Kohler Pamela, Jiang Wenwen, Badia Jacinta, Kibugi James, Dyer Jessica, Kadima Julie, Oketch Dorothy, Beima-Sofie Kristin, Hicks Sarah, Richardson Barbra A, Inwani Irene, Shah Seema K, Agot Kawango, John-Stewart Grace
University of Washington, Seattle, Washington, USA.
IMPACT Research and Development Organization, Kisumu, Kenya.
J Int AIDS Soc. 2025 Jul;28 Suppl 3(Suppl 3):e26501. doi: 10.1002/jia2.26501.
Systematic use of data-driven tools to allocate care services based on needs, including differentiated care for stable individuals and intensive care for those with higher risk, may improve retention and viral suppression in adolescents and young adults living with HIV (AYLHIV).
This cluster randomised trial in western Kenya tested a data-informed stepped care intervention that assigned AYLHIV to four intensities of care according to need. AYLHIV at 12 intervention facilities underwent step assignment at each visit; those at lowest risk were offered differentiated models of service delivery (DSD), and those with risk factors more intensive services. AYLHIV at control sites received standard care. AYLHIV were followed for 12 months. Clinical and viral load data were abstracted from medical records. The primary outcome was the proportion of missed visits (defined as > 30 days late for scheduled visit). Secondary outcomes included loss to follow-up, viral non-suppression and assignment to DSD (multi-month refills or pharmacy fast-track visits). Mixed effects regression was clustered by individual and facility and adjusted for outcomes during the pre-enrolment period and baseline variables that differed by arm.
Between April and July 2022, 1911 AYLHIV ages 10-24 were enrolled (control: 1016, intervention: 895, 1708.8 person-years). Median age was 17, and 1512 (79.5%) were in school. Characteristics were balanced by arm, except for a higher proportion coming to the clinic alone in control arm (68.5% vs. 61.1%, p = 0.04). At intervention facilities, using the DiSC tool, 574 (64.6%) AYLHIV were assigned to DSD, 122 (13.7%) to standard care, 100 (11.3%) to mental health and retention counselling, and 92 (10.4%) to intensive case management. Missed visits were 8.5% in intervention versus 8.3% in control (adjusted risk ratio [aRR]: 1.04, 95% CI: 0.89-1.20); viral non-suppression (7.7% vs. 9.7%, aRR 0.79 95% CI: 0.54-1.16) and antiretroviral therapy adherence (92.8% vs. 94.6%, aRR 0.98 95% CI: 0.94-1.02) were similar between arms. AYLHIV in the intervention arm received more fast-track visits (aRR 1.21, 95% CI: 1.01-1.46). Intervention facilities experienced fewer scheduled appointments compared to control (aRR: 0.95, 95% CI: 0.91-0.98, p = 0.004).
Overall, missed visits and non-suppression were infrequent (< 10%) and did not decrease with the DiSC intervention. The DiSC intervention resulted in increased assignment to differentiated services without increasing missed visits or viral non-suppression.
系统地使用数据驱动工具根据需求分配护理服务，包括为病情稳定者提供差异化护理，为高风险者提供强化护理，可能会提高感染艾滋病毒的青少年和青年（AYLHIV）的留存率并实现病毒抑制。
在肯尼亚西部进行的这项整群随机试验测试了一种基于数据的阶梯式护理干预措施，该措施根据需求将AYLHIV分为四种护理强度。12个干预设施中的AYLHIV在每次就诊时进行分级；风险最低的患者接受差异化服务模式（DSD），有风险因素的患者接受更强化的服务。对照站点的AYLHIV接受标准护理。对AYLHIV进行了12个月的随访。从医疗记录中提取临床和病毒载量数据。主要结局是错过就诊的比例（定义为比预定就诊时间晚30天以上）。次要结局包括失访、病毒未抑制以及被分配到DSD（多月续方或药房快速就诊）。混合效应回归按个体和设施进行聚类，并根据入组前时期的结局以及不同组之间存在差异的基线变量进行调整。
在2022年4月至7月期间，招募了1911名年龄在10 - 24岁的AYLHIV（对照组：1016名，干预组：895名，1708.8人年）。中位年龄为17岁，1512名（79.5%）在上学。除对照组独自前来诊所的比例较高（68.5%对61.1%，p = 0.04）外，各组特征均衡。在干预设施中，使用DiSC工具，574名（64.6%）AYLHIV被分配到DSD，122名（13.7%）接受标准护理，100名（11.3%）接受心理健康和留存咨询，92名（10.4%）接受强化病例管理。干预组的错过就诊率为8.5%，对照组为8.3%（调整风险比[aRR]：1.04，95%置信区间：0.89 - 1.20）；病毒未抑制率（7.7%对9.7%，aRR 0.79，95%置信区间：0.54 - 1.16）和抗逆转录病毒疗法依从性（92.8%对94.6%，aRR 0.98，95%置信区间：0.94 - 1.02）在两组之间相似。干预组的AYLHIV接受了更多的快速就诊（aRR 1.21，95%置信区间：1.01 - 1.46）。与对照组相比，干预设施的预约就诊较少（aRR：0.95，95%置信区间：0.91 - 0.98，p = 0.004）。
总体而言，错过就诊和病毒未抑制情况不常见（<10%），并且DiSC干预并未使其减少。DiSC干预导致分配到差异化服务的比例增加，而未增加错过就诊或病毒未抑制的情况。
