Peer-Educator-coordinated vs Nurse-coordinated ART Refill for Adolescents and Young Adults Living With HIV in Lesotho

HIV/AIDS Clinical Trial

— PEBRA  

Official title:

Peer-Educator-coordinated vs Nurse-coordinated ART Refill for Adolescents and Young Adults Living With HIV in Lesotho - a Cluster Randomized Clinical Trial (PEBRA Trial)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03969030
• Other study ID #: 2019-10
• Status: Completed
• Phase: N/A
• Start date: November 1, 2019
• Est. completion date: April 30, 2021

Study information

• Verified date: May 2021
• Source: Swiss Tropical & Public Health Institute
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Sub-Saharan Africa (SSA) is home to 85% of the adolescents and young people living with HIV (AYPLHIV) globally and they are heavily affected by the HIV/AIDS epidemic: AYPLHIV in SSA are the only population group for whom HIV-related mortality continues to increase, and they have overall poorer outcomes than all other age groups. Lesotho with worldwide the second-highest HIV prevalence shows a viral suppression rate among AYPLHIV of only 49%.

In order to address the multiple barriers in the adolescent HIV care cascade and their unique needs, multicomponent packages of differentiated service delivery (DSD) are a promising approach.

In close collaboration with different local stakeholders, the researchers designed a DSD model specifically for AYPLHIV, called the PEBRA model. In the PEBRA model the peer-educator (PE) plays a pivotal role, by coordinating the ART refill/care according to the patient's preferences using a tablet-based application, called PEBRApp (https://github.com/chrisly-bear/PEBRApp). The PEBRApp helps the PE to assess each participant's preference, to adapt the ART refill according to these preferences in a feasible manner, to keep track of the ART refill, and to ensure regular contact between the PE and the participant. The model includes key innovative options such as individualized automatic SMS notifications and decentralized ART delivery.

The PEBRApp was developed with ❤️ by Technify Maseru, Lesotho (www.technifyls.com) & Christoph Schwizer Zurich, Switzerland (www.christophschwizer.ch).

Description:

STUDY DESIGN

PEBRA study is a cluster randomized, open-label, superiority trial in a resource-limited setting. The rational for a cluster randomized design with health facilities as clusters, is the high risk of cross-contamination between the study arms if randomization would be done at individual level. The clusters (health facilities) will be randomized (randomly-varying block sizes, 1:1 allocation) into the 2 groups using a computer-generated randomization list, stratified by district and size of the AYPLHIV cohort of each facility (<15 vs ≥15). The study will be conducted at 20 health facilities in three districts of Lesotho (Leribe, Butha-Buthe, Mokhotlong).

OBJECTIVES

The overall objective of this study is to evaluate the feasibility and effectiveness of a DSD model ("PEBRA model") among AYPLHIV.

As primary objective this study seeks to assess the rate of viral suppression among AYPLHIV 12 months after enrolment between the intervention clusters, where AYPLHIV were offered the PEBRA model, and the control clusters, where AYPLHIV were offered standard of care.

Secondary objectives include a comparison of adherence to ART, the level of perceived quality of ART care and patient service satisfaction, engagement in care, viral suppression, lost-to-follow-up (LTFU), mortality, and transfer out between the intervention and control clusters. Further objectives include a cost-effectiveness evaluation and qualitative research regarding acceptance, scalability and feasibility of the DSD model.

QUALITATIVE RESEARCH

Besides above outlined qualitative research (QoL, QoC, longitudinal description of participants' preference assessments) the researchers will explore the acceptability of the PEBRA model in a) Focus Group Dis-cussions (FGD) with study participants from the intervention clusters, and b) key informant interviews (KII) with the main stakeholders (District Health Management Team and different health center staff). We plan to conduct at least 2 FGD (with about 5 study participants) per district and 3 KII per district, ac-cording to the concept of saturation. Data will be collected by trained facilitators using piloted interview questionnaires and discussion guides, in the local language (Sesotho). Qualitative data will be record-ed, transcribed, translated into English and coded and analyzed using the Framework Method. All participants in this qualitative research will be required to sign a separate consent form to participate and to be recorded. These consent forms and interview questionnaires will be submitted as an amendment to the ethics committee in Lesotho at a later stage.

