and implementation science can help to advance the practice of economic evaluation toward a science of comparative strategy evaluation.
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Repositioning Implementation Science in the HIV Response: Looking Ahead From AIDS 2018. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S299-S304. [PMID: 31764267 DOI: 10.1097/qai.0000000000002209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implementation science (IS) occupies a critical place in HIV/AIDS research, reflected by a scientific track ("Track E") at the biannual International AIDS Conference. IS seeks to identify health delivery strategies that cost-effectively translate the efficacy of evidence-based interventions for HIV prevention, testing, and treatment into impact on HIV incidence, quality of life, and mortality. METHOD We reviewed the content of Track E, and other presentations relevant to IS, at the 22nd International AIDS Conference held in Amsterdam in 2018. We identified key findings and themes and made recommendations for areas where the field can be strengthened by the 2020 meeting. RESULTS Trials of "treat all" strategies in Africa showed mixed evidence of effect. Innovations in HIV testing included expanding self-testing and index testing, which are reaching groups, such as men, where previously testing rates have been low. Adherence clubs and other innovations are being trialed to improve retention in care, with mixed findings. The implementation of pre-exposure prophylaxis for HIV prevention continues but with many challenges remaining in identifying implementation strategies that strengthen demand and support continuation. DISCUSSION IS for HIV/AIDS treatment and prevention continues to expand. IS for primary HIV prevention must be prioritized with a dearth of rigorous, intersectoral studies in this area. The weakness of routine data must be addressed. Costing and financing studies should form a stronger component of the conference agenda. Implementation scientists must continue to grapple with the methodological challenges posed by the real-world context for their research.
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Huebner DM, Mustanski B. Navigating the Long Road Forward for Maximizing PrEP Impact Among Adolescent Men Who Have Sex with Men. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:211-216. [PMID: 31667642 PMCID: PMC7665846 DOI: 10.1007/s10508-019-1454-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 03/13/2019] [Accepted: 04/06/2019] [Indexed: 06/10/2023]
Abstract
Preexposure prophylaxis (PrEP) has tremendous potential to decrease new HIV infections among populations at high risk, such as men who have sex with men (MSM). That potential is already becoming realized among adult MSM, where PrEP uptake has increased rapidly in the past several years. However, expanding PrEP access to adolescent MSM (AMSM) will be more challenging. This commentary reviews the existing scientific literature relevant to PrEP use for AMSM and highlights critical areas in need of further attention before PrEP is likely to impact the HIV epidemic among adolescents. We highlight concerns that need to be addressed in the areas of (1) achieving adequate coverage of PrEP in the adolescent population, (2) increasing awareness and access, (3) supporting adherence and maintenance, and (4) ensuring that PrEP does not perpetuate existing disparities. Across all of these domains, we highlight the central roles of parents and healthcare providers in supporting AMSM PrEP utilization. Finally, we suggest a number of areas of future research that must be addressed before PrEP is likely to see wide implementation among AMSM.
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Affiliation(s)
- David M Huebner
- Department of Prevention and Community Health, George Washington University, 950 New Hampshire Ave., NW, 3rd Floor, Washington, DC, 20052, USA.
| | - Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
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Windle M, Lee HD, Cherng ST, Lesko CR, Hanrahan C, Jackson JW, McAdams-DeMarco M, Ehrhardt S, Baral SD, D’Souza G, Dowdy DW. From Epidemiologic Knowledge to Improved Health: A Vision for Translational Epidemiology. Am J Epidemiol 2019; 188:2049-2060. [PMID: 30927354 DOI: 10.1093/aje/kwz085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 12/18/2022] Open
Abstract
Epidemiology should aim to improve population health; however, no consensus exists regarding the activities and skills that should be prioritized to achieve this goal. We performed a scoping review of articles addressing the translation of epidemiologic knowledge into improved population health outcomes. We identified 5 themes in the translational epidemiology literature: foundations of epidemiologic thinking, evidence-based public health or medicine, epidemiologic education, implementation science, and community-engaged research (including literature on community-based participatory research). We then identified 5 priority areas for advancing translational epidemiology: 1) scientific engagement with public health; 2) public health communication; 3) epidemiologic education; 4) epidemiology and implementation; and 5) community involvement. Using these priority areas as a starting point, we developed a conceptual framework of translational epidemiology that emphasizes interconnectedness and feedback among epidemiology, foundational science, and public health stakeholders. We also identified 2-5 representative principles in each priority area that could serve as the basis for advancing a vision of translational epidemiology. We believe an emphasis on translational epidemiology can help the broader field to increase the efficiency of translating epidemiologic knowledge into improved health outcomes and to achieve its goal of improving population health.
