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）：广泛采用有效的艾滋病毒抗逆转录病毒疗法（ART）有望降低发病率和艾滋病毒传播，但需要卫生保健系统的持续参与。南非拥有世界上最大的 ART 项目，有 240 万人正在接受治疗。然而，尽管取得了前所未有的成就，联合国艾滋病规划署估计，南非约 60% 需要治疗的人仍然没有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到终身抗逆转录病毒治疗和病毒学抑制的多个关键步骤的消耗。先前关于艾滋病毒护理级联中患者流失的研究主要集中在护理连续体上各个点的横截面快照上。这种方法无法捕捉长期、动态的患者进出级联的运动。连续体的每个步骤的改进必须共同实现，以提高病毒学抑制率和生存率的总体水平。只有了解在连续护理过程中导致进展不理想的患者、结构和地理因素，我们才能设计有效的干预措施，针对那些护理参与度不佳风险最高的人群。需要纵向和跨不同治疗地点评估患者进展的创新方法，以评估艾滋病毒护理连续体的动态、非线性性质。 我们将利用从 NIMH 资助的南非试验 (R01MH090326) 中抽取的近 2,000 名 HIV 感染者的详细特征队列，评估 5 年 HIV 护理轨迹，通过基于组的统计模型（基于国家实验室数据和死亡登记信息相结合）来描述患者特征。由于队列研究受试者在 HIV 检测前已获得同意，且在不同的临床场所进行，并且具有广泛的 CD4 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危险因素。此外，我们将利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度低相关的地理区域。我们提出以下三个具体目标：(1) 评估 HIV 检测后 5 年死亡率的比率和社会行为预测因素，调整基线和 9 个月的临床因素，(2) 确定不同的长期 HIV 基于 CD4 计数和病毒载量模式（例如在护理中、护理中断者中和不在护理中）的护理轨迹，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长期不一致的 HIV 护理轨迹和较高死亡率相关的“热点”。 这项研究将是第一个纵向检验的研究 参与对新诊断出的艾滋病毒感染者的护理。我们的新颖方法将帮助研究人员和政策制定者针对艾滋病毒感染者亚群和艾滋病毒护理参与度较差的可能性较高的地理区域制定有效的干预措施。这些发现可以改善个人、项目和社区层面的艾滋病毒护理。