Shearer Kate, Nonyane Bareng A S, Mulder Christiaan, Kaonga Emmanuel, Nyirenda Rose, Mbendera Kuzani, Sambani Clara, Valverde Emilio, Manguambe Savaiva, Chiau Rogerio, Kawaza Nicole, Jokwiro Juliet, Dube Bongani, Apollo Tsitsi, Weiser Jeff, Chihota Violet, Churchyard Gavin J, Chaisson Richard E, Golub Jonathan E, Hoffmann Christopher J
Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
BMJ Glob Health. 2025 May 24;10(5):e016921. doi: 10.1136/bmjgh-2024-016921.
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.
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.
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).
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.
NCT04466293.
虽然结核病预防性治疗（TPT）在降低结核病（TB）发病风险方面非常有效，但在艾滋病毒感染者（PWH）中未得到充分利用。我们评估了一种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提高医疗机构对PWH开具TPT处方的有效性。
我们在IMPAACT4TB 3HP推广项目中进行了一项整群随机试验，其中57个医疗机构被随机1:1分配到选择架构（干预）或标准TPT处方（对照）组。目的是将TPT与抗逆转录病毒疗法（ART）处方联系起来，并将TPT处方设为默认选项。该干预得到了临床医生培训的支持，在马拉维，护理点艾滋病毒电子病历中内置了默认处方模块，在莫桑比克和津巴布韦，在患者的临床文具上贴上了标签。数据进行汇总收集，主要结局是开始接受ART治疗的患者中开始接受TPT治疗的患者在医疗机构层面的百分比。CAT研究已在clinicaltrials.gov上注册，该研究已列为完成状态。
莫桑比克于2021年10月至2022年9月实施（20个医疗机构），马拉维于2021年4月至2022年3月实施（19个医疗机构），津巴布韦于2021年6月至2022年5月实施（18个医疗机构），对照组和选择架构干预组分别有29个和28个医疗机构。将对照组与干预组医疗机构进行比较，在莫桑比克，开始接受ART治疗的患者中接受TPT处方的比例分别为70.9%和86.9%（差异：-16.0%；95%置信区间：-38.3%，6.3%；p=0.15），在马拉维分别为56.5%和55.5%（差异：1.0%；95%置信区间：-14.0%，16.9%；p=0.89），在津巴布韦分别为56.2%和55.9%（差异：0.2%；95%置信区间：-25.2%，25.8%；p=0.98）。
选择架构干预未能克服TPT处方的障碍。虽然该干预可能使莫桑比克的TPT处方有所改善，但在其他国家未观察到差异。需要进一步创新，以确保所有开始接受ART治疗的患者都能被开具TPT处方或酌情开始抗结核治疗。
NCT04466293。
