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

项目摘要/摘要 具体目标：这项拟议研究的首要目标是评估相关的社会和结构性因素 艾滋病毒携带者中抗逆转录病毒治疗(ART)的使用和最近的结核病诊断；以及评估 控制艾滋病毒的政策的潜在影响。特别是，我们的目标是1：评估暴力之间的联系， 艾滋病病毒携带者妇女中的经济、医疗和政策障碍以及抗逆转录病毒药物的使用；2.描述 社会、经济、医疗和政策障碍与女性近期结核病诊断的关系 艾滋病毒携带者；以及3.评估为抗逆转录病毒治疗采取全民医疗保险政策的潜在影响， 关于病毒抑制、结核病诊断和性别暴力的非歧视保护和性别暴力保护 感染艾滋病毒的妇女死亡人数。 意义：艾滋病毒携带者(PLHIV)患活动性结核病的可能性是男性的19倍，这是主要的 艾滋病毒感染者的死因。在防治艾滋病毒和结核病方面取得了进展，通过整合 艾滋病毒/结核病方案和实现联合国艾滋病规划署疫情控制目标的努力。然而，随着 新冠肺炎和预防和治疗项目的中断威胁着控制这些流行病的努力。 由于经济压力、暴力和耻辱，新冠肺炎还加剧了性别不平等 影响女性。结构性障碍，包括歧视性政策和贫穷，加剧了面临的挑战 这对妇女造成了危害，阻碍了在控制艾滋病毒和结核病方面的进展。对此，世卫组织和联合国艾滋病规划署已将 通过关于抗逆转录病毒治疗、非歧视保护和基于性别的全民保健覆盖的政策 暴力保护。艾滋病毒携带者中治疗依从性差导致结核病进展和 死亡率；并使疫情控制方面的进展复杂化。这项研究旨在评估社会和结构的作用 影响艾滋病毒携带者妇女的因素，并提供直接和可行的证据，为政策变化和 改善艾滋病毒携带者妇女的健康。 方法：我们将利用来自撒哈拉以南非洲8个国家8646名艾滋病毒携带者的数据 2020-2021年，他们参加了艾滋病病毒污名指数2.0。我们将使用多水平Logistic回归模型 通过随机截取来评估与抗逆转录病毒药物使用相关的因素(目标1)和与最近结核病相关的因素 诊断(目标2)。最后，对于目标3，我们将使用马尔可夫模型来评估策略采用的潜在影响 关于莱索托艾滋病毒携带者中的病毒抑制、结核病进展和死亡。 培训信息：Carrie Lyons的培训将包括针对艾滋病毒和结核病的高级方法；高级 在社会和行为流行病学中适当结合背景和结构层面的方法 因素，以及使用多种来源和类型的数据；以及因果推理和 观测数据的分析方法。

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.