COST-EFFECTIVENESS ANALYSIS AND SYSTEM IMPACT EVALUATION

The researchers will perform a system impact evaluation and cost-effectiveness analysis, in order to estimate the im-pact of the PEBRA model on health benefits and costs. First, we will assess the direct costs of the PEBRA model. Secondly, we will assess the cost-effectiveness of the PEBRA model. Thirdly, we will as-sess the economic burden of the PEBRA model to the study participants, i.e. including both direct costs and the opportunity costs of their time. The assessment of direct costs includes staff costs (PEs, clinic staff, VHWs), personnel training costs (especially for the PEs), the cost of equipment needed (PEBRApp, logistics), medical costs to the participant (medication, laboratory tests, consumables, etc.), and non-medical costs to the participant (i.e. cost of transportation to ART service). Data to assess pa-tient level costs will be collected from a randomly selected sub-sample of study participants from each cluster arm, using medical expenditure records and interviews. Cost outcomes will include:

i) The average cost to the service provider per patient achieving the primary endpoint at 12 months in each cluster arm ('per patient suppressed provider cost') ii) The average cost to the patient per patient achieving the primary endpoint at 12 months in each cluster arm ('per patient suppressed patient cost') iii) The annual cost per patient in each cluster arm ('per patient year cost') iv) The cost-effectiveness of the PEBRA model with respect to viral suppression and engage-ment in care Costs will be reported as means (incl. standard deviations) and medians (incl. interquartile range) in local currency and US dollar and International Dollar.

PREFERENCE AND FEASIBILITY ASSESSMENT

The researchers will systematically assess the following exploratory analyses regarding feasibility and youth ART service preference:

1. Youth ART service preferences: Longitudinal description of participants' preference assessments

2. Feasibility of youth ART service according to preferences: Percentage of ART service delivered according to participants' preferences

3. Differentiated Impact of the different support options on key study outcomes

PILOT TRIAL

PEBRA model will be piloted at one representative health facility in Butha-Buthe district, that will be pragmatically chosen in collaboration with the District Health Management Team. The pilot trial will be crucial to assess feasibility of the PEBRA model and the study procedures. The same procedures apply in the pilot trial as in the main trial, using the same consent process and baseline data collection. One PE will be specifically trained for the pilot. Recruitment for the pilot will be closed once 3-5 study participants are enrolled and follow-up will last for 2.5 months after having enrolled the last participant. All endpoints that are evaluable "at 3 months (range 2.5 - 3.5)" will be assessed and analyzed. The aim of the pilot trial is to give a first insight into PEBRA model and provide detailed information for the main trial.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 307
• Est. completion date: April 30, 2021
• Est. primary completion date: April 30, 2021
• Accepts healthy volunteers: No
• Gender: All
• Age group: 15 Years to 24 Years

Eligibility

Eligibility - clusters

Inclusion criteria:

1. the cluster is a public or missionary health center from the study districts, that offers ART services

2. the cluster has at least one PE who is willing to participate and fulfills the following criteria:

1. underwent the Sentebale Peer-Educator two-weeks training

2. attended and successfully passed the study training assessment

Exclusion criteria:

1. health facility authority opposed to trial participation (verbal assent)

2. the health facility is a hospital

3. the health facility is situated in an area without cellphone signal

Eligibility - individuals

1. Individual is living with HIV and in care in a participating cluster

2. Individual is 15-24 years old (AYPLHIV)

3. Informed consent given

4. Declares to seek the next follow-up visit at the same health facility

Related Conditions & MeSH terms

• Acquired Immunodeficiency Syndrome
• HIV Infections
• HIV/AIDS

Intervention

Other:
• PEBRA model
The participants in the intervention clusters are offered the PEBRA model. In the PEBRA model the ART visit/refill is coordinated by the PE, as much as feasible according to the participants' preferences. Thus, the preferences of each participant are captured at enrolment and after a strict schedule thereafter. The PE conducts the preference assessment using a tablet-based application, called PEBRApp, accoring to a specific schedule. First, the participant will be asked his/her preference regarding different domains of DSD (see below) and this will be entered into the PEBRApp. Secondly, the chosen preferences are assessed regarding feasibility with specific questions, as not all preference options are available to everyone all the time. The preference assessment entails the following three domains of DSD: ART Refill SMS notifications Support

