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

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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.