Early post-discharge mortality is high among Zambians living with HIV admitted to the
      hospital. This may be due to missed opportunities in post-discharge care, such as inadequate
      follow-up and treatment. In this study the investigators will develop and pilot a new
      approach to post-discharge HIV care to improve care coordination and treatment adherence.

Re-engagement at Discharge 2

HIV/AIDS

Hospitalization

Transitions of Care

Opportunistic Infections

Many people living with HIV (PLHIV) have poor outcomes following hospitalization, including
      high mortality, readmission, and gaps in HIV care engagement. This is likely multi-factorial
      and not all etiologies may be modifiable. While high mortality may due to incurable cancer,
      the majority of deaths in PLHIV are thought to be caused by infectious diseases for which
      treatments exist. However, succumbing to these life-threatening infections after discharge
      may be due to poor understanding of discharge instructions, lack of post hospital care, and
      poor understanding of required follow up. Psychosocial support also plays a role in the
      mental and physical health of these sick patients.

      In ReCharge 1, the investigators gathered formative data and identified at least three major
      factors that undermine HIV clinical outcomes after hospital discharge. First, there are gaps
      in continuity of care between the discharging facility and outpatient. Second, support from
      family is often suboptimal due to lack of understanding on the cause of illness, lack of HIV
      status disclosure, and the cost of care. Third, HIV comorbidities may underpin or complicate
      the immediate reason for discharge or the post-discharge engagement in care. These data were
      disseminated to local experts in Zambia including from the Ministry of Health and used to
      create a new care model for post-discharge HIV care. The care model draws from other
      successful programs in Zambia. In ReCharge 2 the investigators now propose to pilot the
      program and assess feasibility, acceptability, and potential for clinical impact.

Community Health Worker Post-Discharge Intervention

Re-engagement at Discharge 2: Improving Post-hospital Outcomes for Adults With HIV in Zambia

Proportion of discharged patients who are successfully visited after discharge.

Proportion of discharge follow-up visits by a community health worker that are comprehensive

Proportion of initial post-discharge visits to the HIV clinic that are attended by the participant's community health worker

Associate Professor

Proportion of clients with suppressed HIV viral load at 6 months post-discharge.

Proportion of clients alive at 6 months post-discharge.

Retention in HIV care after discharge defined by no gap of >28 days off antiretroviral therapy from discharge date to 6 months post-discharge date

Antiretroviral therapy clinic visit within 1 month of discharge

This group will be offered a community-based visit from a community health worker following hospital discharge.

Re-engagement at Discharge 2

About this trial

Study ID

Status

Type

Phase

Placebo

Accepting

Not accepting

Trial Timing

What is this trial about?

What are the participation requirements?

Locations

Location

Status