Reducing Post-Hospital Mortality in HIV-Infected Adults in Tanzania

摘要：在非洲，艾滋病毒感染者的住院治疗往往是启动和维持 挽救生命的艾滋病毒护理。尽管抗逆转录病毒疗法的推出，艾滋病毒仍然是进入内科的最常见原因 在非洲的病房。我们在坦桑尼亚的数据和来自非洲的其他数据表明，25%-40%的住院艾滋病毒- 受感染的成年人将在出院后1年内死亡。这种高的院后死亡率是强烈的 与出院后未能与初级艾滋病毒护理挂钩有关。 与坦桑尼亚合作伙伴合作，我们进行了形成性研究，并开发了一种 社会工作者的干预，以解决医院和艾滋病毒诊所之间的这一关键差距。利用Gelberg和 弱势人群卫生服务利用的Andersen行为模型，我们确定了8个因素 与较差的院后诊所联系有关，包括：失业、传统健康信念、低 自我效能感、缺乏交通工具、缺乏社会支持、耻辱、对艾滋病毒护理的低感知需求以及 身体虚弱。基于这些因素，我们采用了循证的社会工作者干预方法 (Artas)，它在改善美国的联系方面一直很有效。社会工作者的领航员 在坦桑尼亚Mwanza的Bugando医疗中心对31名艾滋病毒感染患者进行的干预显示， 与历史对照组相比，存活率从63%提高到100%，存活率从75%提高到90%。 基于这些试点数据，我们建议在布干多公立医疗中心进行随机临床试验 (BMC)及其在坦桑尼亚姆万扎的相关艾滋病毒诊所。我们的主要目标是评估 社会工作者干预连续提高500名HIV感染者的1年存活率 从布干多医疗中心出院。我们假设一年的存活率为90%。 干预组与标准护理组的比例为75%。我们将拥有80%的权力来检测这15%的绝对 P&lt；0.05的存活率差异。次要目标将包括：1)比较与艾滋病毒诊所和 HIV护理连续体中的后续步骤，2)验证Gelberg和Andersen模型，3)确定 干预的可接受性，以及4)计算增量成本和每挽救一次生命的成本。 这项提案的目标是为住院的艾滋病毒感染成年人开发一种护理模式，以改善他们的 与门诊护理和院后生存的联系。改善感染艾滋病毒的成年人的结局可以节省 每年有数十万人生活在非洲各地。在成功完成这项试验后，我们将 与坦桑尼亚卫生部的合作伙伴一起进行实施研究，以展示可伸缩性 和成本效益。

ABSTRACT: Hospitalization of HIV-infected adults in Africa is often the last opportunity to initiate and maintain life-saving HIV care. Despite the roll out of ART, HIV remains the most common cause of admission to medical wards in Africa. Our data in Tanzania and other data from Africa indicate that 25-40% of hospitalized HIV- infected adults will die within 1 year of hospital discharge. This high post-hospital mortality is strongly associated with failure to link to primary HIV care after hospital discharge. In collaboration with our Tanzanian partners, we have conducted formative research and have developed a social worker intervention to address this critical gap between hospital and HIV clinic. Utilizing the Gelberg and Andersen Behavioral Model of Health Services Utilization for Vulnerable Population, we identified 8 factors that are associated with poor post-hospital clinic linkage including: unemployment, traditional health beliefs, low self-efficacy, lack of transportation, lack of social support, stigma, low perceived need for HIV care, and physical weakness. Based on these factors, we adapted an evidence-based social worker intervention (ARTAS) which has been effective in improving linkage in the United States. A pilot of the social worker intervention in 31 HIV-infected patients at Bugando Medical Center in Mwanza, Tanzania showed that linkage improved from 63% to 100% and survival from 75% to 90% when compared to historical controls. Based on these pilot data, we propose a randomized clinical trial at the public Bugando Medical Center (BMC) and its associated HIV clinic in Mwanza, Tanzania. Our primary aim is to evaluate the efficacy of the social worker intervention to increase the 1-year survival rate in 500 HIV infected adults consecutively discharged from the Bugando Medical Center. We hypothesize that the one-year survival will be 90% in the intervention group vs. 75% in the standard care group. We will have >80% power to detect this 15% absolute difference in survival at p<0.05. Secondary aims will include: 1) to compare linkage to the HIV clinic and subsequent steps in the HIV care continuum, 2) to validate the Gelberg and Andersen Model, 3) to determine the acceptability of the intervention, and 4) to calculate the incremental cost and cost per life saved. The goal of this proposal is to develop a model of care for hospitalized HIV-infected adults to improve their linkage to outpatient care and post-hospital survival. Improving outcomes for HIV-infected adults could save several hundred thousand lives across Africa each year. After the successful completion of this trial, we will conduct implementation studies with our partners in the Tanzanian Ministry of Health to demonstrate scalability and cost-effectiveness.