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Abstract
The continuing HIV pandemic calls for broad, multi-sectoral responses that foster community control of local prevention and care services, with the goal of leveraging high quality treatment as a means of reducing HIV incidence. Service system improvements require stakeholder input from across the care continuum to identify gaps and to inform strategic plans that improve HIV service integration and delivery. System dynamics modeling offers a participatory research approach through which stakeholders learn about system complexity and about ways to achieve sustainable system-level improvements. Via an intensive group model building process with a task force of community stakeholders with diverse roles and responsibilities for HIV service implementation, delivery and surveillance, we designed and validated a multi-module system dynamics model of the HIV care continuum, in relation to local prevention and care service capacities. Multiple sources of data were used to calibrate the model for a three-county catchment area of central Connecticut. We feature a core module of the model for the purpose of illustrating its utility in understanding the dynamics of treatment as prevention at the community level. We also describe the methods used to validate the model and support its underlying assumptions to improve confidence in its use by stakeholders for systems understanding and decision making. The model’s generalizability and implications of using it for future community-driven strategic planning and implementation efforts are discussed.
Highlights
As the HIV pandemic approaches four decades, nations, states, and communities increasingly seek broad, multi-sectoral responses to prevent new infections while caring for those infected in order to achieve the goal of controlling the epidemic [1,2,3]
This is the central HIV test, treat, and retention in care module representing the stages of the care continuum and the “treatment cascade,” from HIV exposure and infection, to diagnosis, linkage to care, initiation of anti-retroviral treatment (ART), and viral suppression, or lost to care and mortality
The structure of the scoping model included the stages of the care continuum, from HIV incidence and undiagnosed status, Simulating system dynamics of the HIV care continuum to testing and diagnosis, linkage of people living with HIV (PLWH) to medical care, engagement in care and on ART, and achievement of viral suppression
Summary
As the HIV pandemic approaches four decades, nations, states, and communities increasingly seek broad, multi-sectoral responses to prevent new infections while caring for those infected in order to achieve the goal of controlling the epidemic [1,2,3]. System improvements require stakeholders from across the care continuum to identify service gaps and develop and carry out strategic plans to improve HIV service integration and delivery [11,12,13] Such plans may suffer from stakeholders’ incomplete “mental models,” that is, their internal conceptual representation of the HIV care system [14, 15], and their insufficient recognition of system complexity and limited understanding of system dynamics that affect population health outcomes [16, 17]. The overarching purpose of the tool is to use it to inform effective, community-driven ways of leveraging TasP, which can be visualized as an omnipresent ( not always apparent) feedback loop In this loop, improvements in viral suppression among PLWH serve to decrease likelihood of HIV exposure and infection, theoretically to the point of any further new cases in the total population.
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