The effect of migration on HIV outcomes and HIV care utilization in South Africa

项目摘要 尽管普遍提供抗逆转录病毒疗法，但南非仍然是艾滋病毒流行病的中心，这表明迫切需要 解决“经济一体化”高度移动的人口中获得和利用保健服务之间的脱节问题， 非洲的“引擎”移民是南非艾滋病毒流行的一个既定驱动因素：流动性增加了艾滋病毒的风险 感染和死亡，并且在诊断后，延迟启动和中断对艾滋病毒护理的参与。因此，移民 不成比例地错过了ART的健康和经济效益，他们的伴侣面临着更大的风险， 传输然而，人们对移徙对艾滋病毒结果和艾滋病毒护理利用偏好的影响知之甚少。 拟议的研究将利用两个健康和人口监测系统的数据来解决这一知识差距 南非现有的两个卫生保健系统：非洲卫生研究所和阿金库尔卫生保健系统。这些HDSS 是这项研究的理想数据集，因为在这些数据集中，移民死于艾滋病毒/结核病的可能性是移民的两到四倍。 对这些群体的分析将突出移民模式、流行病和其他疾病的异质性。 经验和地理区域。来自非洲卫生研究所HDSS收集的生物标志物和 每年提供地理位置数据，独特地使艾滋病毒结果研究和地理空间分析成为可能（目标1）。我们将使用 地理空间分析，以创建迁移距离、模式和聚类的度量;我们将创建考克斯比例 风险模型，以评估移民对艾滋病毒感染者（PWH）中病毒抑制的影响， 条描述移民对威尔斯亲王医院护理选择的影响（目标2）将是可行的，也是重要的， 在这两个人群中。我们将创建一个潜在的类转换模型，它是识别异质性的理想模型 在护理利用的偏好结构中，在每个人群中识别未观察到的或“潜在”的护理偏好类别 使用PWH使用的护理特征的观察数据（例如，费用、距离、提供者/设施的类型），以及 个体级预测器（例如，移民、社会人口特征）。识别 移民对艾滋病毒护理利用的影响，涉及其对艾滋病毒结果的影响，可以为紧急建立- 在目前对人口流动反应迟钝的卫生系统内，需要针对移徙者的艾滋病毒政策。具体地说， 这项研究可用于制定干预措施，以增加移民的长期艾滋病毒护理参与， 南非，其移民与健康的关系可能是撒哈拉以南非洲的一个预兆， 在世界上负担最重的大陆消除艾滋病毒的贡献。

PROJECT SUMMARY Despite its universal provision of ART, South Africa remains the epicentre of the HIV pandemic, illustrating the urgency of addressing the disconnect between accessibility and utilization of care within the highly mobile population of the ‘economic engine’ of Africa. Migration is an established driver of the HIV epidemic in South Africa: mobility increases risk of HIV acquisition and death, and, after diagnosis, delays initiation and disrupts engagement in HIV care. Thus, migrants disproportionately miss the health and economic benefits of ART, and their partners face increased risk of onward transmission. However, little is known about the effect of migration on HIV outcomes and HIV care utilization preferences. The proposed research will address this knowledge gap using data from two health and demographic surveillance systems (HDSSs) that exist in South Africa: the Africa Health Research Institute HDSS and the Agincourt HDSS. These HDSSs are ideal data sets for this research given that, within them, migrants are two to four times as likely to die from HIV/TB as their non-migrant counterparts; analyses across these cohorts will highlight heterogeneity in migration patterns, epidemic experiences, and geographic regions. Data from the Africa Health Research Institute HDSS collect biomarker and geolocation data yearly, uniquely enabling the study of HIV outcomes and geospatial analyses (Aim 1). We will use geospatial analyses to create measures of migration distance, pattern, and clustering; we will create a Cox proportional hazards model to evaluate the effect of migration on viral suppression among persons with HIV (PWH) who have initiated ART. Characterizing the effect of migration on care selection among PWH (Aim 2) will be feasible and important to undertake in both populations. We will create a latent class transitional model, which is ideal for identifying heterogeneity in preference structures in care utilization, in each population to identify unobserved or ‘latent’ classes of care preferences using observed data on characteristics of care that PWH utilized (e.g., fees, distance, type of provider/facility), and the individual-level predictors (e.g., migration, sociodemographic characteristics) of belonging to each class. Identifying the effect of migration on HIV care utilization, which relates to its effect on HIV outcomes, can inform the creation of urgently- needed migrant-specific HIV policies within a health system that currently is unresponsive to human mobility. Specifically, this research may be used to contextualize interventions to increase long-term HIV care engagement among migrants in South Africa, whose migration-health relationship is likely a harbinger for sub-Saharan Africa, maximizing this work’s contribution to ending HIV within the world’s highest-burden continent.