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

摘要：在非洲，感染艾滋病毒的成年人住院治疗往往是最后一次机会， 拯救生命的艾滋病护理。尽管抗逆转录病毒疗法已经推出，但艾滋病毒仍然是入院接受医疗服务的最常见原因。 在非洲的病房我们在坦桑尼亚的数据和其他来自非洲的数据表明，25-40%的住院艾滋病毒感染者- 受感染的成年人会在出院后一年内死亡。如此高的住院后死亡率， 与出院后未能与艾滋病毒初级护理联系在一起有关。 我们与坦桑尼亚合作伙伴合作，进行了形成性研究，并制定了一项 社会工作者干预，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 Andersen行为模型，我们确定了8个因素， 与医院后诊所联系不佳有关，包括：失业、传统健康观念、低 自我效能、缺乏交通、缺乏社会支持、耻辱感、对艾滋病毒护理的需求较低，以及 身体虚弱。基于这些因素，我们采用了循证社会工作者干预 （ARTAS）在改善美国的联系方面一直很有效。社会工作者的飞行员 坦桑尼亚姆万扎Bugando医疗中心对31名艾滋病毒感染者的干预表明， 与历史对照相比，从63%提高到100%，存活率从75%提高到90%。 基于这些试点数据，我们建议在公共Bugando医疗中心进行随机临床试验 (BMC)以及坦桑尼亚姆万扎的艾滋病诊所。我们的主要目的是评估 社会工作者干预连续提高500例成人HIV感染者1年生存率 从布甘多医疗中心出院我们假设，一年生存率将是90%， 干预组与标准护理组的75%。我们将有>80%的功率来检测这15%的绝对值， 生存率差异p<0.05。次要目标将包括：1）比较与艾滋病毒诊所的联系， 艾滋病毒护理连续体的后续步骤，2）验证Gelberg和Andersen模型，3）确定 干预措施的可接受性; 4）计算增量成本和挽救的每个生命的成本。 该提案的目标是为住院的艾滋病毒感染成年人制定一种护理模式，以改善他们的健康状况。 与门诊护理和院后生存的联系。改善艾滋病毒感染成年人的结果可以挽救 每年有几十万人死于非洲各地。在这次试验成功后，我们将 与坦桑尼亚卫生部的合作伙伴开展实施研究，以证明可扩展性 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.