Test of an intervention to improve retention in HIV care after hospitalization

描述（由申请人提供）：缺乏医疗保健是当今人们死于艾滋病毒/艾滋病的主要原因之一。现代艾滋病毒治疗已经将这种致命的感染转变为一种可治疗的慢性疾病。没有经过证实的干预措施可以更好地使人们获得艾滋病毒初级保健。感染艾滋病毒的住院患者在护理中滞留不良的风险很高。对于大多数失去护理的患者来说，单次或双次干预是必不可少的，因为任何可以被招募到多次干预的患者都可能被招募回初级保健。7年来，我们的团队一直在研究HIV护理中的滞留问题。使用信息-动机-行为技能模型作为框架，我们的数据表明，在最近被诊断为艾滋病毒感染的患者中，获得艾滋病毒初级保健的机会受到以下因素的影响：关于护理和治疗的可获得性的关键信息差距，与不良应对策略和对医疗保健系统的低信任相关的有限动机，以及表现为低自我效能感和低社会支持的行为技能。这些因素导致驾驭卫生保健系统的能力差，并继续在艾滋病毒护理。我们已经开发了一个结构化的，基于理论的，病人导师计划。患者导师计划旨在通过增加患者对艾滋病毒和护理系统的知识、提高自我效能和促进积极的自我管理来提高艾滋病初级保健的保留率。在托马斯街健康中心的一次互动中，志愿者病人导师迎接新来的病人，他们来到诊所进行就诊，指导他们完成就诊并支持他们。在我们初步的准实验数据中，88%的患者在入院访问期间有患者导师，在接下来的90天内完成了医生访问，相比之下，78%的患者没有导师（p< 0.001）。在调整基线人口统计学和临床特征后，这些影响仍然显著，并持续到摄入后90-180天的间隔。我们将在一项为期5年的随机对照试验中测试TSHC患者导师干预的有效性，该试验在Ben Taub总医院住院的434名社会经济和种族不同的hiv感染患者中进行。我们假设，与注意控制相比，干预将有意义地增加出院后艾滋病毒初级保健的保留率。我们的具体目的是：1)检验患者导师干预对出院后HIV初级保健留置的效果；2)测试患者导师干预对次要结局（包括卫生服务使用、健康相关生活质量和临床结局）的有效性；3)确定与干预反应相关的中介因素，以及个体和系统的促进因素和阻碍HIV初级保健的因素。这项研究解决了当今艾滋病毒护理中最重要的挑战之一，即将现代艾滋病毒治疗扩大到所有有需要的人，并且还可能影响艾滋病毒感染者健康方面基于种族的差异。公共卫生相关性：在医疗保健方面的保留不足是当今人们死于艾滋病毒/艾滋病的主要原因之一。我们已经制定了一个结构化的、基于理论的患者导师计划，以提高艾滋病初级保健的保留率。我们将在一项为期5年的随机对照试验中测试这种患者导师干预的有效性，试验对象是在Ben Taub总医院住院的400多名社会经济和种族不同的艾滋病毒感染者。

DESCRIPTION (provided by applicant): Poor retention in medical care is one of the primary reasons people die of HIV/AIDS today. Modern HIV treatment has transformed this deadly infection into a treatable chronic condition. There are no proven interventions to better retain people in HIV primary care. Hospitalized patients with HIV infection are at high risk for poor retention in care. A single or dual session intervention is essential for most patients out of care, because any patient who could be recruited into a multi-session intervention could likely be recruited back into primary care. Our team has been researching retention in HIV care for over 7 years. Using the information-motivation-behavioral skills model as a framework, our data indicate that among patients recently diagnosed with HIV infection, access to HIV primary care is affected by critical information gaps regarding the availability of care and treatment, limited motivation related to poor coping strategies and low trust in the healthcare system, and weak behavior skills reflected in low self-efficacy and social support around adherence to HIV care. These factors result in poor ability to navigate the health care system and remain in HIV care. We have developed a structured, theory-based, Patient Mentor Program. The Patient Mentor Program was developed to improve retention into HIV primary care by increasing patient knowledge about HIV and the care system, increasing self-efficacy, and promoting active self-management. In a one- time interaction at the Thomas Street Health Center, volunteer patient mentors greet new patients who are arriving for their intake visit to the clinic, guide them through the intake visit and support them. In our preliminary, quasi-experimental data, 88% of patients who had a patient mentor during that intake visit completed a physician visit within the next 90 days, compared to 78% of patients who did not have a mentor (p<.001). These effects remained significant after adjusting for baseline demographic and clinical characteristics, and persisted into the 90-180 day interval after intake. We will test the efficacy of the TSHC patient mentor intervention in a 5-year randomized, controlled trial in 434 socio-economically and racially diverse HIV-infected patients hospitalized at Ben Taub General Hospital. We hypothesize that the intervention will meaningfully increase retention in HIV primary care after discharge compared to an attention control. Our Specific Aims are: 1) To test the efficacy of the patient mentor intervention on retention in HIV primary care after hospital discharge; 2) To test the efficacy of a patient mentor intervention on secondary outcomes that include health services use, health-related quality of life, and clinical outcomes; 3) To determine the mediating factors associated with response to the intervention, and the individual and system facilitators and barriers to retention in HIV primary care. This study addresses one of the most important challenges in HIV care today, i.e., expanding modern HIV treatment to all those in need, and may also impact race-based disparities in the health of people with HIV infection. PUBLIC HEALTH RELEVANCE: Poor retention in medical care is one of the primary reason people die of HIV/AIDS today. We have developed a structured, theory-based, Patient Mentor Program to improve retention into HIV primary care. We will test the efficacy of this patient mentor intervention in a 5-year randomized, controlled trial in more than 400 socio-economically and racially diverse HIV-infected patients hospitalized at Ben Taub General Hospital.