Understanding burden and lived experience of diabetes and hypertension among women living with HIV in the Dominican Republic to improve care integration

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Project Summary/Abstract: The health context across many low-and-middle-income countries reflects the “epidemiologic transition”, or the shift from higher mortality and morbidity attributable to acute, infectious disease to a higher burden of noncommunicable diseases (NCD). As a result of this transition, countries across Latin America and the Caribbean (LAC) increasingly face a triple burden including: 1) ongoing infectious diseases; 2) increasing NCD; and 3) mental health challenges, including substance use. The triple burden is unevenly distributed with certain populations experiencing disproportionate burden relative to their population size. One particularly vulnerable population is female sex workers (FSW), or cisgender women who consensually exchange sex for money or other goods. Global HIV prevalence among FSW is 10.4% compared to 0.7% among adults worldwide. In the Dominican Republic (DR), the site of the proposed study, adult HIV prevalence is 0.9% compared to 4.2% among FSW. In a cohort of FSW living with HIV in Santo Domingo, our team has documented viral suppression levels ranging from 51% to 73%. Determinants of poor HIV treatment outcomes include depression, substance use, anti-retroviral therapy interruption, and various forms and types of stigma, reflecting the embodiment of the triple burden among FSW living with HIV in this setting. Despite sub-optimal levels of viral suppression, many FSW in the DR access care and treatment through a system of decentralized care centers and live with HIV as a chronic condition. As a result, they are vulnerable to NCD associated with HIV, aging, and environmental factors, in particular type-2 diabetes (T2D) and hypertension (HTN). An estimated 10% of Dominican adults have T2D and 31% HTN. There is no systematic research about NCD among FSW nor understanding of how FSW living with HIV navigate a healthcare system with limited sensitization to their context and needs in the DR or elsewhere. The proposed study aims to improve understanding of the burden of NCD among FSW living with HIV in Santo Domingo. Specific aims are: Aim 1: Describe type 2 diabetes (T2D) and hypertension (HTN) prevalence among sex workers with HIV. For Aim 1, we will re-engage our cohort of FSW living with HIV in Santo Domingo (n=200) to screen for T2D/HTN and assess determinants. Aim 2: Explore the lived experience of multiple chronic conditions among FSW with HIV and T2D/HTN. For Aim 2, we will conduct qualitative in-depth interviews with FSW previously diagnosed with T2D/HTN (n=25) to explore their experiences with healthcare, self-management, mental health, and wellbeing. Aim 3: Identify provider and stakeholder perspectives on integration of care for HIV and T2D/HTN. For Aim 3, we will conduct key informant interviews with providers and stakeholders (n=25) to assess the landscape of HIV and T2D/HTN care and probe on opportunities for integration. We will also facilitate a series of focus groups (n=3) and collaborative workshops to develop a model of integrated care in a collaborative and participatory manner.