What happens after diagnosis: Characterizing long-term HIV care trajectories and mortality in South Africa

 描述（由申请人提供）：广泛采用有效的抗逆转录病毒疗法（ART）治疗艾滋病毒有望降低发病率和艾滋病毒传播-但需要与卫生保健系统的一致参与。南非拥有世界上最大的抗逆转录病毒疗法项目，有240万人接受治疗。然而，尽管取得了这一前所未有的成就，但联合国艾滋病规划署估计，南非约60%需要治疗的人仍然没有获得抗逆转录病毒治疗。这反映了从艾滋病毒检测到与艾滋病毒护理挂钩到终身抗逆转录病毒治疗和病毒抑制的多个关键步骤的消耗。以前的研究从艾滋病毒护理级联的病人流失集中在横截面快照的护理连续体上的点。这种方法无法捕获长期的、动态的患者进出级联的运动。必须共同实现连续体中每一步的改进，以提高病毒学抑制和生存的总体率。只有通过了解患者，结构和地理因素，有助于通过连续的护理次优进展，我们才能设计有效的干预措施，针对那些最高风险的护理参与度差。需要采用创新手段，纵向和跨不同治疗地点评估患者进展情况，以评估艾滋病毒护理连续体的动态、非线性性质。 利用来自NIMH资助的南非试验（R 01 MH 090326）的近2，000名HIV感染者的良好特征队列，我们将评估5年HIV护理轨迹，通过基于国家实验室数据和死亡登记信息的组合的基于组的统计建模来表征患者。由于队列研究受试者在HIV检测之前已获得同意，在各种临床研究中心，并具有广泛的CD 4计数，因此我们将能够描述各种患者类型的不同长期轨迹的风险因素。此外，我们将使用护理轨迹的空间分析和2011年南非人口普查数据来定义与护理参与不足相关的地理区域。我们提出了以下三个具体目标：（1）评估HIV检测后5年死亡率的比率和社会行为预测因子，调整基线和9个月临床因素，（2）识别不同的长期HIV感染者， 基于CD 4计数和病毒载量模式的护理轨迹（如在护理中、护理中断者和不在护理中），并评估与这些轨迹之一的成员资格相关的社会行为因素，以及（3）使用地理信息系统和空间统计分析来识别与不一致的长期HIV护理轨迹和较高死亡率的较高可能性相关的“热点”。 这项研究将是第一个研究纵向 参与对新诊断出的艾滋病毒感染者的护理。我们的新方法将帮助研究人员和政策制定者制定有效的干预措施，针对艾滋病毒感染者的亚群和艾滋病毒护理参与可能性较高的地理区域。这些发现可以改善个人、项目和社区层面的艾滋病毒护理。

 DESCRIPTION (provided by applicant): Widespread uptake of potent antiretroviral therapy (ART) for HIV holds the promise of reducing morbidity and HIV transmission - but requires consistent engagement with the health care system. South Africa has the largest ART program in the world, with 2.4 million people on treatment. Yet despite this unprecedented accomplishment, UNAIDS estimates that ~60% of people in South Africa in need of treatment are still not accessing ART. This reflects attrition from the multiple critical steps on the path fom HIV testing to linkage to HIV care to lifelong ART and virologic suppression. Previous research on patient attrition from the HIV care cascade has focused on cross-sectional snapshots of points on the care continuum. This approach fails to capture long-term, dynamic patient movement into and out of the cascade. Improvement in each step of the continuum must be achieved together to improve overall rates of virologic suppression and survival. Only by understanding patient, structural, and geographic factors that contribute to suboptimal progression through the continuum of care can we design effective interventions that target those at highest risk for poor care engagement. Innovative means of assessing patient progression longitudinally and across different treatment sites are needed to assess the dynamic, non-linear nature of the HIV care continuum. Leveraging a well-characterized cohort of nearly 2,000 HIV-infected people drawn from an NIMH- funded trial in South Africa (R01MH090326), we will assess 5-year HIV care trajectories, characterizing patients via group-based statistical modeling based on a combination of national laboratory data and death registry information. Because cohort study subjects were consented prior to HIV testing, in a variety of clinical sites and with a wide spectrum of presenting CD4 counts, we will be able to characterize risk factors for different long-term trajectories for a wide variety of patient types. In addition,we will define geographic areas associated with poor engagement in care using spatial analysis of care trajectories and 2011 South African census data. We propose the following three specific aims: (1) To assess rates and sociobehavioral predictors of 5-year mortality following HIV testing adjusting for baseline and 9-month clinical factors, (2) To identify distinct long-term HIV care trajectories based on the pattern of CD4 counts and viral loads (such as in care, care interrupters, and not in care) and to assess sociobehavioral factors associated with membership in one of these trajectories, and (3) To use geographic information system and spatial statistical analysis to identify "hot spots" associated with a higher likelihood of inconsistent long-term HIV care trajectories and higher mortality. This study will be among the first to examine longitudinal engagement in care for people newly- diagnosed with HIV. Our novel approach will help researchers and policymakers craft effective interventions targeting sub-populations of HIV-infected individuals and geographic areas with a higher likelihood of poor HIV care engagement. These findings can improve HIV care at the individual, program and community levels.