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Affiliation(s)
- Michael Windle
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Hojoon D Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Sarah T Cherng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Colleen Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Mara McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Stephan Ehrhardt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Stefan D Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore Maryland
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Harling G, Tsai AC. Using Social Networks to Understand and Overcome Implementation Barriers in the Global HIV Response. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S244-S252. [PMID: 31764260 PMCID: PMC6923140 DOI: 10.1097/qai.0000000000002203] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite the development of several efficacious HIV prevention and treatment methods in the past 2 decades, HIV continues to spread globally. Uptake of interventions is nonrandomly distributed across populations. Such inequality is socially patterned and reinforced by homophily arising from both social selection (becoming friends with similar people) and influence (becoming similar to friends). METHODS We conducted a narrative review to describe how social network analysis methods-including egocentric, sociocentric, and respondent-driven sampling designs-provide tools to measure key populations, to understand how epidemics spread, and to evaluate intervention take-up. RESULTS Social network analysis-informed designs can improve intervention effectiveness by reaching otherwise inaccessible populations. They can also improve intervention efficiency by maximizing spillovers, through social ties, to at-risk but susceptible individuals. Social network analysis-informed designs thus have the potential to be both more effective and less unequal in their effects, compared with social network analysis-naïve approaches. Although social network analysis-informed designs are often resource-intensive, we believe they provide unique insights that can help reach those most in need of HIV prevention and treatment interventions. CONCLUSION Increased collection of social network data during both research and implementation work would provide important information to improve the roll-out of existing studies in the present and to inform the design of more data-efficient, social network analysis-informed interventions in the future. Doing so will improve the reach of interventions, especially to key populations, and to maximize intervention impact once delivered.
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Affiliation(s)
- Guy Harling
- Institute for Global Health, University College London, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard University, Cambridge MA, United States
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C. Tsai
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard University, Cambridge MA, United States
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston MA United States
- Mbarara University of Science and Technology, Mbarara, Uganda
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Odeny TA, Hughes JP, Bukusi EA, Akama E, Geng EH, Holmes KK, McClelland RS. Text messaging for maternal and infant retention in prevention of mother-to-child HIV transmission services: A pragmatic stepped-wedge cluster-randomized trial in Kenya. PLoS Med 2019; 16:e1002924. [PMID: 31577792 PMCID: PMC6774469 DOI: 10.1371/journal.pmed.1002924] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 08/29/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Timely diagnosis of infant HIV infection is essential for antiretroviral therapy (ART) initiation. In a randomized controlled trial, we found the Texting Improves Testing (TextIT) intervention (a theory-based text messaging system) to be efficacious for improving infant HIV testing rates and maternal retention in prevention of mother-to-child HIV transmission (PMTCT) programs. Using an implementation science approach, we aimed to evaluate real-world effectiveness of the intervention. METHODS AND FINDINGS In a pragmatic, cluster-randomized, stepped-wedge trial with 2 time periods of observation, we randomly allocated 10 clinics to begin implementing the intervention immediately and 10 clinics to begin implementing 6 months later. To approximate real-world conditions, inclusion criteria were broad. Women at clinics implementing the intervention received up to 14 text messages during pregnancy and after delivery and had the option to respond to text messages, call, or send inquiry text messages to a designated clinic phone. The primary outcomes were infant HIV testing and maternal retention in care during the first 8 weeks after delivery. We used modified Poisson regression with robust variance estimation to estimate the relative risk and 95% confidence intervals (CIs). Generalized estimating equations were applied on individual-level data to account for clustering by site. Between February 2015 and December 2016, 4,681 women were assessed for study participation, and 2,515 were included. Participant characteristics at enrollment did not differ by study arm. Overall median age was 27 years (interquartile range [IQR] 23-30), median gestational age was 30 weeks (IQR 28-34), 99% were receiving ART, and 87% who enrolled during intervention phases owned a phone. Of 2,326 infants analyzed, 1,466 of 1,613 (90.9%) in the intervention group and 609 of 713 (85.4%) in the control group met the primary outcome of HIV virologic testing performed before 8 weeks after birth (adjusted relative risk [aRR] 1.03; 95% CI 0.97-1.10; P = 0.3). Of 2,472 women analyzed, 1,548 of 1,725 (90%) in the intervention group and 571 of 747 (76%) in the control group met the primary outcome of retention in care during the first 8 weeks after delivery (aRR 1.12; 95% CI 0.97-1.30; P = 0.1). This study had two main limitations. Staff at all facilities were aware of ongoing observation, which may have contributed to increased rates of infant HIV testing and maternal retention in care at both intervention and control facilities, and programmatic initiatives to improve maternal and infant retention in care were ongoing at all facilities at the time of this study, which likely limited the ability to demonstrate effectiveness of the trial intervention. CONCLUSIONS In this study, a larger proportion of infants in the intervention group received HIV testing compared with the control group, but the difference was small and not statistically significant. There was also a nonsignificant increase in maternal postpartum retention in the intervention periods. Despite the lack of a significant effect of the intervention, key lessons emerged, both for strengthening PMTCT and for implementation research in general. Perhaps most important, improving the implementation of usual care may have been sufficient to substantially improve infant HIV testing rates. TRIAL REGISTRATION ClinicalTrials.gov Trial Number NCT02350140.
