Multi-level determinants of late ART initiation in sub-Saharan Africa

撒哈拉以南非洲地区晚期接受抗逆转录病毒治疗的多层次决定因素

• 批准号: 7930199
• 负责人: Batya Orit Elul
• 金额: $ 70.08万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-05-18 至 2015-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7930199
• 关键词: AIDS prevention; AIDS/HIV problem; Accounting; Acquired Immunodeficiency Syndrome; Adherence; Africa South of the Sahara; African; Age; Alcohol or Other Drugs use; Appointment; Area; Behavior; Behavioral; Cameroon; Caring; Case-Control Studies; Cells; Censuses; Clinic; Clinic Visits; Clinical Management; Complex; Country; Data; Data Set; Databases; Demographic and Health Surveys; Diagnosis; Disease; Early Diagnosis; Early treatment; Education; Emergency Situation; Enrollment; Ethiopia; Family member; Frequencies; Goals; HIV; HIV Infections; HIV Seropositivity; HIV diagnosis; Household; Individual; International; Intervention; Interview; Ivory Coast; Kenya; Knowledge; Life; Literature; Measures; Mediating; Mental Depression; Methodology; Monitor; Morbidity - disease rate; Mozambique; Pathway interactions; Patients; Persons; Phase; Policies; Population; Recommendation; Relative (related person); Research; Research Personnel; Risk Factors; Role; Rural; Rwanda; Sampling; Services; Sexual Partners; Site; Social support; Source; South Africa; Staging; Stigmata; Surveys; Tanzania; Taxes; Testing; Time; Transportation; Travel; Uganda; Work; Zambia; antiretroviral therapy; base; cohort; contextual factors; cost effectiveness; design; experience; health belief; health literacy; improved; indexing; informant; instrument; international center; member; mortality; peer; programs; public health relevance; scale up; sex; social stigma; therapy development; transmission process; treatment adherence; treatment program

DESCRIPTION (provided by applicant): The purpose of this study, proposed by a new investigator, is to determine the multi-level factors associated with late antiretroviral therapy (ART) initiation (i.e., in the advanced stages of HIV disease) in areas of sub-Saharan Africa where ART is rapidly being scaled-up. Most patients in sub-Saharan Africa initiate ART late, resulting in substantial early mortality, more complicated and costly clinical management, and missed opportunities for prevention of HIV transmission. Without a better understanding of the determinants of late ART initiation, including the role of upstream pre-cursors (e.g., late diagnosis and late enrollment into care), efforts aimed at achieving more timely ART initiation will be severely hampered, and the full potential of ART scale-up in the region will not be achieved. The proposed study will consider factors relevant to three critical time points: diagnosis, enrollment into care, and ART initiation, and thus will be able to quantify the relative contribution of late diagnosis and late enrollment to HIV care to late ART initiation. Our ultimate goal is to inform the development of interventions to increase the likelihood of timely ART initiation. We propose a study that utilizes both quantitative and qualitative methodologies to examine the multi-level determinants of late ART initiation (defined as CD4<100 cells/5L or WHO stage IV) among patients initiating ART. These methodologies include retrospective analysis of existing service-delivery data, in-depth clinic and program assessments, and a case-control study. In Aim 1, we will examine the influence of factors at multiple levels-contextual (e.g., urban/rural, testing coverage, stigma), clinic (e.g., appointment adherence support, active testing, staffing), and individual (e.g., age, sex, entry point). We will draw on an existing dataset of routinely-collected clinic-level and individual-level service-delivery data on 72,007 persons who initiated ART from 71 HIV care and treatment clinics in 23 sub-regions of nine African countries. These clinic and individual- level data will be combined with contextual-level data from nationally representative household surveys to examine the multi-level determinants of late ART initiation. Prior studies have not examined these multiple levels of influence over such a wide range of clinics and settings nor have they examined longitudinal data from the pre-ART phase of care leading up to ART initiation. Aims 2 and 3 we be carried at four clinics with historically low, medium, and high rates of late ART initiation. We will conduct in-depth clinic and program assessments to ascertain clinic-level enablers/barriers to earlier ART initiation (Aim 2). Lastly, as very little is known about individual-level risk factors for late ART initiation, we will conduct detailed interviews as part of a case-control study examining the role of normative and behavioral factors (e.g., health beliefs, depression, social-support, substance use) through interviews of 360 cases who started ART late and 360 controls who started ART earlier (Aim 3). The overarching goal of this study is to provide critical information to inform strategies for achieving more timely ART initiation, ultimately reducing HIV-related morbidity and mortality. PUBLIC HEALTH RELEVANCE: The US spends billions per year in tax payer dollars for the President's Emergency Plan for AIDS Relief (PEPFAR), much of which goes to the hardest hit region of sub-Saharan Africa. This project will improve our understanding about why HIV positive persons in sub-Saharan Africa start HIV treatment too late. This in turn will help identify ways to get people onto treatment earlier, thereby greatly improving their chances of survival, reducing the spread of HIV infection, and optimizing the cost-effectiveness of the PEPFAR program.

