Innovations in Implementing Decentralized HIV Services in Peru - Both Peru and the U.S. have similar HIV prevalence and HIV treatment cascades. Despite high HIV diagnosis and antiretroviral therapy initiation in Peru, retention in care and viral suppression remain suboptimal, because HIV services are concentrated in large specialty clinics that create travel, time, stigma, and workforce barriers for patients and providers. These delivery failures are directly relevant to the United States, where safety-net, Ryan White, community health center, and rural or urban primary care systems face similar challenges sustaining long-term HIV care, integrating specialty services into primary care, reducing patient burden, and achieving durable viral suppression across all people with HIV. This study will test a solution-oriented, measurable implementation strategy to decentralize HIV care from specialty HIV clinics to primary healthcare centers using a hub-and-spoke model supported by NIATx workflow redesign and Project ECHO clinical mentoring. The foreign-site design is scientifically justified because Peru’s Ministry of Health has already mandated decentralization, Lima has high-volume specialty HIV clinics linked to numerous primary care centers, and the system provides a real-world setting to assess whether structured implementation support can safely shift stable HIV care into primary care at a scale and pace that would be difficult to achieve in the United States alone. First, we will use a Delphi process to define explicit, measurable criteria for patient transfer, primary care initiation, and quality health indicators needed to monitor safe decentralized HIV care. Second, we will assess patient, clinician, and health-system barriers and facilitators using precise, scientifically relevant descriptors and contextual measures, including clinic capacity, workforce readiness, geographic access, stigma, and service-delivery burden, avoiding broad or unfalsifiable explanations not directly tied to measured outcomes. Third, using a stepped-wedge Type 2 hybrid implementation trial across four hub-and-spoke regions, we will evaluate whether NIATx plus Project ECHO increases the proportion of people with HIV receiving care in primary healthcare centers while improving retention in care, viral suppression, adoption by clinics, fidelity to implementation procedures, and concordance with decentralization guidelines. This project advances NIH priorities by focusing on scientifically valid, measurable health outcomes rather than descriptive disparities alone, and by actively testing, scaling, and implementing evidence-based delivery strategies that can improve chronic HIV outcomes. The results will provide practical tools, clinical criteria, workflow measures, and implementation guidance that can be adapted by U.S. HIV programs seeking to bring care closer to patients, reduce avoidable loss to follow-up, strengthen primary care capacity, and improve health outcomes for Americans living with HIV in diverse service settings. The project also supports responsible stewardship of NIH resources by using a foreign collaboration with clear scientific justification, defined oversight, reproducible methods, and direct relevance to improving HIV care delivery and chronic disease management in the United States.