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Affiliation(s)
- Thomas A. Odeny
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Elvin H. Geng
- University of California San Francisco, San Francisco, California, United States of America
| | - King K. Holmes
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Center for AIDS Research, University of Washington, Seattle, Washington, United States of America
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
| | - R. Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
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Implementation of eHealth Interventions Across the HIV Care Cascade: a Review of Recent Research. Curr HIV/AIDS Rep 2019; 15:403-413. [PMID: 30171519 DOI: 10.1007/s11904-018-0415-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW We review recent implementation science focusing on eHealth interventions to improve outcomes along the HIV care cascade. We highlight several gaps in the eHealth implementation literature and propose areas for future study. RECENT FINDINGS We identified 17 studies conducted in North America, Europe, and sub-Saharan Africa assessing the acceptability, appropriateness, adoption, cost, feasibility, fidelity, penetration, or sustainability of eHealth interventions targeting the HIV care cascade. Most interventions used SMS messages to improve cascade outcomes. Feasibility research has demonstrated the importance of adaptability for intervention scale-up and delivery. Key gaps in the literature remain related to predictors of the adoption of eHealth interventions by health facilities and staff. In addition, no studies explored sustainability and few used theoretical frameworks for implementation research or validated measures of implementation outcomes. We propose next steps for the future of eHealth implementation research to inform the delivery, scale-up, and maintenance of eHealth interventions in the real world.
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28
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Ortblad KF, Baeten JM, Cherutich P, Wamicwe JN, Wasserheit JN. The arc of HIV epidemics in sub-Saharan Africa: new challenges with concentrating epidemics in the era of 90-90-90. Curr Opin HIV AIDS 2019; 14:354-365. [PMID: 31343457 PMCID: PMC6669088 DOI: 10.1097/coh.0000000000000569] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to examine the emerging results from the HIV universal test and treat (UTT) cluster-randomized trials in sub-Saharan Africa, discuss how expanding access to HIV clinical services is likely to reshape the arc of HIV epidemics, and consider implications for HIV prevention and control strategies in the coming decade. RECENT FINDINGS The effect of universal HIV testing followed by immediate antiretroviral treatment (ART) on community-level HIV incidence remains unclear upon completion of five randomized trials. Only two of the four trials that measured HIV incidence found significant reductions in community-level incidence. Even in these trials, HIV incidence remained above levels required for epidemic control (≤1 case per 1000 person-years) despite high levels of ART coverage and viral suppression. These findings may indicate that community-delivered HIV services are not reaching the high-frequency transmitters who sustain HIV epidemics and are likely members of marginalized or hard to engage core groups. SUMMARY With expanded access to HIV services in sub-Saharan Africa, HIV epidemics are transitioning from hyperendemic to declining/endemic epidemic phases, characterized increasingly by the reconcentration of HIV in marginalized or hard to engage core groups. To move toward epidemic control, novel HIV service delivery models and technologies are needed to engage those who continue to drive HIV incidence in this new epidemic phase.