Locations

Country	Name	City	State
Lesotho	Boiketsiso HC	Butha-Buthe
Lesotho	Linakeng HC	Butha-Buthe
Lesotho	Makhunoane HC	Butha-Buthe
Lesotho	Motete HC	Butha-Buthe
Lesotho	Muela HC	Butha-Buthe
Lesotho	Ngoajane HC	Butha-Buthe
Lesotho	Rampai HC	Butha-Buthe
Lesotho	St. Paul HC	Butha-Buthe
Lesotho	St. Peters HC	Butha-Buthe
Lesotho	Tsime HC	Butha-Buthe
Lesotho	Ha Lejone HC	Leribe
Lesotho	Pontmain	Leribe
Lesotho	Libibing HC	Mokhotlong
Lesotho	Linakaneng HC	Mokhotlong
Lesotho	Malefiloane HC	Mokhotlong
Lesotho	Mapholaneng HC	Mokhotlong
Lesotho	Moeketsane HC	Mokhotlong
Lesotho	Molikaliko HC	Mokhotlong
Lesotho	St. James HC	Mokhotlong
Lesotho	St. Martins HC	Mokhotlong

Sponsors (8)

Lead Sponsor	Collaborator
Amstutz Alain	International AIDS Society (CIPHER grant), Sentebale, SolidarMed, Swiss National Science Foundation, Swiss Tropical & Public Health Institute, University Hospital, Basel, Switzerland, University of Basel

Country where clinical trial is conducted

Lesotho, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Serious Adverse Events (SAE)	The proportion out of all participants experiencing a Serious Adverse Events (SAE) within 12 months after enrolment	within 12 months after enrolment
Primary	In care with documented viral suppression	In care with documented viral suppression at 12 months, defined as the proportion of participants in care with a documented VL <20 copies/mL 12 months (range: 9 - 15 months) after enrolment out of all participants enrolled	12 months (range: 9 - 15 months) after enrolment
Secondary	Adherence to ART at 3 months (range 2.5 - 3.5), 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment	Assessed by 4 different setting- and age-validated ART adherence questions: pill count: change in percentage; "When was the last time you missed any medications?" (i) past week, ii) 1-2 weeks ago, iii) 3-4 weeks ago, iv) never): Dichotomous outcome missed doses vs. no missed doses in the past month; "ART missed at two or more consecutive days within last month?" ("drug holiday" question); "How would you rate your adherence over the last month" (i) very poor, ii) poor, iii) fair, iv) good, v) very good, vi) excellent): Dichotomous outcome adherent vs non-adherent (anything less than 'excellent')	3 months (range 2.5 - 3.5), 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment
Secondary	Quality of Life (QoL) at 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment	Assessed by WHO QoL in PLHIV: WHO HIV QoL questionnaire (whoqol_hiv_bref questionnaire with 31 five-point Likert Scale items with categorical outcomes	6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment
Secondary	Perceived quality of ART Care / patient service satisfaction at 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment	Assessed by a setting-validated QoC and patient service satisfaction questionnaire (12 five-point Likert Scale items with categorical outcome) by an external data collector, not the peer-educator	6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment
Secondary	Engagement in care at 6 months	Engagement in care at 6 months, defined as the proportion of participants engaged in care 6 months (range 5 - 8) after enrolment out of all participants enrolled	6 months (range 5 - 8) after enrolment
Secondary	Alternative viral suppression at 12 months	Alternative viral suppression at 12 months, defined as the proportion of participants with a documented VL <1000 copies/mL 12 months (range 9 - 15) after enrolment out of all participants enrolled	12 months (range 9 - 15) after enrolment
Secondary	Engagement in care at 12 months	Engagement in care at 12 months, defined as the proportion of participants engaged in care 12 months (range 9 - 15) after enrolment out of all participants enrolled	12 months (range 9 - 15) after enrolment
Secondary	All-cause mortality	All-cause mortality at 6 and 12 months, defined as the proportion of participants dead 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment, respectively, out of all participants enrolled	6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment
Secondary	LTFU at 6 and 12 months	LTFU at 6 and 12 months, defined as the proportion of participants LTFU 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment, respectively, out of all participants enrolled	6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment
Secondary	Transfer out at 6 and 12 months	Transfer out at 6 and 12 months, defined as the proportion of participants who transferred out to any other health facility (than the initially attached one) with known outcome (documented proof of follow-up visit or laboratory test) 6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment, respectively, out of all participants enrolled	6 months (range 5 - 8) and 12 months (range 9 - 15) after enrolment

External Links

•   PEBRApp