Promoting Engagement in the Drug Resistant TB/HIV Care Continuum in South Africa

 描述（由申请人提供）：结核病（TB）仍然是全球艾滋病毒感染者发病和死亡的主要原因。在全球范围内，耐多药结核病和广泛耐药结核病的发病率在过去15年中大约翻了一番，这两种结核病是耐药性最强的结核病。在南非，结核病和普遍的艾滋病毒/艾滋病流行病之间的相互作用正在造成结核病发病率和病死率的“爆炸性”，威胁到抗逆转录病毒疗法取得的进展。在结核病/艾滋病毒高负担环境中，药物依从性是多重耐药和广泛耐药结核病和艾滋病毒治疗结果的一个关键预测因素，但研究不足。在结核病/艾滋病毒护理连续体过渡期间，患者流失频繁，导致死亡率上升。对耐多药/广泛耐药结核病艾滋病毒治疗的需求是严峻的，包括极大的药物负担、严重的不良反应、漫长的治疗、隔离和耻辱，在现代医学中几乎没有类似的情况。 拟议研究的目标是通过基于社区的策略，包括使用社区依从性小组，提高南非M/XDR-TB HIV患者的依从性和保留率，总体目标是促进患者参与M/XDR-TB HIV连续治疗。虽然ART已得到很好的确立，但这是首次将社区依从性团体干预应用于M/XDR-TB艾滋病毒合并感染人群。为了实现这一目标，我们将描述我们对耐药结核病和艾滋病毒治疗依从性的理解方面的关键实施差距，利用这些数据为基于证据和理论的干预提供信息，以提高依从性并促进护理保留，并使用定量临床结果和对障碍和促进者影响的定性理解，采用混合方法严格评估干预措施。通过这些研究，我们将解决我们对耐药结核病和艾滋病毒治疗依从性理解的关键差距，评估新依从性指标的潜在预测价值，并评估探索性、文化上可接受和以患者为导向的干预措施对支持依从性的影响。

 DESCRIPTION (provided by applicant): Tuberculosis (TB) remains the leading cause of morbidity and mortality worldwide among people living with HIV. Globally, the incidence of multidrug-resistant tuberculosis and extensively drug resistant tuberculosis, the most drug-resistant forms of TB, has approximately doubled over the past fifteen years. Nowhere has this increased incidence generated more concern than South Africa where interactions between TB and generalized HIV/AIDS epidemics are causing `explosive' TB incidence and case-fatality threatening to undermine the progress reached with antiretroviral therapy (ART). Medication adherence, a key predictor of outcomes in multi-and extensively drug-resistant TB (M/XDR-TB) and HIV treatment, is understudied in high burden TB/HIV settings. Patient losses during transitions in the TB/HIV care continuum are frequent and lead to increased mortality. Demands of M/XDR-TB HIV treatment are severe including extraordinary pill burden, severe adverse effects, lengthy treatment, isolation, and stigma, with few parallels in modern medicine. The goal of the proposed study is to enhance adherence and retention in care for M/XDR- TB HIV patients in South Africa through a community-based strategy, including use of community adherence groups, with the overarching goal of promoting patient engagement in a continuum of M/XDR-TB HIV care. Although well established for ART, this is the first application of a community adherence group intervention to an M/XDR-TB HIV co-infected population. To achieve this goal, we will characterize critical implementation gaps in our understanding of adherence to treatment for drug-resistant TB and HIV, use this data to inform an evidence and theory-based intervention to improve adherence and promote retention in care, and rigorously evaluate the intervention with a mixed methods approach using quantitative clinical outcomes and qualitative understanding of impact on barriers and facilitators At the conclusion of these studies we will have addressed critical gaps in our understanding of adherence to treatment for drug-resistant TB and HIV, evaluated the potentially predictive value of novel adherence measures and assessed the impact of an exploratory, culturally acceptable, and patient-oriented intervention to support adherence.