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Affiliation(s)
| | - Jared M Baeten
- Department of Global Health
- Department of Medicine
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | | | | | - Judith N Wasserheit
- Department of Global Health
- Department of Medicine
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
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Villalobos Dintrans P, Bossert TJ, Sherry J, Kruk ME. A synthesis of implementation science frameworks and application to global health gaps. Glob Health Res Policy 2019; 4:25. [PMID: 31485483 PMCID: PMC6712702 DOI: 10.1186/s41256-019-0115-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/01/2019] [Indexed: 11/25/2022] Open
Abstract
Background Implementation science has been growing as discipline in the past decades, producing an increasing number of models in the area. On the other hand, most frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion, proposing a simplified tool that synthesizes common elements of other frameworks, and highlight the usefulness to use implementation science not only in identifying successful implementation strategies but as a tool to assess gaps in global health initiatives. Methods The study was carried out through a combined methodology that included an initial search of implementation science frameworks, experts’ opinions, and the use of references in frameworks to elaborate a list of articles to be reviewed. A total of 52 articles were analyzed, identifying their definitions of implementation science and the elements of different frameworks. Results The analysis of articles allowed identifying the main goals and definitions of implementation science. In a second stage, frameworks were classified into “time-based”, “component-based” and “mixed”, and common elements of each type of model were used to propose a synthetic framework with six elements: Diagnosis, Intervention provider/ system, Intervention, Recipient, Environment, and Evaluation. Finally, this simplified framework was used to identify gaps in global health was using The Lancet Global Health Series. Potential areas of intervention arise for five different global health issues: malaria, non-communicable diseases, maternal and child health, HIV/AIDS, and tuberculosis. Prioritization strategies differ for the different health issues, and the proposed framework can help identify and classify all these different proposals. Conclusions There is a huge variety of definitions and models in implementation science. The analysis showed the usefulness of applying an implementation science approach to identify and prioritize gaps in implementation strategies in global health. Electronic supplementary material The online version of this article (10.1186/s41256-019-0115-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Jim Sherry
- 3University Research Co., LLC, Chevy Chase, USA
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30
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Cox J, Gutner C, Kronfli N, Lawson A, Robbins M, Nientker L, Ostawal A, Barber T, Croce D, Hardy D, Jessen H, Katlama C, Mallolas J, Rizzardini G, Alcorn K, Wohlfeiler M, Le Fevre E. A need for implementation science to optimise the use of evidence-based interventions in HIV care: A systematic literature review. PLoS One 2019; 14:e0220060. [PMID: 31425524 PMCID: PMC6699703 DOI: 10.1371/journal.pone.0220060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/07/2019] [Indexed: 11/24/2022] Open
Abstract
To improve health outcomes in people living with HIV, adoption of evidence-based interventions (EBIs) using effective and transferable implementation strategies to optimise the delivery of healthcare is needed. ViiV Healthcare's Positive Pathways initiative was established to support the UNAIDS 90-90-90 goals. A compendium of EBIs was developed to address gaps within the HIV care continuum, yet it was unknown whether efforts existed to adapt and implement these EBIs across diverse clinical contexts. Therefore, this review sought to report on the use of implementation science in adapting HIV continuum of care EBIs. A systematic literature review was undertaken to summarise the evaluation of implementation and effectiveness outcomes, and report on the use of implementation science in HIV care. Ten databases were reviewed to identify studies (time-period: 2013-2018; geographic scope: United States, United Kingdom, France, Germany, Italy, Spain, Canada, Australia and Europe; English only publications). Studies were included if they reported on people living with HIV or those at risk of acquiring HIV and used interventions consistent with the EBIs. A broad range of study designs and methods were searched, including hybrid designs. Overall, 118 publications covering 225 interventions consistent with the EBIs were identified. These interventions were evaluated on implementation (N = 183), effectiveness (N = 81), or both outcomes (N = 39). High variability in the methodological approaches was observed. Implementation outcomes were frequently evaluated but use of theoretical frameworks was limited (N = 13). Evaluations undertaken to assess effectiveness were inconsistent, resulting in a range of measures. This review revealed extensive reporting on implementation science as defined using evaluation outcomes. However, high variability was observed in how implementation outcomes and effectiveness were defined, quantified, and reported. A more specific and consistent approach to conducting and reporting on implementation science in HIV could facilitate achievement of UNAIDS 90-90-90 targets.
