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Implementation Science at UW

Category: Funding News

Expanding Efforts and Strategies to Protect and Improve Public Health in Kenya Department of Health and Human Services

Funding has been awarded to principal investigator Dr. Peter Rabinowitz by the Centers for Disease Control and Prevention for "Expanding Efforts and Strategies to Protect and Improve Public Health in Kenya Department of Health and Human Services."

 

Abstract:

Rift Valley Fever, and Middle East Respiratory Syndrome (MERS). The COVID-19 pandemic has exposed the country’s need to further increase capacity to prevent, detect and respond appropriately to highly infectious diseases and other emerging threats to health security. While Kenya has made tremendous progress in building various capacities for IHR including development of a National Action Plan for Health Security (NAPHS) based on the 2017 Joint External Evaluation (JEE) for Kenya, the IHR State Party Annual report of 2019 (SPAR report 2019), indicates that significant gaps remain. Figure 1 shows the Most IHR capacity scores for Kenya were below the WHO Afro countries average and the global average, with particular weaknesses in areas of legislation and financing, IHR coordination, surveillance, human resources, National Health Emergency Framework, health service provision, risk
communication, points of entry, chemical events, and radiation emergencies. The International Training and Education Center for Health (I-TECH), based at the University of Washington (UW) has been working on GHSA in Kenya and is uniquely positioned to support the Government of Kenya and the Ministry of Health (MOH) as it works to improve systems for GHS. Since 2016, I-TECH has had a collaborative agreement with the Centers for Disease Control and Prevention (CDC) to support the Global Health Security Agenda in Kenya.

Under this CoAG, UW I-TECH Kenya has supported Kenya MOH to strengthen laboratory systems, improve health facility capacity for Infection Prevention and Control (IPC), track immunization coverage with mobile devices, improve surveillance data quality and efficiency, train the GHS workforce, and work with technical working groups (TWG) on mapping health system vulnerability to outbreaks. I-TECH’s approach to health systems strengthening is based upon a technical assistance model that embraces MOH capacity building and progressive transition of systems to MOH leadership and management from the outset. Our productive working relationships with the MOH and other strategic partners and deep existing involvement in strengthening Kenya’s health systems prepare us to rapidly scale-up technical assistance in support of Kenya’s IHR plans with special emphasis on NAPHS and GHSA.

The purpose of this proposal is to further support the Global Health Security program in Kenya to protect and improve health through national, sub national and local partnerships. I-TECH will work with CDC, MOH, and multiple stakeholders to a) prevent avoidable epidemics including naturally occurring outbreaks and intentional or accidental releases of dangerous pathogens, b) detect threats early, including detecting, characterizing and reporting emerging public health threats, and c) respond rapidly and effectively to public health threats of national and international concern.

I-TECH will focus efforts in six critical areas: 1) national laboratory systems, 2) surveillance, 3) human resources (One Health training) for animal and human sectors, 4) public health emergency management and response, 5) strengthening implementation of the IHR monitoring and evaluation framework, and 6) strengthening implementation science programs and platforms.

Sponsor Award Number: NU2HGH000029

Delivery of Integrated PrEP and ART for HIV prevention for couples in Kenya

Funding has been awarded to principal investigator Dr. Jared Baeten by the National Institute of Mental Health for "Delivery of Integrated PrEP and ART for HIV prevention for couples in Kenya."

 

Abstract:

Maximizing access is key challenges for optimizing the public health impact of pre-exposure prophylaxis (PrEP) for HIV prevention. The coronavirus disease 2019 (COVID-19) epidemic has overwhelmed health systems globally. In Africa, PrEP has been added to an already-burdened health infrastructure, and the overlay of COVID-19 threatens derail the tremendous progress made with HIV treatment and prevention, including provision of PrEP.

Since 2017, in collaboration with the Kenyan Ministry of Health, we have been conducting a large step-wedge randomized roll-out of PrEP delivery in 24 high-volume, PEPFAR-supported, public HIV care facilities, using detailed data abstraction from clinic records and implementation science methods (including the RE-AIM framework), plus training and technical assistance in another ~70 clinics outside of the randomized trial (together, the work is called the Partners Scale-Up Project). We have found high enthusiasm among providers and clients, with good uptake, continuation, and adherence for PrEP and clinic-initiated adaptions that may PrEP delivery more efficient.

