A mid-level health manager intervention to promote uptake of isoniazid preventive therapy among people with HIV in Uganda: a cluster randomised trial.
A mid-level health manager intervention to promote uptake of isoniazid preventive therapy among people with HIV in Uganda: a cluster randomised trial.
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DOI：
10.1016/s2352-3018(22)00166-7
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发表时间：
2022-09
期刊：
影响因子：
16.1
通讯作者：
Chamie, Gabriel
中科院分区：
文献类型：
--
作者：
Kakande, Elijah;Christian, Canice;Balzer, Laura B.;Owaraganise, Asiphas;Nugent, Joshua R.;DiIeso, William;Rast, Derek;Kabami, Jane;Peretz, Jason Johnson;Camlin, Carol S.;Shade, Starley B.;Geng, Elvin H.;Kwarisiima, Dalsone;Kamya, Moses R.;Havlir, Diane, V;Chamie, Gabriel
尽管长期以来的指导方针支持对艾滋病毒感染者进行异烟肼预防性治疗（IPT），但在撒哈拉以南非洲地区的使用率很低。中级保健管理人员在全国监督IPT方案;针对这一群体的干预措施尚未得到检验。我们的目的是确定是否提供结构化的领导和管理培训，并促进次区域合作和例行数据反馈给中层管理人员可以增加IPT启动艾滋病毒感染者与标准做法相比。我们在乌干达地区一级的卫生管理人员中进行了一项群集随机试验。我们以1：1的比例随机将四到七名管理人员分组到干预组或对照组。我们的干预措施将管理人员召集到由乌干达结核病和艾滋病专家促成的小型合作组织中，并提供业务领导和管理培训、短信平台访问和数据反馈。控制是标准做法。受试者对试验组不设盲，但研究统计学家在试验完成前均设盲。主要结果是在参与者监督的设施中，成年艾滋病毒感染者在2年内（2019-21）的IPT启动率。我们进行了预先指定的分析，排除了2019年第三季度（Q3-2019），以了解独立于与2019年第三季度金融意外事件相关的全国100天IPT推动的干预效果。本试验已在ClinicalTrials.gov（NCT 03315962）注册，目前正在进行中。在2017年11月15日至2018年3月14日期间，来自82个合格地区中的82个（乌干达135个地区的61%）的管理人员参加并随机分配：43个地区进行干预，39个地区进行对照。干预分娩发生在2017年12月6日至2022年2月2日之间。2年后，干预组和对照组的IPT启动率分别为0.74和0.65次/人年（发病率比[IRR] 1.14，95%CI 0.88 - 1.46; p= 0.16）。不包括Q3-2019，干预组的IPT启动率高于对照组：0.32 vs 0.25启动/人-年（IRR 1.27，95% CI 1.00 - 1.61; p= 0.026）。在乌干达60%以上的地区进行针对管理人员的干预后，干预组的IPT启动率并没有明显高于对照组。在解释了两组患者100天内IPT的大幅增加后，干预导致IPT率显著增加，并在推动后和COVID-19大流行期间持续。我们的研究结果表明，以中层卫生管理人员为中心的干预措施可以在大规模、次国家范围内改善IPT的实施，值得进一步探索，以应对存在强有力证据但实施仍不理想的关键公共卫生挑战。国家过敏和传染病研究所。
Despite longstanding guidelines endorsing isoniazid preventive therapy (IPT) for people with HIV, uptake is low across sub-Saharan Africa. Mid-level health managers oversee IPT programmes nationally; interventions aimed at this group have not been tested. We aimed to establish whether providing structured leadership and management training and facilitating subregional collaboration and routine data feedback to mid-level managers could increase IPT initiation among people with HIV compared with standard practice. We conducted a cluster randomised trial in Uganda among district-level health managers. We randomly assigned clusters of between four and seven managers in a 1:1 ratio to intervention or control groups. Our intervention convened managers into mini-collaboratives facilitated by Ugandan experts in tuberculosis and HIV, and provided business leadership and management training, SMS platform access, and data feedback. The control was standard practice. Participants were not masked to trial group, but study statisticians were masked until trial completion. The primary outcome was IPT initiation rates among adults with HIV in facilities overseen by participants over a period of 2 years (2019–21). We conducted prespecified analyses that excluded the third quarter of 2019 (Q3–2019) to understand intervention effects independent of a national 100-day IPT push tied to a financial contingency during Q3–2019. This trial is registered with ClinicalTrials.gov (NCT03315962), and is ongoing. Between Nov 15, 2017, and March 14, 2018, managers from 82 of 82 eligible districts (61% of Uganda’s 135 districts) were enrolled and randomised: 43 districts to intervention, 39 to control. Intervention delivery took place between Dec 6, 2017, and Feb 2, 2022. Over 2 years, IPT initiation rates were 0·74 versus 0·65 starts per person-year in intervention versus control groups (incidence rate ratio [IRR] 1·14, 95% CI 0·88–1·46; p=0·16). Excluding Q3–2019, IPT initiation was higher in the intervention group versus the control group: 0·32 versus 0·25 starts per person-year (IRR 1·27, 95% CI 1·00–1·61; p=0·026). Following an intervention targeting managers in more than 60% of Uganda’s districts, IPT initiation rates were not significantly higher in intervention than control groups. After accounting for large increases in IPT from a 100-day push in both groups, the intervention led to significantly increased IPT rates, sustained after the push and during the COVID-19 pandemic. Our findings suggest that interventions centred on mid-level health managers can improve IPT implementation on a large, subnational scale, and merit further exploration to address key public health challenges for which strong evidence exists but implementation remains suboptimal. National Institute of Allergy and Infectious Diseases.