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

诊断后会发生什么：描述南非长期艾滋病毒护理轨迹和死亡率

• 批准号: 9140315
• 负责人: Ingrid Valerie Bassett
• 金额: $ 45.17万
• 依托单位: MASSACHUSETTS GENERAL HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-04-07 至 2020-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9140315
• 关键词: Academia; Achievement; Africa South of the Sahara; Behavioral; Behavioral Model; Behavioral Sciences; Biometry; CD4 Lymphocyte Count; Caring; Censuses; Cessation of life; Clinical; Cohort Studies; Communities; Consent; Continuity of Patient Care; Data; Data Sources; Diagnosis; Disease; Effectiveness; Emotional; Funding; Future; Geographic Factor; Geographic Information Systems; Geographic Locations; Government; HIV; HIV diagnosis; Health; Health Benefit; Healthcare Systems; Hot Spot; Human immunodeficiency virus test; Individual; Intervention; Laboratories; Life; Life Expectancy; Long-Term Care; Longitudinal Studies; Measures; Monitor; Morbidity - disease rate; Movement; National Institute of Mental Health; Nature; Newly Diagnosed; Nonlinear Dynamics; Outcome; Participant; Patients; Pattern; Patterns of Care; Performance; Physicians; Play; Population; Positioning Attribute; Public Health; Registries; Reporting; Research; Research Personnel; Resources; Risk Factors; Services; Social Behavior; Social support; South Africa; South African; Staging; Statistical Data Interpretation; Statistical Models; Study Subject; Testing; Time; Viral Load result; Work; antiretroviral therapy; base; clinical epidemiology; clinical research site; cohort; design; effective intervention; health service use; high risk; improved; innovation; mortality; novel; novel strategies; prevent; programs; public health relevance; social; success; therapy adherence; therapy design; tool; transmission process; treatment program; treatment site; uptake

 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.

 描述(由申请人提供)：广泛采用有效的抗逆转录病毒疗法(ART)治疗艾滋病毒有望减少发病率和艾滋病毒传播--但需要与卫生保健系统保持一致的参与。南非拥有世界上最大的抗逆转录病毒治疗项目，有240万人在接受治疗。然而，尽管取得了这一史无前例的成就，联合国艾滋病规划署估计，南非约60%需要治疗的人仍然无法获得抗逆转录病毒治疗。这反映了从艾滋病毒检测到艾滋病毒护理联系到终身抗逆转录病毒治疗和病毒学抑制的道路上的多个关键步骤的磨损。以前关于HIV护理级联中患者自然减员的研究主要集中在护理连续体上各点的横截面快照。这种方法无法捕捉患者进出级联的长期、动态的流动。必须共同改进连续体的每一步，以提高病毒学抑制和存活率的总体比率。只有通过了解患者、结构和地理因素，才能设计有效的干预措施，针对那些护理参与度较低的高危人群，在整个护理过程中导致不佳的进展。需要采用创新的手段来评估纵向和跨不同治疗地点的患者进展情况，以评估艾滋病毒护理连续体的动态、非线性性质。利用从NIMH资助的南非试验(R01MH090326)中抽取的近2000名艾滋病毒感染者的特征良好的队列，我们将评估5年的艾滋病毒护理轨迹，通过基于国家实验室数据和死亡登记信息的组合的基于分组的统计建模来描述患者的特征。由于队列研究对象是在HIV检测之前在不同的临床地点同意的，并且呈现了广泛的CD4计数，我们将能够表征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，确定与护理参与度较低相关的地理区域。我们提出了以下三个具体目标：(1)评估HIV检测后5年死亡率和社会行为预测因子，调整基线和9个月的临床因素；(2)识别不同的长期HIV (3)利用地理信息系统和空间统计分析，找出与长期艾滋病毒护理轨迹不一致和死亡率较高相关的“热点”。这项研究将是第一批纵向考察的研究之一。 参与护理新诊断的艾滋病毒感染者。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，目标是艾滋病毒感染亚群和艾滋病毒护理参与度较低的地理区域。这些发现可以改善个人、项目和社区层面的艾滋病毒护理。