HIV Treatment Refusal Among Adults Presenting for Testing in Soweto, South Africa

描述(申请人提供)：南非是全球艾滋病毒感染者最多的国家，拥有世界上最大的抗逆转录病毒治疗(ART)计划。超过一半的南非成年人至少接受过一次自愿咨询和检测(VCT)。不幸的是，这些倡议并没有转化为早期的艺术启蒙。一大笔钱 存在未得到满足的需求，在估计200万符合抗逆转录病毒治疗资格的艾滋病毒感染者中，只有37%的人实际上在接受治疗。既然政府已经采纳了世界卫生组织的新指南，将符合抗逆转录病毒治疗资格的人数定为350个/mm3，那么符合抗逆转录病毒治疗资格的人数只会增加。到目前为止，很少有研究研究为什么南非数百万符合抗逆转录病毒治疗资格的人没有接受治疗。我们发现了一个令人高度关注的现象，直接影响南非的ART接受。在2009年期间，7287名成年人在索韦托的一个大容量VCT站点上进行了演示。10%(743人)被发现感染艾滋病毒，有资格立即开始抗逆转录病毒治疗。我们发现，这些患者中有148人(20%)在得知他们的CD4细胞计数后拒绝开始抗逆转录病毒治疗，尽管他们的CD4细胞数的中位数为110个/mm3。虽然VCT传统上被认为是治疗的切入点，但这些数据强调了在ART前护理中未被认识到的挑战的重要性。为了确保扩大艾滋病毒治疗的成功，有必要了解为什么有资格接受抗逆转录病毒治疗的人选择不开始治疗。我颁发这个K23奖项的目的是确定拒绝接受ART的可改变的决定因素，并设计一种有针对性的、知情的干预措施，以抵消索韦托的这种现象，并防止这一弱势群体的过早死亡。使用混合方法，我将通过对40名参加VCT的符合ART资格的成年人和10家医疗保健提供者进行深入的定性访谈，确定可修改的心理-社会决定因素，以根据安德森的医疗利用模型为假设模型提供信息。然后，我将通过在测试时和VCT后6个月的调查实施，检查500名符合治疗条件的成年人拒绝抗逆转录病毒治疗的相关性和结果。最后，我将制定一项干预措施，促进新诊断的艾滋病毒感染者接受艾滋病毒治疗，并在100名符合治疗条件的个人中进行试点测试。拟议的研究领域涉及抗逆转录病毒治疗前护理的一个关键领域，为改善南非高危艾滋病毒阳性个人对抗逆转录病毒治疗的接受和接受提供了一种理论和方案方法。这个K23奖项建议的研究和培训组合将利用我在艾滋病毒治疗和护理以及全球卫生计划实施方面的现有技能。这将使我能够与哈佛大学和威特沃特斯兰德大学的多学科导师团队合作，最终成为一名富有成效和有影响力的独立调查员，专注于提高艺术接受度。

DESCRIPTION (provided by applicant): South Africa, the country with the most HIV-infected citizens globally, has the largest antiretroviral treatment (ART) program in the world. More than half of all South African adults have undergone voluntary counseling and testing (VCT) at least once. Unfortunately, these initiatives have not translated into early ART initiation. A substantial unmet need exists, with only 37% of the estimated 2 million HIV-infected ART-eligible individuals actually in care. The number of ART-eligible individuals will only increase, now that the government has adopted the new WHO guidelines, setting ART-eligibility at CD4 < 350 cells/mm3. To date, few studies have examined why millions of ART-eligible individuals in South Africa are not receiving treatment. We have identified a highly concerning phenomenon directly impacting ART uptake in South Africa. Over the course of 2009, 7,287 adults presented to a high-volume VCT site in Soweto. Ten percent (743) were found to be HIV-infected, and eligible to start immediate ART. We found that 148 (20%) of these clients refused to initiate ART upon learning their CD4 count, despite having a median CD4 of 110 cells/mm3. Though VCT is traditionally viewed as an entry point to treatment, these data underscore the importance of an unappreciated challenge in pre-ART care. To ensure the success of HIV treatment expansion, it will be essential to understand why individuals who qualify for ART choose not to initiate treatment. My goal with this K23 award is to identify modifiable determinants of ART-refusal, and design a targeted and informed intervention to counteract this phenomenon in Soweto, and prevent premature mortality in this vulnerable population. Using a mixed-methods approach, I will identify modifiable psycho-social determinants of ART-refusal by performing in-depth qualitative interviews with 40 ART-eligible adults presenting for VCT, and 10 healthcare providers, to inform category construction for a putative model based upon Anderson's Model of Healthcare Utilization. I will then examine correlates and outcomes of ART-refusal in 500 treatment-eligible adults, through survey implementation at the point of testing and for 6 months post-VCT. Finally, I will develop an intervention to promote HIV treatment acceptance among newly diagnosed HIV-infected individuals and pilot test it in a population of 100 treatment-eligible individuals. The proposed area of research addresses a critical area in pre-ART care, providing a theoretical and programmatic approach to improving ART uptake and acceptance among high-risk HIV-positive individuals in South Africa. The portfolio of research and training proposed for this K23 award will draw on my existing skills in HIV treatment and care, and global health program implementation. It will enable me to work with a multidisciplinary team of mentors across Harvard University and the University of Witwatersrand, and ultimately become a productive and influential independent investigator focused on improving ART acceptance.