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.

NARRATIVE This project will develop and pilot test an intervention for hospitalized HIV-infected adults to address the problem of post-discharge mortality (which reaches 20-40% within 6 months) in sub-Saharan Africa. We will conduct key informant interviews with inpatient and HIV health system leaders in order to design a point-of- care laboratory package for hospitalized HIV-infected patients and focus groups with clinicians who care for these patients to explore their perspectives and beliefs on expanding the HIV care that is provided during admission. Then we will pilot-test the intervention among a group of newly admitted HIV-infected adults to assess feasibility and change in clinician practice, with the results informing a future larger-scale facility-level evaluation of the intervention.