Feasibility of an integrated intervention to reduce advanced HIV disease mortality among hospitalized adults in Zambia

降低赞比亚住院成人晚期艾滋病毒死亡率的综合干预措施的可行性

• 批准号: 10204985
• 负责人: Michael Jeffrey Vinikoor
• 金额: $ 13.28万
• 依托单位: UNIVERSITY OF ALABAMA AT BIRMINGHAM
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-08-15 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10204985
• 关键词: Address; Adherence; Admission activity; Adult; Affect; Africa South of the Sahara; Ambulatory Care Facilities; Antigens; Area; Attitude; Awareness; Behavior; Belief; Biological Assay; CD4 Lymphocyte Count; Caring; Cessation of life; Characteristics; Clinical; Cohort Studies; Cost Analysis; Cryptococcus; Data; Diagnosis; Disease; Drug Prescriptions; Elements; Enabling Factors; Enrollment; Epidemic; Evaluation; Evidence based treatment; Failure; Feedback; Focus Groups; Future; Guidelines; HIV; Health system; Home; Hospital Administrators; Hospital Mortality; Hospitalization; Hospitals; Human immunodeficiency virus test; Individual; Inpatients; Intervention; Interview; Investigation; Knowledge; Laboratories; Life; Measures; Mentors; Methods; Modeling; NIH Office of AIDS Research; Outcome; Patient Care; Patient Discharge; Patient-Focused Outcomes; Patients; Point of Care Technology; Predisposing Factor; Preparation; Prevalence; Procedures; Professional counselor; Prophylactic treatment; Prospective cohort; Provider; Reinforcing Factor; Reporting; Research; Sampling; System; Test Result; Testing; Training; Tuberculosis; Urine; Viral; Viral Load result; World Health Organization; Zambia; antiretroviral therapy; base; co-infection; cohort; cost; cost effectiveness; design; diagnosis evaluation; evidence base; experience; follow-up; health care delivery; hospital readmission; implementation determinants; implementation science; improved; informant; inpatient service; intervention effect; medical specialties; mortality; multi-component intervention; novel strategies; pill; point of care; point of care testing; sample collection; scale up; screening; theories; treatment comparison

PROJECT SUMMARY/ABSTRACT HIV prevalence remains high in inpatient settings in sub-Saharan Africa (SSA) despite robust scale-up of antiretroviral therapy. While HIV-related mortality during hospitalization is high (10-25%), mortality in the 6 months after discharge is even higher (20-40% in several cohort studies), with many deaths resulting from tuberculosis (TB) and Cryptococcal coinfection. Therefore, interventions to optimize the care of advanced HIV disease (i.e., CD4 <200 or WHO clinical stage 3 or 4 conditions) during hospitalization could have a substantial impact on overall HIV-related mortality. In a prospective cohort of HIV-infected adults admitted to the hospital in Zambia, failure to diagnose and treat coinfections during the hospital admission was due to (1) delays in obtaining CD4 count results and additional screening tests for disseminated TB and Cryptococcus and (2) provider misconceptions of the urgency of providing HIV care in inpatient settings. Building on these results and our experience implementing HIV interventions and training clinicians in Zambia, we now propose a multi- component intervention to reduce post-hospital mortality, based on the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) framework. The intervention consists of (a) a package of point-of-care (POC) laboratory tests (such as CD4, urine TB LAM antigen, Cryptococcal antigen, and HIV viral load) to enable clinicians to treat coinfections during admission, (b) targeted knowledge transfer to clinicians regarding best practices for advanced HIV disease to predispose them to treat coinfections, and (c) feedback reporting about post-discharge outcomes to inpatient staff to reinforce the approach. In Aim 1, we will develop the POC laboratory package and related standard operating procedures with input from key informants. In Aim 2, to inform the clinician training component, we will conduct focus group discussions with clinicians to explore perspectives and beliefs of the urgency and potential impact of providing interventions for advanced HIV disease during admission. In Aim 3, we will pilot-test the intervention and evaluate feasibility and impact on clinician practice. We will compare treatment of coinfections during the intervention with historical control data. This study will lead to a better understanding of how to deliver advanced HIV disease interventions during hospitalization. It will also assess the potential of a theory- based intervention to reduce post-discharge mortality among HIV-infected individuals in SSA.

项目概要/摘要 尽管大力扩大艾滋病毒防治工作，但撒哈拉以南非洲地区 (SSA) 的住院患者中艾滋病毒感染率仍然很高 抗逆转录病毒治疗。虽然住院期间与艾滋病毒相关的死亡率很高（10-25%），但 6 岁以下儿童的死亡率 出院后几个月的比例甚至更高（几项队列研究中为 20-40%），许多人因以下原因死亡 结核病 (TB) 和隐球菌合并感染。因此，优化晚期艾滋病毒护理的干预措施 住院期间的疾病（即 CD4 <200 或 WHO 临床 3 期或 4 期病症）可能会产生重大影响 对与艾滋病毒相关的总体死亡率的影响。在入院的艾滋病毒感染成人前瞻性队列中 在赞比亚，入院期间未能诊断和治疗合并感染的原因是 (1) 延误 获得 CD4 计数结果以及播散性结核病和隐球菌的额外筛查测试，以及 (2) 医疗服务提供者对于在住院环境中提供艾滋病毒护理的紧迫性存在误解。建立在这些结果的基础上 以及我们在赞比亚实施艾滋病毒干预措施和培训临床医生的经验，我们现在提出一项多方 基于诱发因素、强化因素和 教育诊断和评估（PRECEDE）框架中的启用构建。干预 包括 (a) 一套即时护理 (POC) 实验室检测（例如 CD4、尿液 TB LAM 抗原、 隐球菌抗原和 HIV 病毒载量）使临床医生能够在入院期间治疗合并感染，(b) 有针对性地向临床医生传授有关晚期艾滋病毒最佳实践的知识，以预防艾滋病毒的易发 他们治疗合并感染，以及（c）向住院工作人员反馈报告出院后的结果 强化方法。目标1，我们将开发POC实验室包和相关标准操作 程序并听取关键信息提供者的意见。在目标 2 中，为了告知临床医生培训部分，我们将进行 与临床医生进行焦点小组讨论，探讨紧迫性和潜在影响的观点和信念 为入院期间的晚期艾滋病毒疾病提供干预措施。在目标 3 中，我们将进行试点测试 干预并评估可行性以及对临床医生实践的影响。我们将比较合并感染的治疗方法 在对历史控制数据进行干预期间。这项研究将有助于更好地理解如何 在住院期间提供先进的艾滋病毒疾病干预措施。它还将评估理论的潜力 - 旨在降低 SSA 艾滋病毒感染者出院后死亡率的干预措施。