An evaluation of a choice architecture-based intervention on prescribing of TB preventive treatment to people living with HIV in southern Africa (the CAT study): a cluster-randomised trial.

IF 7.1 2区医学 Q1 PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH

BMJ Global Health Pub Date : 2025-05-24 DOI:10.1136/bmjgh-2024-016921

Kate Shearer, Bareng A S Nonyane, Christiaan Mulder, Emmanuel Kaonga, Rose Nyirenda, Kuzani Mbendera, Clara Sambani, Emilio Valverde, Savaiva Manguambe, Rogerio Chiau, Nicole Kawaza, Juliet Jokwiro, Bongani Dube, Tsitsi Apollo, Jeff Weiser, Violet Chihota, Gavin J Churchyard, Richard E Chaisson, Jonathan E Golub, Christopher J Hoffmann

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引用次数: 0

Abstract

Introduction: While highly effective for reducing the risk of tuberculosis (TB) disease, TB preventive treatment (TPT) is underused among people living with HIV (PWH). We evaluated the effectiveness of a behavioural economics-based choice architecture approach to increase facility-level TPT prescribing to PWH in Malawi, Mozambique and Zimbabwe.

Methods: We conducted a cluster-randomised trial within the IMPAACT4TB 3HP rollout, in which 57 healthcare facilities were randomly assigned 1:1 to choice architecture (intervention) or standard TPT prescribing (control). The aim was to link TPT to antiretroviral therapy (ART) prescribing and to make TPT prescribing the default. The intervention was supported by clinician training and a default prescribing module built into the point-of-care HIV electronic medical record in Malawi and stickers placed in clients' clinical stationery in Mozambique and Zimbabwe. Data were collected in aggregate, and the primary outcome was the facility-level percentage of clients initiating ART who initiated TPT. The CAT study was registered with clinicaltrials.gov where it is listed as completed.

Results: Implementation occurred from October 2021 to September 2022 in Mozambique (20 facilities), April 2021 to March 2022 in Malawi (19 facilities) and June 2021 to May 2022 in Zimbabwe (18 facilities), for a total of 29 control arm and 28 choice architecture intervention arm facilities, respectively. Comparing control to intervention facilities, mean TPT prescribing to clients initiating ART was 70.9% vs 86.9% in Mozambique (difference: -16.0%; 95% CI: -38.3%, 6.3%; p=0.15), 56.5% vs 55.5% in Malawi (difference: 1.0%; 95% CI: -14.0%, 16.9%; p=0.89) and 56.2% vs 55.9% in Zimbabwe (difference: 0.2%; 95% CI: -25.2%, 25.8%; p=0.98).

Conclusion: The choice architecture intervention did not overcome barriers to TPT prescribing. While the intervention may have led to an improvement in TPT prescribing in Mozambique, no differences were observed in the other countries. Further innovation is needed to ensure that all clients initiating ART are either prescribed TPT or started on anti-TB treatment, as appropriate.

Trial registration number: NCT04466293.

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对非洲南部一项基于选择体系结构的对艾滋病毒感染者开具结核病预防治疗处方的干预措施的评估（CAT研究）：一项集群随机试验。

导言：虽然结核病预防治疗（TPT）对降低结核病（TB）疾病的风险非常有效，但在艾滋病毒感染者（PWH）中未得到充分利用。我们评估了基于行为经济学的选择架构方法在马拉维、莫桑比克和津巴布韦为PWH增加设施级TPT处方的有效性。方法：我们在IMPAACT4TB 3HP推出中进行了一项聚类随机试验，其中57家医疗机构按1:1的比例随机分配到选择架构（干预）或标准TPT处方（对照）。其目的是将TPT与抗逆转录病毒治疗（ART）处方联系起来，并使TPT处方成为默认做法。这一干预措施得到了临床医生培训和马拉维即时护理艾滋病毒电子病历中内置的默认处方模块的支持，以及莫桑比克和津巴布韦在客户的临床文具中放置的贴纸。收集了汇总数据，主要结果是开始抗逆转录病毒治疗的患者开始接受TPT治疗的机构级别百分比。CAT研究已在clinicaltrials.gov上注册，并已完成。结果：实施时间分别为2021年10月至2022年9月莫桑比克（20个设施）、2021年4月至2022年3月马拉维（19个设施）和2021年6月至2022年5月津巴布韦（18个设施），共有29个控制组和28个选择结构干预组设施。对照与干预设施比较，对开始抗逆转录病毒治疗的病人开TPT处方的平均值为70.9%，而莫桑比克为86.9%(差异：-16.0%；95% ci: -38.3%, 6.3%；p=0.15)，马拉维为56.5% vs 55.5%(差异：1.0%；95% ci: -14.0%, 16.9%；p=0.89)和56.2%对55.9%的津巴布韦(差异：0.2%；95% ci: -25.2%, 25.8%；p = 0.98)。结论：选择结构干预没有克服TPT处方障碍。虽然干预措施可能导致莫桑比克TPT处方的改善，但在其他国家没有观察到差异。需要进一步创新，以确保所有开始抗逆转录病毒治疗的患者都得到TPT或开始酌情进行抗结核治疗。试验注册号：NCT04466293。

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来源期刊

BMJ Global Health Medicine-Health Policy

CiteScore

11.40

自引率

4.90%

发文量

429

审稿时长

18 weeks

期刊介绍： BMJ Global Health is an online Open Access journal from BMJ that focuses on publishing high-quality peer-reviewed content pertinent to individuals engaged in global health, including policy makers, funders, researchers, clinicians, and frontline healthcare workers. The journal encompasses all facets of global health, with a special emphasis on submissions addressing underfunded areas such as non-communicable diseases (NCDs). It welcomes research across all study phases and designs, from study protocols to phase I trials to meta-analyses, including small or specialized studies. The journal also encourages opinionated discussions on controversial topics.