During the current COVID-19 emergency, we have continued remote provision of technical assistance to monitor implementation progress and cross-pollinate best practices across clinics. We are hearing that health providers feel ill-prepared to manage or screen for COVID-19 but nevertheless remain committed to serving clients. Clinics have rapidly accelerated adaptations to continue services provision, including dispensing longer PrEP refills, quickly initiating one-stop provision of PrEP services (to minimize staff-client contact), and shifting PrEP services to HIV testing centers and potentially to community-based delivery. Incredibly, PrEP initiations/refills are continuing at a rate similar to 2019. Thus, we hypothesize that despite the alarming implications for individuals and health systems of the COVID-19 emergency, there is both resilience of public health clinic staff and opportunity for health systems to adapt and innovate efficient strategies for provision of critical services.

In this administrative supplement, we propose to add a novel aim (Aim 5) to explore the impact of COVID-19 on PrEP services, specifically clinic adaptation and staff resilience. We propose to document and accelerate rapid adaptations in PrEP services across the ~100 clinics across Kenya in our network, using our technical assistance model to cross-pollinate best practices that mitigate COVID-19 impacts. Qualitative interviews will explore provider distress and identify key components of resilience and PrEP service adaptation. The work is fully within the scope of our ongoing project, which has explicit goals of understanding barriers and facilitating innovations for PrEP delivery for providers and health systems. Given our robust technical assistance network and data collection systems (including phone/video interviews), this work can begin immediately and will be translatable to PrEP delivery across Africa during this public health emergency.

Sponsor Award Number: 3R01MH095507-10S1

Expanding and Scaling Two-way Texting (2wT) to Reduce Unnecessary Follow-Up and Improve Adverse Event Identification Among Voluntary Medical Male Circumcision (VMMC) Clients in the Republic of South Africa

Funding has been awarded to principal investigator Caryl Feldacker by the National Institutes of Health for "Expanding and Scaling Two-way Texting (2wT) to Reduce Unnecessary Follow-Up and Improve Adverse Event Identification Among Voluntary Medical Male Circumcision (VMMC) Clients in the Republic of South Africa."

 

Abstract:

Services providing voluntary medical male circumcision (MC) are struggling to meet ambitious targets of 5 million annual MCs; MC expansion failure reduces the HIV prevention impact where it is most needed in sub-Saharan Africa. Current global MC guidelines require one or more follow-ups for early adverse events (AE) detection. However, with low AE rates, overstretched clinic staff waste invaluable resources conducting routine unnecessary reviews for MC clients without complications; men healing well needlessly pay for transport, miss work, and wait for reviews. In weak healthcare systems in SSA, MC quality is buckling. Innovations focusing MC follow-up only on men with potential AEs could vastly reduce unnecessary visits, providing critical resources for quality MC optimization and scale.

Our randomized control trial (RCT) in two peri-urban clinics in Zimbabwe tested two-way texting (2wT) between patients and providers, allowing men healing without complication to opt-out of routine post-operative visits, streamlining in-person care. 2wT safely reduced client visits by 85% and ascertained more AEs for improved program quality. The Republic of South Africa’s (RSA) MC context of high-volume urban clinics, remote service delivery, and low AE rates threaten MC scale-up. In RSA, 500,000 multi-stage, unnecessary MC reviews are likely conducted, annually. In urban sites, this causes service delivery bottlenecks; in rural areas, follow-up requires multiple, multi-hour trips, curtailing productivity. RSA pressure for MC expansion, good cell coverage, and severe health system constraints suggest 2wT’s impact would be significant for MC care quality and efficiency, especially in rural areas.

