Understanding multilevel barriers and facilitators to HIV treatment among marginalized women living with HIV in the context of intersecting HIV, TB, and COVID-19 pandemics

项目总结/摘要 具体目标：这项拟议研究的总体目标是评估相关的社会和结构因素， 与抗逆转录病毒疗法（ART）的使用和最近的结核病诊断感染艾滋病毒的妇女;并评估 政策对控制艾滋病毒的潜在影响。特别是，我们的目标是1：评估暴力， 艾滋病毒感染妇女的经济、医疗和政策障碍以及抗逆转录病毒疗法的使用; 2.表征 社会、经济、医疗保健和政策障碍与女性近期结核病诊断之间的关联 艾滋病毒感染者; 3。评估采取全民抗逆转录病毒治疗医疗保险政策的潜在影响， 在病毒抑制、结核病诊断方面的非歧视保护和基于性别的暴力保护， 感染艾滋病毒的妇女死亡人数。 重要性：艾滋病毒感染者（PLHIV）患活动性结核病的可能性是其他人的19倍，这是世界上最大的结核病患者。 艾滋病毒感染者的死亡原因。通过将以下方面结合起来，在防治艾滋病毒和结核病方面取得了进展： 艾滋病毒/结核病方案和努力实现艾滋病规划署的流行病控制目标。然而， COVID-19以及预防和治疗计划的中断威胁到控制这些流行病的努力。 由于经济压力、暴力和污名，COVID-19还加剧了性别不平等 影响女性。包括歧视性政策和贫困在内的结构性障碍加剧了所面临的挑战 这阻碍了控制艾滋病毒和结核病的进展。作为回应，世卫组织和艾滋病规划署将 通过抗逆转录病毒疗法的全民医疗覆盖政策、非歧视保护政策和基于性别的政策， 暴力保护。感染艾滋病毒的妇女坚持治疗的情况不佳，导致结核病进展， 死亡率;并使流行病控制的进展复杂化。这项研究旨在评估社会和结构的作用， 影响感染艾滋病毒妇女的因素，并提供直接和可采取行动的证据，为政策变化提供信息， 改善感染艾滋病毒妇女的健康。 方法：我们将利用撒哈拉以南非洲8个国家8646名艾滋病毒感染妇女的数据， 2020年至2021年，谁参加了艾滋病毒污名指数2.0。我们将使用多层次逻辑回归模型 随机截取，以评估与ART使用相关的因素（目标1）和与近期结核病相关的因素 诊断（目标2）。最后，对于目标3，我们将利用马尔可夫模型来评估政策采纳的潜在影响 莱索托艾滋病毒感染妇女的病毒抑制、结核病进展和死亡情况。 培训信息：Carrie里昂的培训将包括专门针对艾滋病毒和结核病的先进方法;先进的 在社会和行为流行病学的方法，以适当地结合上下文和结构水平 因素，以及使用多种来源和类型的数据;以及因果推理和 分析观测数据的方法。

PROJECT SUMMARY/ABSTRACT Specific Aims: The overarching goal of this proposed study is to assess social and structural factors associated with antiretroviral therapy (ART) use and recent TB diagnosis among women living with HIV; and evaluate the potential impact of policies in controlling HIV. Specially, we aim to 1: Assess the associations between violence, economic, healthcare, and policy barriers and ART use among women living with HIV; 2. Characterize the associations between social, economic, healthcare, and policy barriers and recent TB diagnosis among women living with HIV; and 3. Estimate the potential impact of policy adoption of universal healthcare coverage for ART, non-discrimination protections, and gender-based violence protections on viral suppression, TB diagnosis, and deaths among women living with HIV. Significance: People living with HIV (PLHIV) are 19 times more likely to develop active TB, which is the leading cause of death in persons with HIV. Progress in combating HIV and TB has been made through integration of HIV/TB programs and efforts towards the UNAIDS goals for epidemic control. However, the emergence of COVID-19 and disruptions in prevention and treatment programs threaten efforts to control these pandemics. COVID-19 has also exacerbated gender inequities, because of economic pressures, violence, and stigmas affecting women. Structural barriers including discriminatory policies and poverty worsen the challenges faced by women and impede progress in controlling HIV and TB. In response, WHO and UNAIDS have prioritized the adoption of policies for universal healthcare coverage of ART, non-discrimination protections, and gender-based violence protections. Poor treatment adherence among women living with HIV contributes to TB progression and mortality; and complicates progress in epidemic control. This study aims to assess the role of social and structural factors affecting women living with HIV and provide direct and actionable evidence to inform policy changes and improve the health of women living with HIV. Approach: We will leverage data from 8646 women living with HIV in 8 countries in sub–Saharan Africa between 2020-2021 who participated in the PLHIV Stigma Index 2.0. We will use multilevel logistic regression models with random intercepts to assess factors associated with ART use (Aim 1) and factors associated with recent TB diagnosis (Aim 2). Lastly, for aim 3 we will utilize a Markov model to assess the potential impact of policy adoption on viral suppression, TB progression, and death among women living with HIV in Lesotho. Training information: Carrie Lyons’ training will consist of advanced methods specific to HIV and TB; advanced methods in social and behavioral epidemiology to appropriately incorporate contextual and structural level factors, and the use of multiple sources and types of data; and advanced methods in causal inference and methods for the analysis of observational data.