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      Timely initiation of HIV antiretroviral therapy in Haiti 2004–2018: a retrospective cohort study Translated title: Iniciación oportuna del tratamiento antirretroviral de la infección por el VIH en Haití del 2004 al 2018: estudio de cohortes retrospectivo Translated title: Início precoce da terapia antirretroviral para HIV no Haiti entre 2004 e 2018: um estudo de coorte retrospectivo

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          ABSTRACT

          Objective.

          To describe trends in timing of ART initiation for newly diagnosed people living with HIV before and after Haiti adopted its Test and Start policy for universal HIV antiretroviral therapy (ART) in July 2016, and to explore predictors of timely ART initiation for both newly and previously diagnosed people living with HIV following Test and Start adoption.

          Methods.

          This retrospective cohort study explored timing of ART initiation among 147 900 patients diagnosed with HIV at 94 ART clinics in 2004–2018 using secondary electronic medical record data. The study used survival analysis methods to assess time trends and risk factors for ART initiation.

          Results.

          Timely uptake of ART expanded with Test and Start, such that same-day ART initiation rates increased from 3.7% to 45.0%. However, only 11.0% of previously diagnosed patients initiated ART after Test and Start. In adjusted analyses among newly diagnosed people living with HIV, factors negatively associated with timely ART initiation included being a pediatric patient aged 0–14 years (HR = 0.23, p < 0.001), being male (HR = 0.92, p = 0.03), being 50+ years (HR = 0.87, p = 0.03), being underweight (HR = 0.79, p < 0.001), and having WHO stage 3 (HR = 0.73, p < 0.001) or stage 4 disease (HR = 0.49, p < 0.001). Variation in timely ART initiation by geographic department and health facility was observed.

          Conclusions.

          Haiti has made substantial progress in scaling up Test and Start, but further work is needed to enroll previously diagnosed patients and to ensure rapid ART in key patient subgroups. Further research is needed on facility and geographic factors and on strategies for improving timely ART initiation among vulnerable subgroups.

          RESUMEN

          Objetivo.

          Describir las tendencias en cuanto al momento de iniciar el tratamiento antirretroviral (TAR) de personas con infección por el VIH recién diagnosticadas antes y después de julio del 2016, cuando Haití adoptó la política de prueba e inicio del tratamiento con el TAR universal contra el VIH, y explorar los factores predictivos del inicio oportuno del TAR en personas con infección por el VIH recién diagnosticada y diagnosticada con anterioridad después de la adopción de esta política.

          Métodos.

          En este estudio de cohortes retrospectivo se exploró el momento en que se inició el TAR en 147 900 pacientes con diagnóstico de infección por el VIH en 94 consultorios que administran TAR del 2004 al 2018 mediante datos secundarios de expedientes médicos electrónicos. El estudio empleó métodos de análisis de supervivencia para evaluar las tendencias temporales y los factores de riesgo del inicio del TAR.

          Resultados.

          La observancia oportuna del TAR se amplió con la política de prueba e inicio del tratamiento, de tal manera que el inicio del TAR en el mismo día aumentó de 3,7 % a 45,0 %. Sin embargo, solo 11,0 % de los pacientes anteriormente diagnosticados iniciaron el TAR tras la adopción de la política. En los análisis ajustados con personas con infección por el VIH recién diagnosticadas, los factores asociados negativamente con el inicio oportuno del TAR comprendían ser un paciente pediátrico entre 0 y 14 años de edad (HR = 0,23, p < 0,001), ser varón (HR = 0,92, p = 0,03), tener más de 50 años (HR = 0,87, p = 0,03), tener un peso bajo (HR = 0,79,p < 0.001) y estar en el estadio 3 (de HR = 0,73, p < 0,001) o en estadio 4 (HR = 0,49, p < 0,001) de la enfermedad según la OMS. Se consideró la variación en el inicio oportuno del TAR según departamento geográfico y establecimiento de salud.

          Conclusiones.

          Haití ha logrado avances considerables en la ampliación a mayor escala de la política de prueba e inicio del tratamiento, pero es necesario seguir trabajando para registrar a los pacientes diagnosticados con anterioridad y para asegurar el inicio rápido del TAR en los subgrupos de pacientes clave. Es preciso llevar a cabo investigaciones adicionales sobre los factores geográficos y los relacionados con los establecimientos y sobre las estrategias para mejorar el inicio oportuno del TAR en los subgrupos vulnerables.

          RESUMO

          Objetivo.

          Descrever as tendências para o momento do início da terapia antirretroviral (TAR) em pessoas recém diagnosticadas vivendo com HIV antes de e após o Haiti adotar a política Testar e Tratar com a TAR universal para HIV, em julho de 2016, e analisar os preditores do início precoce da TAR em pessoas recém ou previamente diagnosticadas que vivem com HIV após a adoção da política Testar e Tratar.

          Métodos.