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Affiliation(s)
- Joseph Cox
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | | | - Nadine Kronfli
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Anna Lawson
- ViiV Healthcare, London, England, United Kingdom
| | | | | | | | - Tristan Barber
- Chelsea and Westminster Hospital, London, England, United Kingdom
| | | | - David Hardy
- Whitman-Walker Centre, Washington, DC, United States of America
| | | | | | | | | | - Keith Alcorn
- NAM publications, London, England, United Kingdom
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Lin C, Li L, Lee SJ, Chen L, Pan Y, Guan J. Using Conjoint Analysis to Investigate Hospital Directors' Preference in Adoption of an Evidence-based Intervention. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2019; 14:328-334. [PMID: 34239710 DOI: 10.1080/20479700.2019.1645925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study used conjoint analysis, a marketing research technique, to investigate hospital stakeholders' decision-making in adoption of evidence-based interventions (EBI). An efficacious hospital-based stigma-reduction intervention was used as a "product" to study adoption of EBI. Sixty hospital directors in Fujian, China evaluated the likelihood of adopting the EBI in their hospitals by rating across eight hypothetical scenarios with preferred and non-preferred levels of seven attributes, including 1) administrative support, 2) cost, 3) personnel involvement, 4) format, 5) duration, 6) technical support, and 7) priority alignment with the hospital. A hierarchical generalized linear model was fit to the likelihood of intervention adoption for the eight scenarios, with the seven attributes served as independent variables. Monetary cost of intervention implementation (impact score=2.12) had the greatest impact on the directors' reported likelihood of adopting the EBI, followed by duration of the intervention (impact score=0.88), availability of technical support (impact score=0.69), and flexibility of format (impact score=0.36). The impact scores of other attributes were not statistically significant. Conjoint analysis was feasible in modeling hospital directors' decision-making in adoption of EBI. The findings suggested the importance of considering cost, duration, technical support, and flexibility of format in development and dissemination of interventions in healthcare settings.
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Affiliation(s)
- Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles, Los Angeles, CA, U.S.A
| | - Li Li
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles, Los Angeles, CA, U.S.A
| | - Sung-Jae Lee
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles, Los Angeles, CA, U.S.A
| | - Liang Chen
- Fujian Provincial Center for Disease Control and Prevention, Fuzhou, China
| | - Yunjiao Pan
- Fujian Provincial Center for Disease Control and Prevention, Fuzhou, China
| | - Jihui Guan
- Fujian Provincial Center for Disease Control and Prevention, Fuzhou, China
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Lama JR, Mayer KH, Perez-Brumer AG, Huerta L, Sanchez H, Clark JL, Sanchez J, Reisner SL. Integration of Gender-Affirming Primary Care and Peer Navigation With HIV Prevention and Treatment Services to Improve the Health of Transgender Women: Protocol for a Prospective Longitudinal Cohort Study. JMIR Res Protoc 2019; 8:e14091. [PMID: 31250829 PMCID: PMC6620883 DOI: 10.2196/14091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Public health strategies are urgently needed to improve HIV disparities among transgender women, including holistic intervention approaches that address those health needs prioritized by the community. Hormone therapy is the primary method by which many transgender women medically achieve gender affirmation. Peer navigation has been shown to be effective to engage and retain underserved populations living with HIV in stable primary medical care. OBJECTIVE This study aims to assess the feasibility and acceptability of an integrated innovative HIV service delivery model designed to improve HIV prevention and care by combining gender-affirming primary care and peer navigation with HIV prevention and treatment services. METHODS A 12-month, nonrandomized, single-arm cohort study was implemented in Lima, Peru, among adult individuals, assigned a male sex at birth, who identified themselves as transgender women, regardless of initiation or completion of medical gender affirmation, and who were unaware of their HIV serostatus or were living with HIV but not engaged in HIV treatment. HIV-negative participants received quarterly HIV testing and were offered to initiate pre-exposure prophylaxis. HIV-positive participants were offered to initiate antiretroviral treatment and underwent quarterly plasma HIV-1 RNA and peripheral CD4+ lymphocyte cell count monitoring. All participants received feminizing hormone therapy and adherence counseling and education on their use. Peer health navigation facilitated retention in care by visiting participants at home, work, or socialization venues, or by contacting them by social media and phone. RESULTS Patient recruitment started in October 2016 and finished in March 2017. The cohort ended follow-up on March 2018. Data analysis is currently underway. CONCLUSIONS Innovative and culturally sensitive strategies to improve access to HIV prevention and treatment services for transgender women are vital to curb the burden of HIV epidemic for this key population. Findings of this intervention will inform future policies and research, including evaluation of its efficacy in a randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov NCT03757117; https://clinicaltrials.gov/ct2/show/NCT03757117. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14091.
