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

项目摘要 在撒哈拉以南非洲国家，艾滋病毒感染者的失访率和死亡率很高 入院后。在卢萨卡大学教学医院的艾滋病毒感染者中， 在赞比亚，我们发现出院后三个月的死亡率为21%。需要新的方法来重新- 通过艾滋病毒护理连续体的“侧门”，让住院病人参与抗逆转录病毒疗法。重新参与在 出院（再充电）研究旨在了解和描述重新参与艾滋病毒治疗的挑战 出院后的护理;适应称为社区艾滋病毒流行病控制的既定干预措施 （CHEC）在出院后支持患者;并测试出院“d-CHEC”干预措施，以获得初步的 为将来的试验提供数据和经验。CHEC是一项基于证据且得到PEPFAR支持的干预措施， 利用社区卫生工作者（CHW），通过解决病人和 系统层面的障碍，我们将使用PRISM框架进行调整，以改善住院后的结果。 这项临床试验计划资助包括3个目标：在目标1中，我们将使用定性方法， 了解赞比亚出院后艾滋病毒护理的障碍。深入开展 与患者、其护理人员、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，以重新参与卫生保健 出院后，并确定可以通过调整来解决的可改变的护理障碍， CHEC。在目标2中，我们将转化目标1的发现，以调整CHEC模型， 在出院后期间保持护理和病毒抑制。除了程序组件 目标1中确定的，我们预计适应性干预可能需要：（a）尽早与生态学理事会接触 （B）电子出院摘要，方便病人从医院获得资料 （c）社区卫生福利院在出院后尽早进行家访。在目标3中，调整后的d-CHEC 将在试验前/试验后进行试点测试和评估。我们将招募一组有代表性的艾滋病毒感染者， 在d-CHEC实施之前和之后UTH的成人住院患者，然后将在实施后6个月随访 放电待评估的结局包括6个月时的护理保留率、病毒抑制率和死亡率。 使用混合方法，我们将评估适应性d-CHEC干预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角度。 这些结果将为一项完全有把握度的群集随机R 01试验提供信息，以评估 d-CHEC模型该项目意义重大，因为艾滋病毒感染者住院治疗很常见， 因为撒哈拉以南非洲缺乏有效的出院干预措施。我们已经做好充分准备， 由于我们对赞比亚艾滋病毒卫生系统的深刻理解和广泛的跟踪记录， 规模艾滋病毒计划，在临床，定性，实施科学和卫生系统研究的专业知识。

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.