Leveraging mHealth to Enable and Adapt CHW Strategies to Improve TB/HIV Patient Outcomes in SA

Summary

Participation Requirements

Description

Mycobacterium tuberculosis (TB) is the leading cause of death for persons living with HIV (PLWH) in South Africa (SA). Estimates suggest that if factoring in immediate lost to follow-up, a mere 52% of TB/HIV co-infected individuals have successful treatment outcomes. Factors contributing to this ble...

Mycobacterium tuberculosis (TB) is the leading cause of death for persons living with HIV (PLWH) in South Africa (SA). Estimates suggest that if factoring in immediate lost to follow-up, a mere 52% of TB/HIV co-infected individuals have successful treatment outcomes. Factors contributing to this bleak reality occur throughout the TB/HIV cascade and include: limited capacity for TB screening; delays in linkage or failure to link into care; treatment non-adherence; and long and toxic treatment regimens that lead to disengagement in care. Reducing mortality and improving TB treatment outcomes among PLWH requires system-level, patient-centered interventions that enhance movement along both cascades. Through innovative mobile health (mHealth) approaches, designed to optimize human resources, and create efficiency for all users and engage patients in care, it is possible to reduce system bottlenecks and rapidly improve treatment outcomes. Studies addressing the TB or HIV care cascades are increasingly common, yet few offer an integrated, sustainable approach to TB/HIV co-infection and, to date, no intervention spans the entire cascade. The TB/HIV care cascade begins with diagnosis of TB in a PLWH or in a person newly diagnosed with both diseases. Patients newly diagnosed with TB and HIV face a burdensome model of care influenced by: a) timing of HIV treatment initiation; b) worsened symptom profiles associated with immune reconstitution syndrome; c) higher pill burden; d) differential adherence challenges; e) and more frequent care visits for directly observed therapy (DOT) and laboratory evaluations. Many, have struggled with adherence to HIV regimen, prior to the TB diagnosis. Data found that 44% of PLWH on anti-retroviral therapy (ART) present with viral suppression to first TB visit, suggesting the need to further intensify adherence interventions in this group. Hypothesis: The intervention will have fewer composite negative TB outcomes (i.e. treatment failure, loss to follow-up, and death) compared to attention controls. Primary Aims: to evaluate willingness to participate, the time to linkage to care and time to treatment initiation in a time-limited prospective cohort to determine the feasibility, acceptability and preliminary impact of a triggered, escalating mHealth enabled linkage, engagement, and adherence intervention by community health workers (CHW) to improve TB treatment outcomes among PLWH in Kwa-Zulu Natal, South Africa through a pilot randomized controlled trial. Secondary Aims: to evaluate study process indicators to further refine the behavioral and technological components of the intervention (patient symptom reporting; vDOT submission compliance; CHW adherence coaching sessions; intervention theoretical models; and m-health application feature enhancements to support care coordination). To characterize the emergence of resistance among patients with non-adherence to TB treatment, by obtaining two additional sputum specimens (i.e., 1) on treatment initiation for all phase II intervention patients and 2) among intervention patients with a 30-day period of sporadic adherence, defined as <90% of vDOT submissions) to fully characterize resistance patterns through genotypic and phenotypic resistance testing through whole genome sequencing techniques. Future Aim: to assess the feasibility of bi-monthly home-based sputum collection and telehealth-based video visits for highly adherent patients in the continuation phase of treatment. Details of this aim are not included in this protocol, as it will be submitted as a sub-study at a later time.

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