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Affiliation(s)
- Javier R Lama
- Asociacion Civil Impacta Salud y Educacion, Lima, Peru
| | | | - Amaya G Perez-Brumer
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States
| | | | | | - Jesse L Clark
- Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Jorge Sanchez
- Centro de Investigaciones Tecnologicas, Biomedicas y Medioambientales, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Sari L Reisner
- The Fenway Institute, Boston, MA, United States
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, United States
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Lau B, Duggal P, Ehrhardt S. Epidemiology at a time for unity. Int J Epidemiol 2019; 47:1366-1371. [PMID: 30165517 DOI: 10.1093/ije/dyy179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephan Ehrhardt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Theobald S, Brandes N, Gyapong M, El-Saharty S, Proctor E, Diaz T, Wanji S, Elloker S, Raven J, Elsey H, Bharal S, Pelletier D, Peters DH. Implementation research: new imperatives and opportunities in global health. Lancet 2018; 392:2214-2228. [PMID: 30314860 DOI: 10.1016/s0140-6736(18)32205-0] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 08/22/2018] [Accepted: 08/29/2018] [Indexed: 12/31/2022]
Abstract
Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.
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Affiliation(s)
- Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Neal Brandes
- US Agency for International Development, Bureau for Global Health, Washington, DC, USA
| | | | - Sameh El-Saharty
- Middle East and North Africa Region, Human Development Sector, The World Bank, Washington, DC, USA
| | - Enola Proctor
- Brown School of Social Work, Washington University in St Louis, St Louis, MO, USA
| | - Theresa Diaz
- Department of Maternal, Newborn, Child, and Adolescent Health, WHO, Geneva, Switzerland
| | - Samuel Wanji
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Soraya Elloker
- City of Cape Town, City Health Department, Cape Town, South Africa
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Elsey
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | | | - David Pelletier
- Programme in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Lancaster KE, Hetrick A, Jaquet A, Adedimeji A, Atwoli L, Colby DJ, Mayor AM, Parcesepe A, Syvertsen J. Substance use and universal access to HIV testing and treatment in sub-Saharan Africa: implications and research priorities. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30342-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Geng EH, Glidden DV, Padian N. Strengthening HIV-prevention trials: a dose of implementation science? THE LANCET. INFECTIOUS DISEASES 2018; 18:1166-1168. [PMID: 30507394 DOI: 10.1016/s1473-3099(18)30567-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Elvin H Geng
- University of California, San Francisco, CA 94117, USA.
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Implementation science for integration of HIV and non-communicable disease services in sub-Saharan Africa: a systematic review. AIDS 2018; 32 Suppl 1:S93-S105. [PMID: 29952795 DOI: 10.1097/qad.0000000000001897] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE As the burden of chronic non-communicable diseases (NCDs) rises across sub-Saharan Africa (SSA), global donors and governments are exploring strategies to integrate HIV and NCD care. Implementation science is an emerging research paradigm that can help such programs achieve health impact at scale. We define implementation science as a systematic, scientific approach to ask and answer questions about how to deliver what works in populations who need it with greater speed, appropriate fidelity, efficiency, and relevant coverage. We identified achievements and gaps in the application of implementation science to HIV/NCD integration, developed an HIV/NCD implementation science research agenda, and detailed opportunities for capacity building and training. DESIGN We conducted a systematic review of the application of implementation science methods to integrated HIV/NCD programs in SSA. METHODS We searched PubMed, CINAHL, PsycINFO, and EMBASE for evaluations of integrated programs in SSA reporting at least one implementation outcome. RESULTS We identified 31 eligible studies. We found that most studies used only qualitative, economic, or impact evaluation methods. Only one study used a theoretical framework for implementation science. Acceptability, feasibility, and penetration were the most frequently reported implementation outcomes. Adoption, appropriateness, cost, and fidelity were rare; sustainability was not evaluated. CONCLUSIONS Implementation science has a promising role in supporting HIV/NCD integration, although its impact will be limited unless theoretical frameworks, rigorous study designs, and reliable measures are employed. To help support use of implementation science, we need to build sustainable implementation science capacity. Doing so in SSA and supporting implementation science investigators can help expedite HIV/NCD integration.
