Linkage & Retention: A Randomized Trial to Optimize HIV/TB Care in South Africa

说明(由申请人提供)：抗逆转录病毒疗法(ART)的益处只能通过及时诊断艾滋病毒、成功地与护理挂钩和开始治疗才能实现。然而，在南非，只有一小部分新确诊的艾滋病毒感染者进入艾滋病毒护理。在艾滋病毒检测之后但在抗逆转录病毒疗法启动之前这段时间是结核病流行助长的死亡率非常高的时期，因此，改善获得结核病筛查和艾滋病毒护理的机会将带来重大好处。尽管结核病是撒哈拉以南非洲艾滋病毒携带者的主要死亡原因，但只有不到三分之一的感染艾滋病毒的南非人接受了结核病筛查。迫切需要努力执行和评估改善早期诊断以及与艾滋病毒和结核病护理的联系的战略，并在卫生保健资源有限的情况下考虑这些战略。我们提出了两个具体目标。第一个目标是进行随机对照试验，以确定卫生系统导航员干预措施在改善南非德班新诊断的艾滋病毒感染门诊患者与艾滋病毒和结核病护理的联系方面的有效性。以安徒生的医疗服务利用模型为理论框架，我们将提供一个医疗系统导航器，帮助患者识别和克服护理障碍，并研究影响护理联系的背景因素和患者层面因素的交叉点。第二个目标是评估在艾滋病毒筛查时促进与艾滋病毒和结核病护理挂钩的干预措施的成本和成本效益。2010年跨国立卫生研究院艾滋病毒相关研究计划优先评估与结核病和艾滋病毒护理一体化有关的结果对存活率、护理质量和成本的影响，以及不同的检测、联系和保留护理方法在改善艾滋病毒疾病结局方面的影响。这项拟议的研究将通过在美国和艾滋病和结核病流行率最高的南非省份工作的医疗、行为和成本效益专家之间的合作来解决其中几个重要问题。这一结果将为南非和其他资源有限环境中的艾滋病毒和结核病护理提供信息。 与公共卫生相关：在新的艾滋病毒诊断之后但在开始抗逆转录病毒治疗之前这段时间是南非患者死亡率非常高的时期，因此，改善获得艾滋病毒护理的机会将带来重大好处。我们建议研究一项干预措施的影响和成本效益，以改善南非德班新诊断的艾滋病毒感染者与艾滋病毒和结核病护理的联系。

DESCRIPTION (provided by applicant): The benefits of antiretroviral therapy (ART) can only be achieved through timely HIV diagnosis, successful linkage to care, and treatment initiation. In South Africa, however, only a fraction of those newly diagnosed with HIV enter HIV care. The period after HIV testing but prior to ART initiation represents a time of very high mortality, fueled by the tuberculosis (TB) epidemic, and therefore a time when improving access to TB screening and HIV care would be of substantial benefit. Though TB is the leading cause death among those with HIV in sub-Saharan Africa, less than one-third of HIV-infected South Africans have been screened for TB. Efforts are urgently needed to implement and evaluate strategies that improve early diagnosis and linkage to HIV and TB care, and to consider such strategies in the context of constrained healthcare resources. We propose two specific aims. The first aim is to conduct a randomized controlled trial to establish the efficacy of a health system navigator intervention in improving linkage to HIV and TB care among newly diagnosed HIV-infected outpatients in Durban, South Africa. Using Andersen's model of health service utilization as a theoretical framework, we will provide a health system navigator to help patients identify and overcome barriers to care and we will examine the intersection of contextual and patient-level factors that affect linkage to care. The second aim is to evaluate the cost and cost-effectiveness of this intervention for promoting linkage to HIV and TB care at the time of HIV screening. The 2010 Trans-NIH Plan for HIV-related research prioritizes the assessment of outcomes related to TB and HIV care integration on survival, quality of care, and cost, as well as the impact of different approaches for testing, linkage, and retention in care in improving outcomes of HIV disease. The proposed study will address several of these important issues through collaboration among medical, behavioral and cost- effectiveness experts working in the US and the South African province with the highest prevalence of HIV and TB. The results will inform HIV and TB care in South Africa and in other resource-limited settings. PUBLIC HEALTH RELEVANCE: The period after a new HIV diagnosis, but prior to starting antiretroviral therapy, is a time of very high mortality for patients in South Africa, and therefore a time when improving access to HIV care would be of substantial benefit. We propose to study the impact and cost-effectiveness of an intervention to improve linkage to HIV and TB care for newly diagnosed HIV-infected people in Durban, South Africa.