The HIV treatment cascade for Jamaica in September 2018 shows many gaps affecting ultimate viral suppression. Firstly, the approximately 22% decline between those estimated to be infected (UNAIDS SPECTRUM analysis) and those diagnosed with HIV and secondly, a further 11% reduction in those linked to care. In 2013, the National HIV/STI/Tb Unit (HSTU) of the Ministry of Health (MOH), introduced universal routine HIV screening for attendees of healthcare centres in Jamaica. However, the coverage and constancy of this intervention has remained low. Consultation at healthcare sites revealed competing priorities, limited structural capacity and insufficient human resources as key barriers to increasing coverage, particularly in hospital settings.


HIV self-testing (HIVST) kits have primarily been used as provider assisted targeted testing of high risk groups in Jamaica. Currently, HIVST kits are available in the private sector in the absence of any accompanying education, linkage or monitoring components. The HSTU of the Jamaica Ministry of Health wishes to develop a comprehensive programme to ensure the maximum possible benefits of HIVST on the epidemic.


The introduction of HIVST in the EMD is therefore well placed to fill gaps both at the University Hospital of the West Indies, by fulfilling the mandate of expanded coverage of routine HIV screening, in the context of limited human and structural capacity, and at the National level by providing critical information for HIVST programme development and expansion.


A phased approach will be adopted to address these two projects aims. This study represents Phase I with a focus on reach, adoption, clinical effectiveness and implementation fidelity and cost, while Phase II will focus on maintenance and dissemination


This study relates to the first of the 90-90-90 targets set out by UNAIDS/WHO.

 

What is the reach, adoption, implementation fidelity, implementation cost and implementation strategies that can improve the uptake of HIV Self-Testing (HIVST) to increase routine HIV screening coverage of non-emergency patients in an urban hospital’s emergency medicine department (EMD) in Jamaica?

1 Primary objective

The primary aim is to assess the reach, adoption, implementation fidelity, implementation cost of HIVST in the EMD

2 Secondary objective

The secondary aims are to evaluate the implementation strategies that can make HIVST successful in the EMD, as well as evaluate facilitators and barriers and to assess the clinical effectiveness of HIVST in to capture undiagnosed HIV positive patients and their secondary contacts and successfully link them to care.

An initial implementation study using a hybrid type 3 design


Two Implementation Science Frameworks have been proposed for this study. One to provide the overarching structure of the implementation approach (i-PARIHS1) and the other to provide the implementation outcomes to be measured (RE-AIM2).


The i-PARIHS implementation science framework has been chosen for this research for the following reasons:
 

01.  

Previous use in HIV routine screening projects3

02.  

Detailed focus on Facilitation. The role of the facilitator for this project will be critical for the successful initial implementation of the project but, also for its’ subsequent continuation and sustainability. The identification of this key role and the specific activities required will support a seamless transition to the EMD staff who will be responsible for the continuation after the 3-month demonstration project. Additionally, it allows for a focus on capacity building of UHWI staff in implementation science during and after the project.  

03. 

The improvement in the initial PARIHS to the i-PARIHS addresses the key dimension of the intended targets of the intervention. This will allow us to gather critical information on participant experiences and recommendations which will be used for the dissemination of the project to the private sector.

Successful Implementation = Facilitation (Innovation + Recipients + Context)


a. Innovation:

i. Implementation strategies

b. Recipients:

i. Study participants

ii. Emergency Medicine Department staff

iii. Facilitators

c. Context:

i. Inner: Emergency Medicine Department

ii. Outer: University Hospital of the West Indies and Jamaican Health System

 

The RE-AIM} has been selected as the framework to evaluate the following implementation outcomes:

a. Reach

i. Proportion of eligible EMD clients who agree to participate

b. Effectiveness

i. Proportion of participants who test positive

c. Adoption

i. Proportion of EMD staff who agree to participate in Phase II

d. Implementation

i. Fidelity – provider and patient levels

ii. Cost – Healthcare facility-based implementation costs


 

Conclusion

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Limitations

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    • Harvey G and Kitson A. PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2016; 11: 33
    • Harden SM, Smith ML, Ory MG, Smith-Ray RL, Estabrooks PA and Glasgow RE. RE-AIM in Clinical, Community, and Corporate Settings: Perspectives, Strategies, and Recommendations to Enhance Public Health Impact. Frontiers in Public Health. 2018; 6
    • Bokhour BG, Saifu H, Goetz MB, et al. The role of evidence and context for implementing a multimodal intervention to increase HIV testing. Implement Sci. 2015; 10: 22