Multi-level and Intersectional Stigma and other Social Determinant Effects on TB Case Detection, Care, and Treatment Outcomes: The MISSED TB Outcomes Study

项目摘要 2018年，全球约有1000万人患上结核病，其中约150万人死亡；艾滋病毒是最主要的 死因是。估计有430万例“失踪”结核病病例与活动性结核病病例一起导致了持续传播 未保留在护理中心的结核病病例。我们将在南非进行研究(结核病患病率=852/10万人口； HIV混合感染=50%)，其中最近的结核病级联分析和国家结核病规划指标报告 沿着整个结核病护理级联的差距。定性研究表明结核病污名是发现病例、护理的障碍 寻求、治疗启动和坚持。然而，很少有研究量化污名对结核病的影响。 护理级联，使用有效的污名措施的较少，没有人采用前瞻性的全面护理 级联研究设计。我们提出了一项四目标、严谨、多层次、混合方法的研究。我们将表演家居 这些调查将汇总成社区一级的数据，并纳入对所有目标的分析。目标1： 利用混合方法识别和衡量个人和社区层面的污名和社会 在积极推荐的接触者中介绍结核病检测的相关决定因素。我们将进行 一项在主动转介进行检测的有症状HHC中的前瞻性研究(n=750)，以调查 多种程度的结核病和艾滋病毒污名与其他社会决定因素和感染之间的关系 结核病检测的结果。目标2：利用混合方法确定和衡量个人和社区一级的污名 以及与返回接受检测的症状个体的检测结果相关的社会决定因素 治疗结核病。我们将对被动提出研究的有结核病症状的个体进行前瞻性研究。 并进行结核病检测(n=1000)，以调查多种水平的结核病与艾滋病毒之间的关系 耻辱和其他社会决定因素以及返回或获得检测结果。目标3：利用混合方法 识别和衡量个人和社区层面的污名和与以下方面相关的社会决定因素 开始进行结核病治疗的个人的LTFU和治疗结果。我们将进行一次前瞻性的 在开始治疗的结核病患者中进行的研究(n=1250)，以调查预期、实施和 内在化的结核病和艾滋病毒污名对LTFU和糟糕的结核病治疗结果。定性的方法将探索 在治疗期间和治疗后感受到的和经历过的结核病污名的轨迹、持久性和影响。目标4： 利用混合方法识别和衡量个人和社区层面的污名和社会 共同感染者在接受结核病治疗后的HIV护理与LTFU相关的决定因素。 以前作为目标3的一部分收集的结核病/艾滋病毒共同感染参与者的相关数据(n=~600)，以及其他 将使用艾滋病毒结果数据。通过这个，我们将调查相交的存在和潜在的影响 在完成结核病治疗后保留艾滋病毒护理方面的耻辱。这项研究最终将告知有针对性的， 多层次的干预措施，根植于社区的需求和挑战，理论上知情，并充分 以解决南非的结核病危机，并为全球类似的干预措施提供信息。

PROJECT ABSTRACT In 2018, ~10 million individuals developed TB disease globally, of which ~1.5 million died; HIV was the leading cause of death. Ongoing transmission results from an estimated 4.3 million “missing” TB cases along with active TB cases not retained in care. We will conduct our study in South Africa (TB prevalence=852/100,000 population; HIV co-infection=>50%), where a recent TB cascade analysis and national TB program indicators report significant gaps along the entire TB care cascade. Qualitative studies suggest TB stigma as a barrier to case finding, care seeking, treatment initiation, and adherence. However, few studies have quantified the impact of stigma on the TB care cascade, fewer have used validated stigma measures, and none have employed prospective, full care cascade study designs. We propose a 4-aim, rigorous, multilevel, mixed-methods study. We will perform household surveys, which will be aggregated into community-level data and incorporated into the analysis of all aims. Aim 1: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with presentation for TB testing among actively referred contacts. We will conduct a prospective study amongst symptomatic HHCs actively referred for testing (n= 750) to investigate the relationships within and between the multiple levels of TB and HIV stigma and other social determinants and uptake of TB testing. Aim 2: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with returning for test results among symptomatic individuals tested for TB. We will conduct a prospective study of individuals with TB symptoms who passively present to a study clinic and are tested for TB (n= 1000) to investigate the relationships between the multiple levels of TB and HIV stigma and other social determinants and returning for or obtaining the test results. Aim 3: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with LTFU and treatment outcomes among individuals initiated on TB treatment. We will conduct a prospective study among TB patients initiating treatment (n= 1250) to investigate the association of anticipated, enacted and internalized TB and HIV stigma on LTFU and poor TB treatment outcomes. Qualitative methods will explore the trajectory, persistence, and impact of perceived and experienced TB stigma during and after treatment. Aim 4: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with LTFU from HIV care following TB treatment among co-infected individuals. Relevant data for TB/HIV co-infected participant previously collected as part of Aim 3 (n= ~600), and additional HIV outcome data will be used. Through this, we will investigate the presence and potential impact of intersecting stigmas on retention in HIV care following completion of TB treatment. This study will ultimately inform targeted, multi-level interventions, rooted in the needs and challenges of communities, theoretically informed, and fully contextualized, to address the TB crisis in South Africa, and inform similar interventions globally.