Immediate Fast-Track Versus Standard Care for Persons Living With HIV in Haiti

Study Overview
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Brief Summary
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In the proposed R34 grant, the investigators will develop and test a strategy of immediate fast-track care. The study population will include adult patients with early HIV infection. Participants will be randomized to immediate fast-track or standard (deferred fast-track) care. All participants will receive same-day HIV testing and ART initiation prior to study enrollment. The intervention group will receive immediate fast-track care, which is conditional upon timely visits, and after 24 weeks in care, an undetectable viral load (HIV-1 RNA <200 copies/ml). The standard group will be eligible to start fast-track care at 24 weeks, if they are on time for that visit and have an undetectable viral load. Participants in either group who are >3 days late for any fast-track visit will lose fast-track care for that visit; those in either group with detectable viremia on their 24-week viral load test will be evaluated by a physician, with follow-up visits every 4 weeks until they have an undetectable viral load. Participants will be followed for 48 weeks. With the proposed pilot study, the investigators aim to conduct the formative work that is necessary to successfully implement a future clinical trial with the same primary outcome. The investigators hypothesize that immediate fast-track care will result in higher retention with viral suppression.

Detailed Description
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This study is a randomized, open-label pilot study comparing immediate fast-track vs. standard care for patients with WHO Stage 1 or 2 disease at HIV diagnosis. Participants will be enrolled on the day of HIV diagnosis, and will be followed for 48 weeks. The total sample size will be 254 participants; of these, 56 will be patients or providers enrolled in one-time focus groups, 20 will be enrolled for testing the manuals and study procedures, and 178 will be enrolled in the pilot RCT. The study site is GHESKIO (Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections) in Port-au-Prince, Haiti. The study population includes men and women who are at least 18 years of age who are ART-naïve, and who present with WHO Stage 1 or 2 diseases at HIV diagnosis. Participants in both groups will initiate ART on the day of HIV testing, prior to enrollment and randomization. They will then be randomized to immediate versus standard (deferred fast-track) care. Those in the immediate group will start fast-track care on the day of HIV testing. Those in the standard group will start fast-track care if they are on time for their 24-week visit, with HIV-1 RNA <200 copies/ml. Participants in both groups will receive identical care from weeks 24 to 48. Once a patient qualifies for fast-track care, it is provided in the same manner for both groups. Reminder phone call and point-of-service dispensing of ART: The CHW calls patient one day in advance, to ensure they can attend visit. If patient responds in the affirmative, then their ART and prophylactic medications are packaged in advance. Minimal waiting time to see clinician, with short, focused visits: Total visit time is about 30 minutes. Less frequent clinic visits: Other than the first 3 months for the immediate group, fast-track care includes quarterly nurse visits, with CHW phone calls during months when no clinic visit is scheduled; Nurse-led care: Fast-track visits are all staffed by nurses, except in the case that a patient has a new symptom; in that case, the patient receives a fast-track physician evaluation, with appropriate fast-track follow-up care. For example, in the rare case that a patient develops active TB, they will receive fast-track care with physician and nurse visits as appropriate.

Official Title
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Immediate Fast-Track Versus Standard Care for Persons Living With HIV in Haiti: A Randomized Pilot Study

Conditions
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HIV/AIDS

Intervention / Treatment
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* Behavioral: Immediate Fast-Track Care
* Behavioral: Deferred Fast-Track Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Men and women of ≥18 years of age Ability and willingness to give written informed consent Documentation of positive HIV status (test conducted at GHESKIO), and initiation of same-day ART prior to enrollment Physician-confirmed WHO Stage 1 or 2 disease Acceptance of HIV diagnosis, defined as affirmative responses to two questions: I believe that HIV and AIDS exist and I believe that the results of my HIV test show that I am infected. Access to a phone, or able to provide a contact person with a phone (this does not require disclosure of HIV status to the contact person) Agreement to provide a contact phone number and address, and to accept home visits from a CHW. Exclusion Criteria: Any use of ART in the past Pregnancy or breastfeeding at the screening visit WHO Stage 3 or 4 disease Active drug, alcohol use, or mental condition that would interfere with the ability to adhere to study requirements, in the opinion of the study physician Score of <3 for any of the 7 questions on the ART readiness survey Planning to transfer care to another clinic during the study period

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Patients will be randomized in a 1:1 ratio
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard Group<br>Deferred fast-track care | Behavioral: Deferred Fast-Track Care<br>* Eligible for fast-track care after 6 months on ART<br>|
| Experimental: Immediate Fast-Track Group<br>Immediate fast-track care | Behavioral: Immediate Fast-Track Care<br>* Eligible for fast-track care at enrollment<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Viral Suppression; cut-off <200 copies/ml | HIV-1 RNA <200 copies/ml | 48 weeks after enrollment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Viral Suppression; cut-off <50 copies/ml | HIV-1 RNA <50 copies/ml | 48 weeks after enrollment | 
| Viral Suppression; cut-off <1000 copies/ml | HIV-1 RNA <1000 copies/ml | 48 weeks after enrollment | 
| Adherence by pharmacy refill records | ART dispensed by the pharmacy for at least 90% of the days in the study period (302 days of ART dispensed during the 336-day study period) | 48 weeks after enrollment | 
| Cost-effectiveness | Cost per patients with undetectable viral load | 48 weeks after enrollment | 
| Connectedness to Treatment Setting Scale | Mean score; range 10-60; a higher score indicates greater connection to treatment setting | Day of enrollment, and 24 weeks and 48 weeks after enrollment | 
| State Hope Scale | Mean score; range 6 to 30; a higher score indicates greater hopefulness | Day of enrollment, and 24 weeks and 48 weeks after enrollment | 
| Patient Satisfaction Survey | Mean score; range 5 to 25; a higher score indicates greater satisfaction | Weeks 2, 24, and 48 after enrollment | 
| Social Provisions Scale | Mean score; range 24 to 96; a higher score indicates greater degree of perceived support | Day of enrollment, and 24 and 48 weeks after enrollment | 
| Coping Survey | Mean score; range 38 to 152; a higher score indicates a greater sense of being able to cope with a situation | Weeks 2, 24, and 48 after enrollment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HIV/AIDS, Fast-track care, Behavioral economics, Differentiated care