          Este estudo de coorte retrospectivo analisou o momento do início da TAR de 147 900 pacientes diagnosticados com HIV em 94 ambulatórios de TAR entre 2004 e 2018, usando dados de registros médicos eletrônicos secundários. O estudo usou métodos de análise de sobrevivência para avaliar as tendências temporais e os fatores de risco para o início da TAR.

          Resultados.

          A adoção precoce da TAR foi ampliada com a política Testar e Tratar de tal maneira que as taxas do início da TAR no mesmo dia do diagnóstico aumentaram de 3,7% para 45%. Porém, somente 11% dos pacientes previamente diagnosticados iniciaram a TAR após a política Testar e Tratar. Nas análises ajustadas entre as pessoas recém diagnosticadas vivendo com HIV, os fatores negativamente associados ao início precoce da TAR incluíram: ser paciente pediátrico de 0 a 14 anos de idade (HR = 0,23, p < 0,001), ser do sexo masculino (HR = 0,92, p = 0,03), ter 50 anos de idade ou mais (HR = 0,87, p = 0,03), ter peso inferior ao normal (HR = 0,79, p < 0.001) e estar na fase 3 da OMS (HR = 0,73, p < 0,001) ou fase 4 da doença (HR = 0,49, p < 0,001). Foi observada variação no início precoce da TAR por região geográfica e instituição de saúde.

          Conclusões.

          O Haiti obteve avanços substanciais na ampliação da política Testar e Tratar, mas é necessário mais trabalho para inscrever pacientes previamente diagnosticados e para assegurar a TAR rápida em subgrupos-chave de pacientes. Mais pesquisas são necessárias sobre fatores geográficos e de instituições de saúde e sobre estratégias para a melhoria do início precoce da TAR entre subgrupos vulneráveis.

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          Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

          Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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            Diffusion of innovations in service organizations: systematic review and recommendations.

            This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.
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              A Tutorial on Multilevel Survival Analysis: Methods, Models and Applications

              Summary Data that have a multilevel structure occur frequently across a range of disciplines, including epidemiology, health services research, public health, education and sociology. We describe three families of regression models for the analysis of multilevel survival data. First, Cox proportional hazards models with mixed effects incorporate cluster-specific random effects that modify the baseline hazard function. Second, piecewise exponential survival models partition the duration of follow-up into mutually exclusive intervals and fit a model that assumes that the hazard function is constant within each interval. This is equivalent to a Poisson regression model that incorporates the duration of exposure within each interval. By incorporating cluster-specific random effects, generalised linear mixed models can be used to analyse these data. Third, after partitioning the duration of follow-up into mutually exclusive intervals, one can use discrete time survival models that use a complementary log–log generalised linear model to model the occurrence of the outcome of interest within each interval. Random effects can be incorporated to account for within-cluster homogeneity in outcomes. We illustrate the application of these methods using data consisting of patients hospitalised with a heart attack. We illustrate the application of these methods using three statistical programming languages (R, SAS and Stata).
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                Author and article information

                Journal
                Rev Panam Salud Publica
                Rev Panam Salud Publica
                rpsp
                Revista Panamericana de Salud Pública
                Organización Panamericana de la Salud
                1020-4989
                1680-5348
                19 November 2021
                2021
                : 45
                : e139
                Affiliations
                [1 ] normalizedUniversity of Washington Washington United States of America originalUniversity of Washington, Washington, United States of America
                [2 ] normalizedNational Association of State and Territorial AIDS Directors Port-au-Prince Haiti originalNational Association of State and Territorial AIDS Directors, Port-au-Prince, Haiti
                [3 ] normalizedCentre Haitien pour le Renforcement du Système de Santé Port-au-Prince Haiti originalCentre Haitien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
                [4 ] normalizedUnited States Centers for Disease Control and Prevention Port-au-Prince Haiti originalUnited States Centers for Disease Control and Prevention, Port-au-Prince, Haiti
                [5 ] normalizedMinistère de Santé Publique et de la Population Port-au-Prince Haiti originalMinistère de Santé Publique et de la Population, Port-au-Prince, Haiti
                Author notes
                Nancy Puttkammer, nputt@ 123456uw.edu
                Article
                RPSP.2021.139
                10.26633/RPSP.2021.139
                8603999
                34815736
                69c42c6c-6632-4e47-a6f8-cb9ce24941b4

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. Open access logo and text by PLoS, under the Creative Commons Attribution-Share Alike 3.0 Unported license.

                History
                : 28 December 2020
                : 07 June 2021
                Page count
                Figures: 2, Tables: 3, Equations: 0, References: 23
                Funding
                Financial support. The work has been supported by NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA, NIGMS, NIDDK of the National Institutes of Health ( https://www.nih.gov/) under award number AI027757 to the University of Washington Center for AIDS Research (CFAR) and by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention ( https://www.cdc.gov/), under the cooperative agreement number NU2GGH001130, to the International Training and Education Center for Health (I-TECH) at the University of Washington.
                Categories
                Original Research

                hiv,antiretroviral therapy, highly active,implementation science,haiti,vih,terapia antirretroviral altamente activa,ciencia de la implementación,haití,terapia antirretroviral de alta atividade,ciência da implementação

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