Reducing Post-Hospital Mortality in HIV-Infected Adults in Tanzania

降低坦桑尼亚艾滋病毒感染成人的院后死亡率

• 批准号: 9761597
• 负责人: Robert N Peck
• 金额: $ 54.19万
• 依托单位: WEILL MEDICAL COLL OF CORNELL UNIV
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-09 至 2023-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9761597
• 关键词: Address; Adherence; Admission activity; Adult; Africa; African; Ambulatory Care; Behavioral Model; Caring; Cities; Clinic; Clinics and Hospitals; Collaborations; Continuity of Patient Care; Control Groups; Country; Data; Equation; Failure; Goals; Guidelines; HIV; Health; Health Personnel; Home environment; Hospital Mortality; Hospitalization; Hospitals; Intervention; Interview; Lesion; Life; Link; Medical; Medical center; Modeling; Outcome; Outpatients; Participant; Patients; Pilot Projects; Primary Health Care; Provider; Publishing; Randomized Clinical Trials; Reporting; Research; Resources; Savings; Self Efficacy; Social Workers; Social support; Structure; Survival Rate; Tanzania; Testing; Time; Transportation; Unemployment; United States; United States National Institutes of Health; Vulnerable Populations; World Health Organization; base; cost; cost effectiveness; evidence base; group intervention; health belief; health service use; high risk; improved; improved outcome; inpatient service; intervention cost; intervention effect; meetings; mortality; mortality risk; randomized trial; response; social stigma; standard care; standard of care; virology; ward

ABSTRACT: Hospitalization of HIV-infected adults in Africa is often the last opportunity to initiate and maintain life-saving HIV care. Despite the roll out of ART, HIV remains the most common cause of admission to medical wards in Africa. Our data in Tanzania and other data from Africa indicate that 25-40% of hospitalized HIV- infected adults will die within 1 year of hospital discharge. This high post-hospital mortality is strongly associated with failure to link to primary HIV care after hospital discharge. In collaboration with our Tanzanian partners, we have conducted formative research and have developed a social worker intervention to address this critical gap between hospital and HIV clinic. Utilizing the Gelberg and Andersen Behavioral Model of Health Services Utilization for Vulnerable Population, we identified 8 factors that are associated with poor post-hospital clinic linkage including: unemployment, traditional health beliefs, low self-efficacy, lack of transportation, lack of social support, stigma, low perceived need for HIV care, and physical weakness. Based on these factors, we adapted an evidence-based social worker intervention (ARTAS) which has been effective in improving linkage in the United States. A pilot of the social worker intervention in 31 HIV-infected patients at Bugando Medical Center in Mwanza, Tanzania showed that linkage improved from 63% to 100% and survival from 75% to 90% when compared to historical controls. Based on these pilot data, we propose a randomized clinical trial at the public Bugando Medical Center (BMC) and its associated HIV clinic in Mwanza, Tanzania. Our primary aim is to evaluate the efficacy of the social worker intervention to increase the 1-year survival rate in 500 HIV infected adults consecutively discharged from the Bugando Medical Center. We hypothesize that the one-year survival will be 90% in the intervention group vs. 75% in the standard care group. We will have >80% power to detect this 15% absolute difference in survival at p<0.05. Secondary aims will include: 1) to compare linkage to the HIV clinic and subsequent steps in the HIV care continuum, 2) to validate the Gelberg and Andersen Model, 3) to determine the acceptability of the intervention, and 4) to calculate the incremental cost and cost per life saved. The goal of this proposal is to develop a model of care for hospitalized HIV-infected adults to improve their linkage to outpatient care and post-hospital survival. Improving outcomes for HIV-infected adults could save several hundred thousand lives across Africa each year. After the successful completion of this trial, we will conduct implementation studies with our partners in the Tanzanian Ministry of Health to demonstrate scalability and cost-effectiveness.

摘要：非洲艾滋病毒感染者的住院治疗往往是启动和维持治疗的最后机会。 拯救生命的艾滋病毒护理。尽管推出了抗逆转录病毒疗法，但艾滋病毒仍然是导致就医的最常见原因 非洲的病房。我们在坦桑尼亚的数据和来自非洲的其他数据表明，25-40% 的住院艾滋病毒患者 感染的成年人将在出院后一年内死亡。这种高出院后死亡率强烈 与出院后未能获得艾滋病毒初级护理有关。 我们与坦桑尼亚合作伙伴合作，进行了形成性研究并开发了 社会工作者进行干预，以解决医院和艾滋病毒诊所之间的这一重大差距。利用格尔伯格和 弱势群体健康服务利用的安徒生行为模型，我们确定了 8 个因素 与院后诊所联系不良有关，包括：失业、传统健康观念、低 自我效能、缺乏交通、缺乏社会支持、耻辱、对艾滋病毒护理的需求较低，以及 身体虚弱。基于这些因素，我们采用了基于证据的社会工作者干预措施 （ARTAS）已有效地改善了美国的联系。社会工作者的飞行员 在坦桑尼亚姆万扎的布干多医疗中心对 31 名艾滋病毒感染者进行的干预表明，这种联系 与历史对照相比，生存率从 63% 提高到 100%，生存率从 75% 提高到 90%。 根据这些试点数据，我们提议在公共布干多医疗中心进行随机临床试验 (BMC) 及其位于坦桑尼亚姆万扎的相关艾滋病毒诊所。我们的主要目的是评估 社会工作者干预连续提高500名艾滋病毒感染成年人的1年生存率 从布干多医疗中心出院。我们假设一年生存率为 90% 干预组与标准护理组的 75% 相比。我们将有 >80% 的能力来检测这 15% 的绝对值 生存率差异p<0.05。次要目标包括：1）比较与艾滋病毒诊所的联系和 HIV 护理连续体中的后续步骤，2) 验证 Gelberg 和 Andersen 模型，3) 确定 干预措施的可接受性，以及 4) 计算增量成本和每个挽救生命的成本。 该提案的目标是为住院的艾滋病毒感染者制定一种护理模式，以改善他们的生活质量。 与门诊护理和出院后生存的联系。改善艾滋病毒感染成人的治疗结果可以挽救生命 非洲每年有数十万人丧生。成功完成本次试验后，我们将 与坦桑尼亚卫生部的合作伙伴进行实施研究，以证明可扩展性 和成本效益。