We seek to develop an adaptable 2wT dissemination and implementation model at scale (2wT-2-SCALE) delivered by routine MC teams, not research teams. First, an RCT will rigorously demonstrate how 2wT improves AE ascertainment and follow-up efficiency in both high-volume urban and remote rural clinics. Then, we then scale (2wT-2-SCALE) via a one-year, quasi-experimental, step-wedge research design (intensive) with insights gained from one additional year of 2wT-based follow-up using routine VMMC teams (maintenance). Guided by implementation science frameworks and tools, we employ mixed-methods evaluation to assess 2wT-2-SCALE’s impact on VMMC service quality.

We aim to 1) generate SA evidence determining how 2wT increases AE ascertainment while reducing workload; 2) develop an effective dissemination and implementation strategy at scale (2WT-2-SCALE), using RE-AIM-based evaluation of program Reach, Effectiveness,Adoption, Implementation, and Maintenance; and 3) use activity based micro-costing estimate the budget and program impact from the payer perspective to scale-up the 2wT intervention compared to the standard of care.

This mHealth implementation research is a highly innovative and systems-focused, establishing both the local evidence-base and the timely, real-world information to support its further adaptation, adoption, and spread to improving efficient, safe scale up of high quality MC services in RSA and beyond.

Sponsor Award Number: 1R01NR019229-01

Integrating PrEP delivery in family planning clinics in Kenya

Funding has been awarded to principal investigator Kenneth Mugwanya by the National Institutes of Health for "Integrating PrEP delivery in family planning clinics in Kenya."

 

Abstract:

Women in HIV high burden settings are a priority population for HIV prevention, because they carry disproportionately high fraction of new HIV infections. A recent large clinical study (ECHO Study) in four African countries found that incident HIV infections were unacceptably high among women desiring contraception– an average of 3.8%. These results have rightly spurred discussions about the need to strengthen integration of HIV prevention and sexual reproductive health services. Oral pre-exposure prophylaxis (PrEP) is an attractive user-controlled HIV prevention strategy, given its high effectiveness and safety.

Integrating HIV prevention services, including PrEP provision into care settings that women trust and access routinely may offer an efficient platform to reach at-risk women for HIV prevention. In a recent pilot study, we demonstrated that it was feasible to integrate PrEP provision in FP clinics with program-dedicated staff. However, that approach also highlighted the need for delivery models that integrate efficiently with existing staff for sustainability. With a multidisciplinary team and drawing from lessons from the pilot work, we propose to catalyze scale up PrEP provision for at-risk women accessing FP clinics in Kisumu, Kenya – a region with an HIV prevalence of up to 28% among young women. We will aim for a sustainable, institutionalized, and cost- and time-efficient
PrEP delivery in FP clinics. We hypothesize that FP clinics will provide woman-centered ‘one-stop’ location for PrEP and FP services that could address barriers women face to access HIV prevention services, including lack of time, cost, and stigma of visiting a facility solely for HIV prevention.

We will conduct a stepped wedge cluster-randomized trial to test a multifaceted implementation strategy in 12 FP clinics (n=3600 women) with the following Aims: In Aim 1, we will deliver PrEP in public health FP clinics in staged fashion, implementing and optimizing HIV prevention service provision with existing FP clinic staffing. We will rigorously evaluate program reach, effectiveness, adoption, implementation, maintenance, and impact using the RE-AIM framework. The multifaceted implementation strategy to integrate PrEP in FP clinics will include: 1) provider training; 2) promotion of HIV testing, partner HIV testing, screening for HIV and STIs risk and offer
of PrEP; 3) ongoing technical assistance; 4) Audit and feedback to optimize delivery; 5) work-flow mapping; and 6) streamlined data and PrEP supply systems.

In Aim 2, guided by the Organizational Readiness for Implementing Change and the Consolidated Framework for Implementation Science Research, we will assess readiness to implement, fidelity, impact on current services, facilitators, and barriers to integration PrEP provision in FP clinic context.

In Aim 3, we will assess programmatic cost, budget impact, and affordability of integrating PrEP delivery in FP clinics in Kenya. Costs will be estimated over a 5 year horizon considering the payer’s perspective as well as societal perspective to account for client opportunity and financial costs.

