Improving the Care Cascade for HIV-associated Kaposi's Sarcoma in sub-Saharan Africa

改善撒哈拉以南非洲地区与艾滋病毒相关的卡波西肉瘤的护理梯级

• 批准号: 10202435
• 负责人: Esther E Freeman
• 金额: $ 19.95万
• 依托单位: MASSACHUSETTS GENERAL HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-07-19 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10202435
• 关键词: AIDS related cancer; AIDS/HIV problem; Acquired Immunodeficiency Syndrome; Address; Adherence; Africa; Africa South of the Sahara; Area; Award; Behavior; Behavioral; Behavioral Sciences; Belief; Biometry; Caring; Clinic; Collaborations; Databases; Dermatologist; Dermatology; Development; Diagnosis; Diagnostic; Disease; Doctor of Philosophy; Early Diagnosis; Epidemiologist; Epidemiology; Event; Evidence based treatment; Foundations; Goals; HIV; Health; Health Personnel; Health system; Healthcare; Incidence; International; Intervention; K-Series Research Career Programs; Kaposi Sarcoma; Kenya; Length; Malignant Neoplasms; Malignant neoplasm of prostate; Mentored Patient-Oriented Research Career Development Award; Mentors; Mentorship; Methodology; Methods; Modeling; Motivation; Newly Diagnosed; Oncogenic Viruses; Oncology; Outcome; Patient-Focused Outcomes; Patients; Persons; Population; Population Attributable Risks; Positioning Attribute; Prevalence; Primary Health Care; Provider; Public Health; Qualitative Methods; Qualitative Research; Quality of Care; Randomized; Research; Research Infrastructure; Research Methodology; Research Personnel; Resources; Risk; Series; Skin; Stage at Diagnosis; Structure; Symptoms; Testing; Time; Training; Treatment outcome; United States; United States National Institutes of Health; Ursidae Family; Viral; Vulnerable Populations; Work; acceptability and feasibility; advanced disease; antiretroviral therapy; base; care seeking; career; chemotherapy; clinical epidemiology; cohort; data standards; design; disparity reduction; global health; health care availability; implementation intervention; implementation science; improved; improved outcome; malignant breast neoplasm; mortality; multidisciplinary; novel; optimal treatments; prospective; prototype; provider intervention; skin lesion; theories; therapy design; time interval; treatment disparity

PROJECT SUMMARY Resource-poor settings bear the greatest burden of HIV-associated malignancies, with high background prevalence of HIV and oncogenic viruses. HIV-associated Kaposi’s sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Incidence has decreased with more widespread use of antiretroviral therapy (ART), but remains higher than prostate cancer in the United States. Survival after a diagnosis with HIV-associated KS in sub-Saharan Africa, even in the ART era, remains poor, with almost half of patients dead by two years. One reason for poor outcomes is that by the time patients seek care for their skin lesions, the disease has progressed to an advanced stage. Even after diagnosis, a substantial number of patients have delays in starting appropriate treatment. My own work has shown that 17-29% of KS patients do not receive timely initiation of ART and that nearly half of those with indications for chemotherapy never receive it. In order ultimately to improve survival, we first need to better understand the gaps in KS care. The KS care cascade includes a series time intervals separated by discrete events: noting symptoms, presenting to healthcare, receiving a diagnosis, and finally starting and completing treatment. Identifying personal and health system barriers at each step of the cascade is critical to designing and implementing interventions that improve outcomes for this vulnerable population. I am a PhD-trained epidemiologist and board certified dermatologist, with a career goal of becoming an independent investigator in the global health epidemiology of HIV- associated malignancies and associated skin conditions, and implementation of interventions to improve the treatment of these conditions in resource-poor settings. I will draw upon the methodological training of the K23 award and leverage the existing research infrastructure of my co-mentors and collaborators in a large NIH- sponsored cohort of HIV patients from the International Epidemiology Databases to Evaluate AIDS (IeDEA) in western Kenya to accomplish the following specific aims: (1) Evaluate the determinants of advanced disease stage at KS diagnosis and associated attributable risk, as well as the distribution and determinants of time intervals leading up to diagnosis, (2) Among patients newly diagnosed with KS, evaluate the timing and determinants of ART initiation and, where indicated, chemotherapy initiation and adherence after a diagnosis of KS and (3) Develop and pilot test a multi-level intervention including both patient and healthcare provider- centered components to promote prompt, appropriate treatment for KS. Building on my quantitative background in HIV epidemiology, this award will provide training in qualitative methods, behavioral theory based in intervention design, and implementation science. This combination, along with mentorship from a multidisciplinary team of experts in global health, HIV epidemiology, oncology, global dermatology, and implementation science, will ideally position me to launch my career as an independent investigator in HIV- associated malignancies with a focus on interventions to improve outcomes in resource-limited settings.

项目总结 资源贫乏的环境承受着艾滋病毒相关恶性肿瘤的最大负担，背景较高 艾滋病毒和致癌病毒的流行。HIV相关的卡波西肉瘤(KS)是最常见的 撒哈拉以南非洲地区与艾滋病毒相关的恶性肿瘤。随着更广泛的使用，发病率已经下降 抗逆转录病毒疗法(ART)，但在美国仍然高于前列腺癌。一年后的生存 在撒哈拉以南非洲，即使在抗逆转录病毒治疗时代，与艾滋病毒相关的KS的诊断仍然很差，几乎有一半 两年前死亡的病人的比例。预后不佳的一个原因是，当患者寻求治疗时， 皮肤受损，该病已发展到晚期。即使在确诊后，仍有相当数量的 患者在开始适当治疗方面存在延误。我自己的研究表明，17%-29%的KS患者 没有及时接受抗逆转录病毒治疗，有化疗指征的患者中有近一半从未 接受它。为了最终提高存活率，我们首先需要更好地了解KS护理方面的差距。这个 KS护理级联包括由离散事件分隔的一系列时间间隔：记录症状，出现 医疗保健，接受诊断，最后开始并完成治疗。确定个人和健康 级联中每一步的系统障碍对于设计和实施可改进的干预措施至关重要 对这一弱势群体的影响。我是受过博士训练的流行病学家和委员会认证的皮肤科医生， 职业目标是成为全球艾滋病毒健康流行病学的独立调查员- 相关的恶性肿瘤和相关的皮肤病，以及实施干预措施以改善 在资源匮乏的情况下处理这些情况。我将借鉴K23的方法论培训 奖励和利用我在大型NIH的合作导师和合作者的现有研究基础设施- 年国际流行病学数据库(IeDEA)赞助的HIV患者队列评估艾滋病 肯尼亚西部以实现以下具体目标：(1)评估晚期疾病的决定因素 KS诊断阶段和相关归因风险，以及时间的分布和决定因素 诊断前的间隔时间，(2)在新诊断的KS患者中，评估时间和 ART启动的决定因素以及确诊后化疗启动和依从性(如有指征) 和(3)开发和试点包括患者和医疗保健提供者在内的多层次干预- 以组件为中心促进对KS的及时、适当的治疗。建立在我的量化基础上 艾滋病毒流行病学背景，该奖项将提供定性方法、行为理论方面的培训 基于干预设计和实施科学。这一组合，以及来自 全球健康、艾滋病毒流行病学、肿瘤学、全球皮肤病和 实施科学，将理想地让我开始我的职业生涯作为艾滋病毒的独立调查员- 在资源有限的情况下，将重点放在改善结果的干预措施上，以应对相关的恶性肿瘤。