摘要：Objectives. We tested a modified Network for the Improvement of Addiction Treatment (NIATx) process improvement model to implement improved HIV services (prevention, testing, and linkage to treatment) for offenders under correctional supervision. Methods. As part of the Criminal Justice Drug Abuse Treatment Studies, Phase 2, the HIV Services and Treatment Implementation in Corrections study conducted 14 cluster-randomized trials in 2011 to 2013 at 9 US sites, where one correctional facility received training in HIV services and coaching in a modified NIATx model and the other received only HIV training. The outcome measure was the odds of successful delivery of an HIV service. Results. The results were significant at the .05 level, and the point estimate for the odds ratio was 2.14. Although overall the results were heterogeneous, the experiments that focused on implementing HIV prevention interventions had a 95% confidence interval that exceeded the no-difference point. Conclusions. Our results demonstrate that a modified NIATx process improvement model can effectively implement improved rates of delivery of some types of HIV services in correctional environments. The National Institute on Drug Abuse launched the Criminal Justice Drug Abuse Treatment Studies, Phase 2 in 2008, under a cooperative agreement with multiple research organizations and a coordinating center. The purpose was to test implementation strategies for health-related interventions for offenders incarcerated in prisons and jails or supervised by probation and parole agencies. The research centers designed the protocols and conducted the trials. The HIV Services and Treatment Implementation in Corrections (HIV-STIC) study evaluated implementation strategies in HIV/AIDS prevention–education, testing, and treatment. Inmates and other offenders are at high risk for HIV infection, and the rate of confirmed AIDS cases among state and federal prisoners has been about 2.4 times the rate in the general US population. 1–4 In 2009, the Centers for Disease Control and Prevention released practice guidelines for managing HIV risk among offenders in correctional systems; they called for HIV testing, prevention programming, and discharge planning for seropositive inmates. 5 Although many correctional facilities offer HIV testing, prevention, and antiretroviral medication services, studies have demonstrated that many gaps remain in delivering effective HIV services. 6 Furthermore, although inmates identified as HIV positive are provided with antiretroviral therapy (ART) by correctional facilities, gaps in access to medications when inmates are released to the community are common and can have catastrophic consequences for offenders and collateral contacts. 7,8 For the HIV-STIC study, we found helpful ideas in the model of implementation research developed by Proctor et al. 9,10 They (and other theorists) propose that experimental testing has identified many effective public health interventions, so that now the pressing need is to test implementation strategies to achieve successful use of those interventions in organizations. Another important concept is service penetration to recipients (the number of eligible persons who use a service as a proportion of the total number of persons eligible for the service). 10,11 Effective HIV prevention models for correctional populations have been identified, 12,13 but transferring these programs from carefully controlled trials into real-world practice is difficult, 14,15 and few studies have tested the implementation processes in field settings. 14,16 Quality improvement strategies have become common in health care systems. The Network for the Improvement of Addiction Treatment (NIATx) 17 trains coaches to help local agency change teams learn how to try out and assess new organizational processes for targeted improvements such as improved patient retention in treatment. 18,19 HIV continues to be a major public health problem (even though research has established the efficacy of HIV testing, prevention practices, and ART) because these services have not been adequately implemented for high-risk populations. We sought to expand the new field of implementation science to evidence-based HIV services for a very high-risk population: offenders in correctional facilities or recently released from such facilities. We also tested a NIATx model modified for the implementation of HIV services in prisons and jails. Nine research centers cooperated in planning and conducting the research. Our long-term goal was improved health services for an at-risk population: offenders under correctional supervision. Specifically, we aimed to more effectively implement improvements in HIV services for preventing, detecting, and treating HIV. Our primary hypothesis was that, compared to the control condition facilities, proportionally more offenders in our experimental condition facilities (where staff were exposed to the modified NIATx model) would receive improved delivery of HIV services.