描述(由申请人提供)：这项研究由一位新的研究人员提出，目的是确定在撒哈拉以南非洲地区抗逆转录病毒疗法(ART)正在迅速扩大的地区，与晚期抗逆转录病毒疗法(ART)启动(即在艾滋病毒疾病的晚期阶段)相关的多层次因素。撒哈拉以南非洲的大多数患者开始抗逆转录病毒治疗的时间较晚，导致大量早期死亡，临床管理更加复杂和昂贵，并错过了预防艾滋病毒传播的机会。如果不能更好地了解晚期ART启动的决定因素，包括上游前体的作用(例如，延迟诊断和延迟加入CARE)，旨在实现更及时ART启动的努力将受到严重阻碍，ART在该地区扩大规模的全部潜力将无法实现。这项拟议的研究将考虑与三个关键时间点相关的因素：诊断、加入护理和抗逆转录病毒治疗启动，因此将能够量化晚诊断和晚注册对艾滋病毒治疗的相对贡献对晚启动抗逆转录病毒治疗的贡献。我们的最终目标是通知干预措施的发展，以增加及时启动ART的可能性。我们提出了一项研究，利用定量和定性方法来研究启动抗逆转录病毒治疗的患者中晚期抗逆转录病毒治疗启动的多水平决定因素(定义为CD4100细胞/5L或WHO IV期)。这些方法包括对现有服务交付数据的回顾分析，深入的临床和计划评估，以及病例对照研究。在目标1中，我们将审查多个层面的因素的影响--背景(例如，城市/农村、测试覆盖范围、耻辱)、诊所(例如，遵守预约的支助、积极的测试、人员配置)和个人(例如，年龄、性别、入口点)。我们将利用从9个非洲国家23个次区域的71个艾滋病毒护理和治疗诊所定期收集的72,007名发起抗逆转录病毒治疗的人的诊所级和个人级服务提供数据的现有数据集。这些临床和个人层面的数据将与来自具有全国代表性的家庭调查的背景层面的数据相结合，以检查晚期抗逆转录病毒治疗启动的多层面决定因素。以前的研究没有检查过这些对如此广泛的临床和环境的影响的多个水平，也没有检查导致ART启动的ART前护理阶段的纵向数据。目标2和3我们在四个诊所进行，晚期ART启动率分别为历史上最低、中等和较高。我们将进行深入的临床和计划评估，以确定临床层面上促进/阻碍更早开始抗逆转录病毒治疗的因素(目标2)。最后，由于对延迟开始抗逆转录病毒治疗的个体水平的风险因素知之甚少，我们将进行详细的访谈，作为病例对照研究的一部分，通过对360名较晚开始抗逆转录病毒治疗的患者和360名较早开始抗逆转录病毒治疗的对照患者的访谈，考察规范和行为因素(例如，健康信念、抑郁、社会支持、物质使用)的作用。这项研究的首要目标是提供关键信息，为实现更及时的抗逆转录病毒治疗的战略提供信息，最终减少艾滋病毒相关的发病率和死亡率。 与公共卫生相关：美国每年花费数十亿美元用于总统艾滋病紧急救援计划(PEPFAR)，其中大部分用于撒哈拉以南非洲受灾最严重的地区。该项目将提高我们对撒哈拉以南非洲艾滋病毒阳性者为什么开始艾滋病毒治疗太晚的理解。这反过来将有助于确定让人们更早接受治疗的方法，从而极大地提高他们的生存机会，减少艾滋病毒感染的传播，并优化PEPFAR计划的成本效益。