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.

项目概要 资源匮乏的环境承受着艾滋病毒相关恶性肿瘤的最大负担，且背景较高 HIV 和致癌病毒的流行。与 HIV 相关的卡波西肉瘤 (KS) 是最常见的一种 撒哈拉以南非洲地区与艾滋病毒相关的恶性肿瘤。随着更广泛使用，发病率有所下降 抗逆转录病毒治疗（ART），但在美国仍高于前列腺癌。生存后 即使在 ART 时代，撒哈拉以南非洲地区艾滋病毒相关 KS 的诊断率仍然很低，几乎一半的患者 患者死亡两年。结果不佳的原因之一是，当患者寻求治疗时 皮肤病变，病情已发展到晚期。即使在确诊后，仍有相当多的人 患者延迟开始适当的治疗。我自己的研究表明 17-29% 的 KS 患者会这样做 没有及时开始 ART，并且近一半有化疗指征的人从未接受过 收到它。为了最终提高生存率，我们首先需要更好地了解 KS 护理方面的差距。这 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、向患者报告 医疗保健、接受诊断、最后开始和完成治疗。识别个人和健康 级联每一步的系统障碍对于设计和实施改善的干预措施至关重要 这些弱势群体的成果。我是一名受过博士学位的流行病学家和经过委员会认证的皮肤科医生， 职业目标是成为艾滋病毒全球健康流行病学的独立研究者 相关的恶性肿瘤和相关的皮肤状况，以及实施干预措施以改善 在资源匮乏的地区治疗这些疾病。我将借鉴K23的方法论培训 奖励并利用我的共同导师和合作者在大型 NIH 中的现有研究基础设施 由国际流行病学数据库评估艾滋病 (IeDEA) 赞助的艾滋病毒患者队列 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 诊断的阶段和相关的归因风险，以及时间的分布和决定因素 (2) 在新诊断为 KS 的患者中，评估诊断前的时间间隔和 ART 启动的决定因素，以及诊断后化疗启动和依从性（如有指示）的决定因素 KS 和 (3) 开发并试点测试包括患者和医疗保健提供者在内的多层次干预措施 - 集中成分促进 KS 的及时、适当的治疗。以我的定量为基础 HIV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。这种组合，加上来自 由全球健康、艾滋病毒流行病学、肿瘤学、全球皮肤病学等领域的多学科专家组成的团队 实施科学，将使我成为艾滋病毒独立调查员，开启我的职业生涯 相关恶性肿瘤，重点是在资源有限的环境中采取干预措施以改善结果。