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Maulsby C, Sacamano P, Jain KM, Enobun B, Brantley ML, Kim HY, Riordan M, Werner M, Holtgrave DR. Barriers and Facilitators to the Implementation of a National HIV Linkage, Re-Engagement, and Retention in Care Program. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:443-456. [PMID: 29068718 PMCID: PMC5889075 DOI: 10.1521/aeap.2017.29.5.443] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The 2020 National HIV AIDS Strategy (NHAS) sets a target of 90% of diagnosed people living with HIV (PLWH) retained in HIV care. Access to Care (A2C) was a national HIV linkage, re-engagement, and retention in care program funded by AIDS United with support from the Corporation for National and Community Service that aimed to link and retain the most vulnerable PLWH into high-quality HIV care. This study explores the barriers and facilitators of implementing the A2C program from the perspective of program staff. Ninety-eight qualitative interviews were conducted with staff at implementing organizations over the 5 years of the project. Barriers included challenges with recruiting and retaining participants, staffing and administration, harmonizing partnerships, and addressing the basic and psychosocial needs of participants. Facilitators included strong relationships with partner organizations, flexible program models, and the passion and dedication of staff. Findings will inform the development of future programs and policy.
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Affiliation(s)
- Cathy Maulsby
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul Sacamano
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kriti M Jain
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Blessing Enobun
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Hae-Young Kim
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - David R Holtgrave
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Potential Impact of Integrated Stigma Mitigation Interventions in Improving HIV/AIDS Service Delivery and Uptake for Key Populations in Senegal. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S52-S59. [PMID: 27930612 PMCID: PMC5147043 DOI: 10.1097/qai.0000000000001209] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Men who have sex with men (MSM) and female sex workers (FSW) are consistently shown to have a higher burden of HIV compared with other adults in Senegal. This study, HIV Prevention 2.0, evaluates the impact of the 3-tiered integrated stigma mitigation interventions (ISMIs) approach to optimizing HIV service delivery for key populations in Senegal. METHODS Baseline assessment includes a questionnaire and biological testing for HIV. A proportion of participants enrolled into a 24-month longitudinal cohort with questionnaires and biological testing every 3 months. In these preliminary analyses, ISMIs are evaluated from participants in the cohort through uptake of HIV services and implementation outcomes. RESULTS Overall, 724 MSM and 758 FSW participated in the baseline assessment. HIV prevalence is 30.2% (n = 219/724) among MSM and 5.3% (n = 40/758) among FSW. Fear of seeking health services among MSM is 17.7% (n = 128/724) at baseline, 10.5% (n = 18/172) at month 3, and 9.8% (n = 10/102) at month 6 (P < 0.004); and among FSW is 21.9% (n = 166/758) at baseline, 8.1% (n = 15/185) at month 3, and 10.7% (n = 18/168) at month 6 (P < 0.001). Overall, 63.9% (n = 62/97) of MSM and 82.5% (n = 118/143) of FSW agreed that the intervention is effective in addressing stigma; however, loss to follow-up was 41.1% among MSM and 10% among FSW. CONCLUSION Baseline data reinforce the need for stigma mitigation interventions, combined with enhanced linkage and retention to optimize HIV treatment. Preliminary results show high levels of HIV-related risk determinants and suggest the potential utility of the ISMI to decrease perceived stigma relating to engagement in HIV prevention, treatment, and care services among key populations in Senegal.
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Evaluation of a Systems Analysis and Improvement Approach to Optimize Prevention of Mother-To-Child Transmission of HIV Using the Consolidated Framework for Implementation Research. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S108-16. [PMID: 27355497 PMCID: PMC5113237 DOI: 10.1097/qai.0000000000001055] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Despite large investments to prevent mother-to-child-transmission (PMTCT), pediatric HIV elimination goals are not on track in many countries. The Systems Analysis and Improvement Approach (SAIA) study was a cluster randomized trial to test whether a package of systems engineering tools could strengthen PMTCT programs. We sought to (1) define core and adaptable components of the SAIA intervention, and (2) explain the heterogeneity in SAIA's success between facilities. Methods: The Consolidated Framework for Implementation Research (CFIR) guided all data collection efforts. CFIR constructs were assessed in focus group discussions and interviews with study and facility staff in 6 health facilities (1 high-performing and 1 low-performing site per country, identified by study staff) in December 2014 at the end of the intervention period. SAIA staff identified the intervention's core and adaptable components at an end-of-study meeting in August 2015. Two independent analysts used CFIR constructs to code transcripts before reaching consensus. Results: Flow mapping and continuous quality improvement were the core to the SAIA in all settings, whereas the PMTCT cascade analysis tool was the core in high HIV prevalence settings. Five CFIR constructs distinguished strongly between high and low performers: 2 in inner setting (networks and communication, available resources) and 3 in process (external change agents, executing, reflecting and evaluating). Discussion: The CFIR is a valuable tool to categorize elements of an intervention as core versus adaptable, and to understand heterogeneity in study implementation. Future intervention studies should apply evidence-based implementation science frameworks, like the CFIR, to provide salient data to expand implementation to other settings.
