Re-engagement at Discharge (Re-Charge): Improving post-hospital outcomes for HIV-infected adults in Zambia

项目总结 在撒哈拉以南非洲国家，艾滋病毒感染者的随访率和死亡率都很高。 在入院后。在卢萨卡大学教学医院(UTH)的艾滋病毒感染者中， 在赞比亚，我们在出院三个月后发现21%的死亡率。需要新的方法来重新 通过艾滋病毒护理连续体的“侧门”让住院患者参与抗逆转录病毒治疗。重新订婚的时间是 出院(重新充电)研究旨在了解和描述再次接触艾滋病毒的挑战 出院后的护理；适应被称为社区艾滋病毒流行控制的既定干预措施 (CHEC)在病人出院后给予支持；并测试出院‘D-CHECK’干预，以获得初步的 为将来的试验提供数据和经验。Check是一项以证据为基础、由PEPFAR支持的干预措施 利用社区卫生工作者(CHW)通过解决患者和 系统层面的障碍，我们将使用PRISM框架对其进行调整，以改善住院后的结果。 这项临床试验计划拨款包括三个目标：在目标1中，我们将使用定性方法来更好地 了解赞比亚出院后艾滋病毒护理方面的障碍。我们将深入开展 与患者、他们的照顾者、CHW、临床医生和其他赞比亚人进行访谈和焦点小组讨论 卫生系统利益相关者了解患者和系统层面的障碍，以重新参与医疗保健 出院后，确定可通过适应以下情况来解决的可修改的护理障碍 勾选。在目标2中，我们将转换来自目标1的结果，以调整检查模型以改善患者 在出院后保留护理和病毒抑制。除了程序组件之外 在目标1中确定的，我们预计调整后的干预可能需要：(A)及早参与检查 出院前小组；(B)电子出院摘要，以方便病人资料从医院流出 (C)出院后的早期家庭探视；(C)家庭护理中心出院后的早期家访。在目标3中，修改后的D-Check 将在试验前/试验后进行试点测试和评估。我们将招募一个有代表性的艾滋病毒感染者群体 在实施D-Check前后，UTH的成人住院患者将在6个月后进行随访 出院。要评估的结果包括6个月的护理保留、病毒抑制和死亡率。 我们将使用混合方法评估改编后的D-CHEC干预措施的可行性和可接受性。 包括患者、护理人员和卫生保健工作者在内的多个视角。 这一结果将提供给一项全功能的整群随机R01试验，以评估 D-Check模型。该项目意义重大，因为住院在艾滋病毒感染者中很常见，而且 创新，因为撒哈拉以南非洲缺乏有效的排放干预措施。我们做好了充分的准备 由于我们对赞比亚艾滋病毒健康系统的深入了解，以及在大型项目中的良好记录，因此实施R34。 扩大艾滋病毒项目，具备临床、定性、实施科学和卫生系统研究方面的专业知识。

PROJECT SUMMARY In sub-Saharan African countries, HIV-infected patients suffer high rates of loss-to-follow-up and mortality following hospital admission. Among HIV-infected patients at University Teaching Hospital (UTH) in Lusaka, Zambia, we found 21% mortality three months after hospital discharge. Novel approaches are needed to re- engage hospitalized patients in ART via the `side door' of the HIV care continuum. The Re-engagement at Discharge (Re-Charge) study aims to understand and characterize the challenges of re-engagement in HIV care following hospital discharge; to adapt an established intervention called Community HIV Epidemic Control (CHEC) to support patients after discharge; and to test the discharge `d-CHEC' intervention to gain preliminary data and experience for a future trial. CHEC is an evidence-based and PEPFAR-supported intervention that utilizes community health workers (CHWs) to improve the HIV care continuum by addressing patient- and system-level barriers, which we will adapt using the PRISM framework to improve post-hospitalization outcomes. This clinical trial planning grant includes 3 Aims: in Aim 1, we will use qualitative methods to better understand barriers to HIV care that arise after hospital discharge in Zambia. We will conduct in-depth interviews and focus group discussions with patients, their caregivers, CHWs, clinicians, and other Zambian health system stakeholders to understand the patient- and system-level obstacles to health care re-engagement following hospital discharge and identify modifiable barriers to care that may be addressed by adaptations to CHEC. In Aim 2, we will translate the findings from Aim 1 to adapt the CHEC model to improve patient retention in care and viral suppression in the post-discharge period. In addition to program components identified in Aim 1, we anticipate the adapted intervention may require: (a) early engagement with the CHEC team before discharge; (b) an electronic discharge summary to facilitate flow of patient information from hospital to the outpatient clinic; and (c) an early post-discharge home visit from a CHW. In Aim 3, the adapted d-CHEC will be pilot-tested and evaluated in a pre/post trial. We will enroll a representative group of HIV-infected adult inpatients at UTH before and after d-CHEC implementation, who will then be followed 6 months after discharge. Outcomes to be assessed include retention in care at 6 months, viral suppression, and mortality. Using mixed methods, we will evaluate the feasibility and acceptability of the adapted d-CHEC intervention from multiple perspectives including patients, caregivers and health care workers. The results will inform a fully-powered cluster-randomized R01 trial to evaluate effectiveness and costs of the d-CHEC model. The project is significant as hospitalization is common among HIV-infected individuals, and innovative as effective discharge interventions are lacking in sub-Saharan Africa. We are well prepared to implement this R34 due to our strong understanding of the Zambian HIV health system and track record in large- scale HIV programs, with expertise in clinical, qualitative, implementation science, and health systems research.