The results of this project will lay the ground for wider scale delivery of oral PrEP and next-generation PrEP formulations in FP clinics, not only in Kenya but in other resource-limited settings globally.

Sponsor Award Number: 1R01MH123267-01

Women and HIV: Translation of Research into Practice

Renewal funding has been awarded to principal investigator Dr. Carey Farquhar and co-principal investigator Dr. Elizabeth Bukusi by the John E. Fogarty International Center for "Women and HIV: Translation of Research into Practice."

 

Abstract:

In this 5-year renewal application for the Kenya Medical Research Institute (KEMRI) and University of Washington (UW) program entitled, Women and HIV: Translation of Research into Practice, will continue to build research capacity to prevent new HIV infections among women and adolescent girls in Kenya and sub-Saharan Africa and optimize care and treatment for this high-risk, vulnerable population. To reduce incident infections and ensure long, healthy lives for persons living with HIV, it is necessary to conduct locally relevant research that addresses the know-do gap and informs national guidelines, clinical practice and policy. It is also essential that communities and local health officials participate in identifying the most pressing problems and in finding feasible, sustainable and innovative solutions to address them.

The proposed training program’s primary goal is to build capacity at KEMRI and the Kenya Ministry of Health (MOH) in implementation science focused on HIV, women and adolescents, while creating bridges to communities of adolescent girls and young women (AGYW), local health officials, and other organizations responsible for healthcare practice and service delivery.

KEMRI’s strong commitment to conducting research that informs service delivery and improves national health outcomes in Kenya provides a strong foundation for the program, which will continue to be led by Drs. Carey Farquhar and Elizabeth Bukusi. Dr. Farquhar is a UW Professor of Global Health, Medicine, and Epidemiology recently appointed Vice Dean for Education in the School of Public Health. Dr. Bukusi is a Chief Research Officer at KEMRI who trained as an obstetrician-gynecologist and epidemiologist, earning her MPH and PhD at UW.

The first aim builds on the successful first 4 years of the training program. Seven Kenyans received support for long- term training during this period: 4 MPH, 2 PhD, and 1 MPH/PhD. In addition, 5 trainees completed medium-term, non-degree training at UW. In the next 5 years, we propose to fund more doctoral level training in-country, supporting 6 trainees from KEMRI or MOH to pursue a PhD in implementation science at the University of Nairobi. To ensure a pipeline of candidates, we will also support 5 MPH trainees at UW and 5 year-long certificate trainees who will be based primarily in Kenya and take 1 month of coursework in Seattle, followed by workshops and UW distance-learning courses in Kenya. The third aim will extend the reach of training to a greater number of KEMRI and MOH staff by providing 1-week courses on implementation science, grant writing, and manuscript preparation.

Conferences that bring together members of the AGYW community with KEMRI and MOH researchers and county health directors will be offered to promote community engagement in local care, treatment and prevention in Western Kenya, where adolescents and women are at unacceptably high risk for HIV. Using UW’s well-established approaches to training, this program will establish greatly needed implementation science research capacity at KEMRI and MOH, and contribute to changing the face of the HIV epidemic in Kenya.

Sponsor Award Number: 2D43TW009783-06

Community participatory action research to increase MDA coverage in hard-to-reach urban populations

Funding has been awarded to principal investigator Judd Walson by the Neglected Tropical Diseases Support Center (NTDSC) for "Community participatory action research to increase MDA coverage in hard-to-reach urban populations".

 

Abstract:

Disease focus: Lymphatic filariasis and onchocerciasis

The success of preventative-chemotherapy (PC) neglected tropical disease (NTD) programs in reaching global control and elimination benchmarks is predicated on high mass drug administration (MDA) coverage and compliance. In order to engage communities and achieve high treatment coverage, NTD programs have often utilized strategies such as community-directed interventions (CDI), community participatory mapping, or engagement of volunteer community drug distributors (CDDs) or other lay health workers to lead drug delivery within their own communities and neighborhoods. However, formal participatory action research (PAR) has rarely been deployed within NTD implementation research. Rapid PAR has the potential to transform MDA mobilization and delivery activities to ensure that hard-to-reach populations are more fully engaged in MDA campaigns via implementation strategies that are customized and fit for purpose.