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Bajunirwe F, Tumwebaze F, Abongomera G, Akakimpa D, Kityo C, Mugyenyi PN. Identification of gaps for implementation science in the HIV prevention, care and treatment cascade; a qualitative study in 19 districts in Uganda. BMC Res Notes 2016; 9:217. [PMID: 27074947 PMCID: PMC4831085 DOI: 10.1186/s13104-016-2024-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/05/2016] [Indexed: 12/12/2022] Open
Abstract
Background Over the last 20 years, countries in sub Saharan Africa have made significant strides in the implementation of programs for HIV prevention, care and treatment. Despite, the significant progress made, many targets set by the United Nations have not been met. There remains a large gap between the ideal and what has been achieved. There are several operational issues that may be responsible for this gap, and these need to be addressed in order to achieve the targets. Therefore, the aim of this study was to identify gaps in the HIV prevention, care and treatment cascade, in a large district based HIV implementation program. We aimed to identify gaps that are amenable for evaluation using implementation science, in order to improve the delivery of HIV programs in rural Uganda. Methods We conducted key informant (KI) interviews with 60 district health officers and managers of HIV/AIDS clinics and organizations and 32 focus group discussions with exit clients seeking care and treatment for HIV in the 19 districts. The data analysis process was guided using a framework approach. The recordings were transcribed verbatim. Transcripts were read back and forth and codes generated based on the framework. Results Nine emerging themes that comprise the gaps were identified and these were referral mechanisms indicating several loop holes, low levels of integration of HIV/TB services, low uptake of services for PMTCT services by pregnant women, low coverage of services for most at risk populations (MARPs), poor HIV coordination structures in the districts, poor continuity in the delivery of pediatric HIV/AIDS services, limited community support for orphans and vulnerable (OVC’s), inadequate home based care services and HIV services and support for discordant couples. The themes indicate there are plenty of gaps that need to be covered and have been ignored by current programs. Conclusions Our study has identified several gaps and suggested several interventions that should be tested before large scale implementation. The implementation of these programs should be adequately evaluated in order to provide field evidence of effectiveness and replicability in similar areas.
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Affiliation(s)
- Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, P.O.BOX 1410, Mbarara, Uganda.
| | - Flora Tumwebaze
- Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda
| | | | - Denis Akakimpa
- Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda
| | - Cissy Kityo
- Joint Clinical Research Center, P.O.BOX 10005, Kampala, Uganda
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Rhodes T, Abdool R. Drug harms and drug policies in Sub-Saharan Africa: Implementation science and HIV epidemics. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 30:1-6. [PMID: 26997543 DOI: 10.1016/j.drugpo.2016.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Tim Rhodes
- London School of Hygiene and Tropical Medicine, UK; National Centre for Social Research on Health, University of New South Wales, Australia.
| | - Reychad Abdool
- Senior HIV Consultant, formerly United Nations Office of Drugs and Crime, Nairobi, Kenya
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Abstract
There is new hope that we can significantly reduce HIV rates. The United Nations AIDS organization, UNAIDS, has challenged all countries to strive for aggressive targets that could significantly bend the curve on HIV infections and deaths: 90% of people living with HIV diagnosed; 90% of people diagnosed on treatment; and 90% of people on treatment virally suppressed. This new optimism is largely driven by strong research findings that early and ongoing HIV treatment improves individual health outcomes and reduces people's viral load, making them less infectious. However, the risk of HIV infection is far from evenly distributed among populations most at risk. Those most at risk will find it hardest to reach these targets as they are caught in a syndemic (synergistic epidemic) of intertwining health and social issues. Our research, and that of others, shows that those who are in a syndemic of co-occurring mental health, addiction and social issues (e.g. homelessness, food insecurity) are significantly more likely to fall out of care, less likely to adhere to treatment and less likely to achieve/maintain an undetectable viral load. Intervention studies have found that a combination approach to HIV prevention and treatment that goes beyond primary care and mental health tools to include social and structural interventions has a protective effect, and can reduce risk and improve adherence. People living with and at risk of HIV need better access to social and mental health services as well as clinical treatment services that will help them achieve and maintain optimal health and well-being. We strongly encourage those in the HIV sector across the country to identify a common vision, with clear goals and targets. With concerted and targeted efforts, a focus on program and implementation science, and a willingness to see and treat HIV as a social as well as a biomedical problem-the fourth decade of HIV in Canada could well be the last.
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