HIV Treatment Interruptions Among Labor Migrants in South Africa

描述(申请人提供)：虽然全球艾滋病毒/艾滋病疫情给撒哈拉以南非洲的社会和经济边缘化人口造成了不成比例的负担，但艾滋病毒治疗的扩大极大地改善了所有人获得抗逆转录病毒治疗(ART)的机会。尽管如此，要想减少ART的发病率和死亡率，持续的治疗坚持是必不可少的。当免费提供抗逆转录病毒治疗时，边缘化人群坚持治疗的最大障碍仍然是结构性的：前往诊所的交通费、粮食不安全、无家可归和机会成本。这种结构性因素导致移民的治疗中断甚至比固定移民更严重，因为移民的流动性和非正规就业使收入、交通、食物、住房和医疗保健的近在咫尺更加不确定。因此，移民有很高的抗逆转录病毒治疗中断风险。移民人口治疗中断对公共卫生的影响是巨大的，因为由于中断和移民的共同作用，移民可能会对艾滋病毒的传播和抗逆转录病毒药物耐药性做出重大贡献。尽管大量文献探讨了抗逆转录病毒治疗坚持的结构性障碍，但很少有研究专注于治疗中断，特别是在劳动力流动人口中。我的长期职业目标是成为一名独立的医生兼调查员，将临床医学、人类学和公共卫生结合在一起，以了解和解决撒哈拉以南非洲艾滋病毒流行的结构性(社会、经济和政治)复杂性。作为人类学的医学博士候选人，我需要更多的公共卫生方面的指导和培训，以帮助我制定一种跨学科的研究方法。我的三年培训计划将包括课程作业、受监督的实地研究和数据分析、手稿写作，以及出席专业会议和发表演讲。我将利用这次培训和我的项目共同发起人在撒哈拉以南非洲进行抗逆转录病毒治疗相关研究的专业知识来实现我的科学目标：更有力地了解南非感染艾滋病毒的劳工移民抗逆转录病毒治疗中断的原因。为了追求这一点 为了实现这一目标，我将努力实现两个具体目标：(1)用定性研究方法描述南非感染艾滋病毒的劳工移民中抗逆转录病毒治疗中断的原因；(2)建立一个概念模型，说明结构性因素如何导致这一移民人口的治疗中断。南非是这项研究的理想背景，因为它比其他任何国家都有更多感染艾滋病毒的公民，而且许多公民要么是劳工 移民或家庭--劳工移民的成员。这项拟议的研究具有创新性，因为它针对的是研究不足的人群，他们既是抗逆转录病毒治疗中断的高危人群，也是艾滋病毒传播的组成部分。它之所以重要，是因为它有可能为未来的干预和卫生政策提供信息，因为它提供了对推动劳工移民中断抗逆转录病毒治疗的结构性因素的更全面的了解。 公共卫生相关性：拟议的研究与公共卫生相关，因为它旨在提供干预措施，防止艾滋病毒抗逆转录病毒治疗中断，从而降低发病率、死亡率和抗逆转录病毒耐药性。了解结构性因素如何导致抗逆转录病毒治疗中断，将有助于确定战略干预点，以促进治疗坚持，从而优化健康结果。这项拟议的研究与NIH 2012财年艾滋病毒相关研究跨NIH计划中规定的使命相关，因为它旨在确定在不成比例的感染人群(南非劳工移民)中促进治疗坚持的社区和系统层面的因素，更具体地说，它调查哪些因素促进和阻碍季节性劳工移民参与艾滋病毒治疗。

DESCRIPTION (provided by applicant): While the global HIV/AIDS epidemic has disproportionately burdened socially and economically marginalized populations in sub-Saharan Africa, HIV treatment scale-up has dramatically improved access to antiretroviral therapy (ART) for all. Nonetheless, for ART to decrease morbidity and mortality, sustained treatment adherence is essential. When ART is provided free of charge, the greatest barriers to treatment adherence for marginalized populations remain structural: cost of transportation to clinic, food insecurity, homelessness, and opportunity costs. Such structural factors lead to treatment interruptions for migrants even more than for their stationary counterparts because migrants' mobility and irregular employment make income, transportation, food, housing, and proximity to health care even more uncertain. Thus, migrants are at very high risk for ART treatment interruptions. The public health ramifications of treatment interruptions in migrant populations are substantial because migrants may contribute significantly to the spread of HIV and antiretroviral drug resistance because of the combination of interruptions and migration. Though a large body of literature explores structural barriers to ART treatment adherence, few studies have focused on treatment interruptions specifically in labor migrant populations. My long-term career goal is to become an independent physician-investigator who brings together clinical medicine, anthropology, and public health to understand and address the structural (social, economic, and political) complexities of the HIV epidemic in sub-Saharan Africa. As an MD-PhD candidate in anthropology, I need additional mentorship and training in public health to help me craft an interdisciplinary research approach. My three-year Training Plan will include coursework, supervised field research and data analysis, manuscript writing, and attendance and presentations at professional meetings. I will utilize this training and my Project Co-Sponsors' expertise on conducting ART adherence-related research in sub-Saharan Africa to accomplish my scientific objective: to acquire a more robust understanding of reasons for ART treatment interruptions specific to HIV-infected labor migrants in South Africa. In pursuit of this objective, I will seek to achieve two specific aims: (1) characterize reasons for ART treatment interruptions among HIV-infected labor migrants in South Africa using qualitative research methods and (2) develop a conceptual model for how structural factors lead to treatment interruptions in this migrant population. South Africa is an ideal setting for this research becaus it has more HIV-infected citizens than any other country, and many of its citizens are either labor migrants or family/household-members of labor migrants. The proposed research is innovative because it targets an understudied population both at high risk for ART treatment interruptions and integral to the spread of HIV. It is significant because it has the potential to inform future interventions and health policies by providing a more comprehensive understanding of the structural factors driving ART treatment interruptions among labor migrants. PUBLIC HEALTH RELEVANCE: The proposed research is relevant to public health because it aims to inform interventions that will prevent HIV ART treatment interruptions and thereby reduce morbidity, mortality, and antiretroviral drug resistance. Understanding how structural factors lead to to ART treatment interruptions will help identify strategic points of intervention o promote treatment adherence and thereby optimize health outcomes. The proposed research is relevant to the mission of the NIH as laid out in the FY 2012 Trans-NIH Plan for HIV-Related Research in that it aims to identify community and systems-level factors that promote treatment adherence in a disproportionately infected population (South African labor migrants) and more specifically, in that it investigates what factors facilitate and impede seasonal labor migrants' engagement in HIV treatment.