Well-Integrated Screening and Evaluation for Women Across The Nation

Funding has been awarded to principal investigator Miruna Petrescu-Prahova by the Washington State Department of Health (DOH) for "Well-Integrated Screening and Evaluation for Women Across The Nation (WISEWOMAN)".

 

Abstract:

DOH is contracting with the University of Washington Health Promotion Research Center (UW-HPRC) to improve access to and participation in Health Behavior Support System (HBSS) programs for hypertension and high blood cholesterol management. UW-HPRC will also support the implementation of the use of self measured blood pressure monitoring (SMBP) combined with clinical support among adults with hypertension. Through three CDC funded grants, this contract with UW-HPRC will also support policy, systems, and environmental (PSE) change activities that seek to reduce heart disease, stroke, and support disease management program sustainability. UW-HPRC will collaborate with other contractors to test and implement PSEs and best practices in the clinical environment
and disseminate evidence-based programs for self-management practices for adults with high blood cholesterol and/or high blood pressure in a variety of settings.

Find out more about WISEWOMAN.

Peer PrEP referral + HIV self-test for PrEP initiation among young Kenyan women

Career development funding has been awarded to Katrina Ortblad with primary mentor Jared Baeten by National Institutes of Health (NIH) for "Peer PrEP referral + HIV self-test for PrEP initiation among young Kenyan women".

 

Abstract:

The overall goal of this proposed K99/R00 award is to support my research training so that I can develop into an independent researcher whose work focuses on novel delivery models for effective HIV prevention interventions that operate outside of healthcare clinics. My pre-doctoral, doctoral, and post-doctoral training have given me over a decade of experience in global HIV research and expertise in quantitative methods, randomized trials, HIV self-testing, peer-based interventions, fieldwork, and pre-exposure prophylaxis (PrEP) for HIV prevention. This K99/R00 proposal outlines an intentional training and career development plan that builds on and expands my research skills and experiences so that I can become a competitive applicant for a tenured-track faculty position in an interdisciplinary department, such as global health, at a leading research university.

Training plan: To complete my research toolkit and transition to independence, I have assembled a multidisciplinary team of expert mentors from the US and Kenya. Together, we have designed a robust training plan that includes regular mentored meetings and relevant advanced coursework, seminars, workshops, and mentoring groups at the University of Washington and international scientific conferences. The specific training goals for the K99 phase of this award are to: 1) learn how to apply the most commonly used frameworks, strategies, and theories in implementation and behavioral research; 2) develop new and complementary skills in costing methods and qualitative research; 3) conduct formative research and a pilot to develop and refine a peer PrEP referral + HIV selftest (HIVST) delivery model for PrEP initiation among young Kenyan women; and 4) transition to scientific independence by building a publication record in implementation and behavioral science.

Research plan: PrEP for HIV prevention is highly effective. However, in Kenya, where the government offers PrEP free of change, few young women at high HIV risk are initiating PrEP. We propose developing, piloting, and testing an innovative model that might overcome barriers to PrEP initiation among young Kenyan women: peer PrEP referral + HIVST delivery. The specific aims of the proposed research are to: 1) develop a peer PrEP referral + HIVST delivery model to facilitate PrEP initiation among young Kenyan women using in-depth interviews with young women informed by implementation frameworks and behavioral theory (Y1); 2) pilot the proposed delivery model and refine the model using focus group discussions with pilot participants informed by implementation
frameworks (Y2); 3) test the effect and implementation of the refined delivery model on PrEP initiation and other outcomes (including other metrics of PrEP adoption, model fidelity, and costs) using a hybrid randomized trial (Y3-5).

This proposed K99/R00 research directly builds on my previous research experiences, enables me to gain new skills in implementation and behavioral research, addresses one of the greatest challenges to PrEP scale-up today, and will inform an R01 proposal for a community-randomized trial and budget impact analysis.

Sponsor Award Number: 1K99MH121166-01A1

Project Updates]