Prevent TB: Application of choice architecture to implement TB preventive therapy in South Africa

项目总结 抗逆转录病毒疗法(Art)的可获得性已显著减少了艾滋病毒相关死亡的主要原因。 和非洲的发病率，包括结核病(TB)。然而，结核病仍然是人类死亡的主要原因。 艾滋病毒携带者。使用结核病预防疗法(TPT)可降低结核病发病率和死亡率，即使是在接受 艺术。尽管TPT在艾滋病毒携带者中的好处已经知道30年了，而且国际上 而国家指南提供了明确的处方建议，TPT的处方很差。整体处于低水平 中等收入国家有10-30%的艾滋病毒携带者有资格获得TPT。对于那些确实收到了 TPT和ART一样，坚持性通常是好的。多个系统和提供商级别的障碍似乎是 开出贫血的TPT处方。其中几个障碍导致TPT处方成为例外 而不是例行公事--为不准确的关切而实施的基于复杂程序的障碍。主要 其中包括完全“排除”活动性结核病的努力，以及对TPT潜在的肝脏问题的担忧。 值得注意的是，一项专注于更复杂(和更敏感)结核病诊断的研究导致了#年死亡率的增加。 有较高结核病诊断的手臂。这支手臂还推迟了TPT的处方，并降低了TPT的处方。这项研究旨在 使用CHOICE体系结构使TPT只在以下情况下才会开出通常的处方或不开处方的默认处方 临床医生有一个真正的担忧(例如，对结核病的高度担忧)。选择的有效性 将基于体系结构的实施策略与集群中的常见实施进行比较- 随机试验。诊所将是随机单位，所有患者将在研究诊所接受服务 接收统一的TPT实现。主要结果将是患者启动抗逆转录病毒治疗的比例。 他们也会接受TPT。选择架构的基本概念是优化决策可以 导致认知负荷降低。因此，我们建议将TPT处方的认知负荷与 学习手臂。我们还将评估处方方法与临床工作流程的一致性、可接受性 提供者、实施措施和患者级别的实施(例如，收到TPT、遵从性、患者 报告的问题)。这项研究有可能在重塑TPT和其他 南非及类似地区诊所的常规服务。如果这一实施战略被证明 有效地，它将有助于实现降低艾滋病毒相关死亡率和结核病发病率的国家和全球目标。

PROJECT SUMMARY The availability of antiretroviral therapy (ART) has markedly reduced leading causes of HIV-related mortality and morbidity in Africa, including tuberculosis (TB). Yet TB remains the leading cause of death among people with HIV. Use of TB preventive therapy (TPT) reduces TB incidence and death, even among people receiving ART. Although the benefits of TPT among people with HIV have been known for 30 years and international and national guidelines provide clear prescribing recommendations, TPT is poorly prescribed. Overall in low and middle income countries 10-30% of people with HIV eligible for TPT receive it. For those who do receive TPT along with ART, adherence is generally good. Multiple system and provider level barriers appear to be driving anemic TPT prescribing. Several of these barriers have caused TPT prescribing to be the exception rather that the routine – barriers based on complex procedures implemented for inaccurate concerns. Primary among are efforts to completely “rule-out” active TB and concerns for potential liver problems with TPT. Notably, a study focused on more complex (and more sensitive) TB diagnosis resulted in increased mortality in the arm with greater TB diagnosis. That arm also had delayed and lower TPT prescribing. This study seeks to use choice architecture to make TPT prescribing the usual or “default” with not-prescribing occurring only when the clinician has a real concern (e.g. high concern for TB disease). The effectiveness of the choice architecture-based implementation strategy will be compared to the usual implementation in a cluster- randomized trial. Clinics will be the unit of randomization with all patients receiving services at a study clinic receiving uniform TPT implementation. The primary outcome will be the proportion of patients initiating ART who also receive TPT. The underlying concept of choice architecture is that optimizing decision making can lead to reduced cognitive load. Thus we propose to compare cognitive load regarding TPT prescribing between study arms. We will also assess congruence of the prescribing approach with clinic work flow, acceptability to providers, implementation measures, and patient-level implementation (e.g. receipt of TPT, adherence, patient reported problems). This study has the potential to lead the way in reshaping the delivery of TPT and other routine services in clinics in South Africa and similar settings. Should this implementation strategy prove effective it will contribute to national and global goals to reduce HIV-associated mortality and TB incidence.