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: 8437234
• 负责人: Batya Orit Elul
• 金额: $ 58.01万
• 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/8437234
• 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; 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.

描述（由申请人提供）：本研究由一位新研究者提出，目的是确定与抗逆转录病毒治疗（ART）开始（即艾滋病毒疾病晚期）相关的多层次因素，在撒哈拉以南非洲地区，抗逆转录病毒治疗正在迅速扩大。撒哈拉以南非洲的大多数患者较晚开始抗逆转录病毒治疗，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延迟开始抗逆转录病毒治疗的决定因素，包括上游前体的作用（例如，较晚诊断和较晚接受治疗），旨在更及时开始抗逆转录病毒治疗的努力将受到严重阻碍，并且该地区扩大抗逆转录病毒治疗的全部潜力将无法实现。拟议的研究将考虑与三个关键时间点相关的因素：诊断、入组治疗和开始抗逆转录病毒治疗，因此将能够量化晚期诊断和晚期入组治疗对晚期开始抗逆转录病毒治疗的相对贡献。我们的最终目标是为干预措施的制定提供信息，以增加及时启动抗逆转录病毒治疗的可能性。我们提出了一项研究，利用定量和定性方法来检查开始抗逆转录病毒治疗的患者中开始抗逆转录病毒治疗晚期（定义为CD4<100细胞/5L或WHO IV期）的多层次决定因素。这些方法包括对现有服务提供数据的回顾性分析、深入的诊所和项目评估以及病例对照研究。在目标1中，我们将在多个层面上研究因素的影响-环境（例如，城市/农村，检测覆盖率，耻辱感），诊所（例如，预约依从性支持，积极检测，人员配置）和个人（例如，年龄，性别，切入点）。我们将利用9个非洲国家23个次区域71个艾滋病毒护理和治疗诊所的72007名开始抗逆转录病毒治疗的患者的常规收集的诊所层面和个人层面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全国代表性家庭调查的背景层面的数据相结合，以检查晚期开始抗逆转录病毒治疗的多层次决定因素。先前的研究并没有在如此广泛的诊所和环境中检查这些多层次的影响，也没有检查从抗逆转录病毒疗法开始前的护理阶段到开始抗逆转录病毒疗法的纵向数据。目标2和目标3将在四个历史上晚期抗逆转录病毒治疗起始率低、中、高的诊所进行。我们将进行深入的临床和项目评估，以确定早期抗逆转录病毒治疗的临床层面的推动因素/障碍（目标2）。最后，由于对晚期开始抗逆转录病毒治疗的个人层面风险因素知之甚少，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例开始抗逆转录病毒治疗较晚的病例和360例开始抗逆转录病毒治疗较早的对照组进行访谈，研究规范和行为因素（例如，健康信念、抑郁、社会支持、物质使用）的作用（目标3）。这项研究的首要目标是提供关键信息，为更及时地开始抗逆转录病毒治疗提供战略依据，最终降低艾滋病毒相关的发病率和死亡率。