Syndemics and Loss From the HIV Care Continuum in India - Intervention

Study Overview
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Brief Summary
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The investigators will assess the feasibility and acceptability of a pilot intervention to keep people living with HIV (PLHIV) in southern India in care and virologically suppressed. The lack of understanding of the causes of loss from the HIV care continuum in India stifles the armamentarium of effective interventions to keep Indian PLHIV in care. The results of this research will demonstrate the feasibility and acceptability of a pilot intervention targeting the multiple mechanisms by which PLHIV become lost to care. By targeting these mechanisms, this intervention will be designed to be scalable in a setting where access to mental health specialists is limited.

Detailed Description
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This pilot intervention represents the final Aim of the NIMH-sponsored study Syndemics and Loss from the HIV Care Continuum in India. This trial will be conducted at the Y.R. Gaitonde Centre for AIDS Research and Education (YRG CARE), located in Chennai, the capital of Tamil Nadu state and one of the epicenters of the Indian HIV epidemic. The investigators will recruit 50 adult (age >=18) PLHIV presenting to care at YRG CARE and ART-naïve. Participants will be recruited at their first visit to YRG CARE, at which the participant's HIV diagnosis is established or confirmed and the participant receives initial counseling and clinical care. At this recruitment stage, research assistants will conduct a pre-intervention questionnaire including measures of depressive symptoms, internalized stigma, self-efficacy, mental health, and physical health. The investigators will then randomize the patient to usual care vs. enhanced-care intervention (25 in each arm). The enhanced-care intervention will be multi-faceted, reflecting the likelihood of multiple syndemic conditions as well as evidence from LMICs suggesting that programs combining multiple approaches are the most effective in improving retention in care. The enhanced-care intervention will consist of the following components: Active outreach, including bidirectional weekly SMS messaging / automated voice messaging (depending on literacy) Appointments (specific appointment times/dates). Financial support, including free clinic visits, labs, medications, and transportation incentives on a sliding scale based on distance to clinic Microenterprise, including bag-making or food-making ventures for women Enhanced counseling. Participants in the enhanced-care intervention will participate in an individual enhanced counseling program called Steps to Success, based upon a Life Steps and Problem Solving curriculum.

Official Title
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Syndemics and Loss From the HIV Care Continuum in India - Intervention

Conditions
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HIV Infections

Intervention / Treatment
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* Behavioral: Active outreach
* Behavioral: Appointments
* Behavioral: Financial support
* Behavioral: Microenterprise
* Behavioral: Enhanced counseling
* Behavioral: Usual clinical care and counseling


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult PLHIV presenting to care at YRG CARE who are ART-naïve and who plan to follow-up at YRG CARE Speaks Tamil, Telugu, or English Exclusion Criteria: Previous ART exposure Not competent to provide informed consent or participate in the study

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Enhanced Care<br>Usual clinical care + intervention components | Behavioral: Active outreach<br>* Participants will get bidirectional weekly SMS messaging / automated voice messaging (depending on literacy), with messages to be programmed by the participant in the enhanced counseling sessions.<br>Behavioral: Appointments<br>* Participants in the enhanced-care intervention will be given specific appointment times/dates.<br>Behavioral: Financial support<br>* Participants in the enhanced-care intervention will receive free clinic visits, labs, and medications. They will also receive transportation incentives on a sliding scale based on distance to clinic, to range between 200-700 INR to be given each clinic/study visit. All participants, in both the usual care and enhanced care arms, will be offered VL testing free of charge, although this will not be known to the participants prior to the visit.<br>Behavioral: Microenterprise<br>* YRG CARE is affiliated with two microenterprise programs in bag-making and food-vending which can be leveraged as part of an intervention, particularly for women. There is an established training and mentoring program for individuals who wish to join the bag-making or food-making ventures. Participants who opt for this will be linked to the bag-making and food-vending programs, with all up-front costs (e.g. vending kiosk, training, serving materials, etc.) covered.<br>Behavioral: Enhanced counseling<br>* Participants in the enhanced-care intervention will participant in an individual enhanced counseling program called Steps to Success, based upon a Life Steps and Problem Solving curriculum. Steps to Success will consist of five one-on-one sessions of approximately 1 to 1.5 hours each. The first session will take place at the time of the participant's second clinical visit to YRG CARE, which will be between 1-3 weeks after the participant is recruited.<br>|
| Active Comparator: Usual Care<br>Usual clinical care and counseling | Behavioral: Usual clinical care and counseling<br>* Usual clinical care and counseling<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility as assessed by semi-structured qualitative interviews | Minimal negative impact on clinical work flow and ability to deliver all intervention components, particularly all sessions of enhanced counseling, as measured by semi-structured qualitative interviews of providers | 12 months | 
| Acceptability among participants and providers as assessed by semi-structured qualitative interviews | Acceptability among patients and providers as measured by semi-structured qualitative interviews of participants and providers | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Retention in care | No unexpected absences > 90 days | 12 months | 
| Viral suppression (Undetectable HIV-1 RNA, <50 copies / mL) | Undetectable HIV-1 RNA, <50 copies / mL | 3 months | 
| ART initiation success (accepted ART and continued ART for at least 6 months) | Successful ART initiation (accepted ART and continued ART for at least 6 months) | 6 months | 
| Depressive symptoms as measured by PHQ-9 | Score of >10 indicates probable depression | 12 months | 
| Internalized stigma as measured by Internalized AIDS-Related Stigma Scale | Includes six items related to concerns about disclosure as well as items related to feelings of shame and/or self-hatred. Responses are elicited on a binary scale (yes/no) and scores represent the sum of endorsed items. | 12 months | 
| Self-efficacy as measured by General Self-Efficacy Scale--shortened version | Six item scale of self-efficacy | 12 months | 
| Social support as measured by Multidimensional Scale of Perceived Social Support | 12 item scale of social support | 12 months | 
| Food insecurity as measured by Household Food Insecurity Access Scale | 8 item scale of food insecurity | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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hiv, India, retention, continuum