# Adaption of the Transition of Care Model for Post-Discharge HIV-NCD care in Malawi

> **NIH NIH R21** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2024 · $160,083

## Abstract

PROJECT SUMMARY
Most hospitals in Low Middle-Income countries (LMICS) do not practice the discharge planning models
shown in high-income settings (HICS) to avert adverse outcomes posthospitalization. In the absence of
such integrated programs and an increment in the double burden of disease of HIV and NCDs, the
mortality in people living with HIV(PWH) continues to be high post-hospitalization. The long-term goal is
to improve discharge practices and linkage to care for PWH and NCDS and achieve dual control of both
conditions. The objective of this R21 application is to adapt the Transitional care Mode based in HICS
(TCM) for targeted use as a post-discharge intervention for adults hospitalized with comorbid HIV and
NCDs in Malawi and evaluate the feasibility and acceptability of the adapted intervention in preparation
for a larger implementation science evaluation. The rationale for the project, is that there is a high
mortality post-hospitalization for PWH and NCDS, in part because of the lack of integrated discharge-
related interventions to support care post-hospitalization. TCM is an evidence-based model in the U.S.
adopted into clinical practice for diverse patient populations and demonstrated effectiveness in
improving patient outcomes after discharge. This model can be useful if adapted to the context and
resources available in LMICS, and feasibility tested for long-term adoption in the care of PWH and NCDs.
This research study will explore three specific aims: 1. Adapt the TCM for PWH hospitalized with NCDs
in Malawi. 2. Pilot test the adapted TCM with PWH admitted with NCDs. 3. Evaluate the feasibility,
effectiveness and acceptability of the adapted intervention. For the first aim, through in-depth
interviews (IDI) and focus groups discussions (FGDs) with HIV/NCD stakeholders, hospital staff, patients,
and caregivers, we will develop the SOPs for an adapted TCM. For the second aim, we will enroll 62
consecutive adults hospitalized with HIV and known with at least one common HIV- cardiometabolic
comorbidity (hypertensive urgency, heart failure, or diabetes,) and provide the adapted TCM. For the
third aim, using mixed methods, FGDs and IDI to hospital staff and patient/caregivers who participated
in TCM, we will evaluate the feasibility of providing TCM for a larger study. We will describe 3-month
post-discharge outcomes including re-admission, linkages and retention in care, mortality, and dual
control of HIV and NCDs. Comparison with a historical control group recruited just prior to the pilot
phase will provide preliminary data in regard to potential effects on readmission and death. This project
is innovative in that it will adapt a known model of transitional care from HICS to LMICS for PWH/NCDS
using existing resources to avert adverse outcomes. It will reinforce integrated linkages to care for both
HIV/NCDs. The proposed research is significant because it represents a new effort to bridge the gap
between inpatient and community-base...

## Key facts

- **NIH application ID:** 10884287
- **Project number:** 5R21TW012647-02
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** Cecilia Kanyama
- **Activity code:** R21 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $160,083
- **Award type:** 5
- **Project period:** 2023-07-10 → 2026-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10884287

## Citation

> US National Institutes of Health, RePORTER application 10884287, Adaption of the Transition of Care Model for Post-Discharge HIV-NCD care in Malawi (5R21TW012647-02). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10884287. Licensed CC0.

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