Background: Voluntary assisted contact tracing (ACT) is an evidence-based approach that efficiently identifies persons in need of HIV treatment and prevention. Malawi, like many countries in sub-Saharan Africa, has adopted ACT policies to support its ?95-95-95? targets for HIV testing, treatment, and viral suppression. However, Malawi?s ACT implementation has been poor due to deficits in health worker capacity and clinical coordination. Through preliminary work, our team has 1) developed a set of implementation strategies (theory-based health worker training and continuous quality improvement processes) that address these barriers; 2) packaged these strategies into a blended learning platform that combines digital and face-to-face modalities; and 3) field-tested the package in Malawi with promising preliminary results. In this proposal, the package will be rigorously evaluated in Malawi for implementation, service uptake, and cost-effectiveness outcomes. The overarching hypothesis is that the blended learning ACT package will be feasible and acceptable to implement, build health worker and facility ACT capacity, lead to more contacts tested for HIV, and be cost-effective in the Malawian context.
Aims and Methods: Through a two-arm pragmatic cluster randomized implementation trial, the proposed research will address these gaps through three specific aims. Twenty Malawian facilities in two districts will be randomized 1:1 to receive the blended learning implementation package (enhanced) versus standard implementation package (standard) and followed for two years. In the first aim, ACT implementation outcomes will be compared between the enhanced and standard arms. Health worker fidelity to ACT procedures (primary outcome) will be assessed through audio-recorded ACT encounters. Secondary outcomes include facility adoption of the enhanced implementation strategy, as well as health worker feasibility and acceptability. In the second aim, HIV service uptake outcomes will be compared between the enhanced and standard arms. The number of indexes offered ACT, number of contacts elicited, number of contacts tested for HIV (primary outcome), and number of contacts diagnosed as HIV-positive will be compared between the two arms. In the third aim, cost and cost-effectiveness outcomes will be examined. The primary outcome is the incremental cost per disability adjusted life year saved. This will be estimated in the trial population and projected nationally. Team: The team is led by a new and early stage Principal Investigator with ACT expertise. The work is a collaborative endeavor between academic institutions and a large Malawi-based PEPFAR implementing partner with guidance from the Malawi Ministry of Health. The team has expertise in HIV implementation, implementation science, technology-based interventions, qualitative and quantitative research methods, and cost-effectiveness analysis. Impact: This proposal addresses a significant knowledge gap via an innovative research question using a well-designed research plan. The findings will offer important insights and innovations into how to bridge the gap between ACT research and practice, a critical step towards achieving the 95-95-95 targets.
Having health workers assist HIV-infected persons with the recruitment and testing of their sexual contacts and biological children is an effective and efficient way of identifying persons in need of HIV treatment and prevention. However, in Malawi, a country with a generalized HIV epidemic, health workers lack the counseling and coordination skills to routinely assist their HIV-infected clients with these services. This study will determine how to help health workers in Malawi to provide these services through a set of digital capacity-building tools.
