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