Multi-level and Intersectional Stigma and other Social Determinant Effects on TB Case Detection, Care, and Treatment Outcomes: The MISSED TB Outcomes Study

项目摘要 2018年，全球约有1000万人患上结核病，其中约150万人死亡;艾滋病毒是主要的结核病感染者。 死因了正在进行的传播是由于估计有430万“失踪”结核病例沿着活动性结核病， 结核病病例未得到护理。我们将在南非进行研究（结核病患病率=852/100，000人口; 艾滋病毒合并感染=>50%），最近的结核病级联分析和国家结核病规划指标报告显示， 沿着整个结核病护理级联的差距。定性研究表明，结核病耻辱感是病例发现和护理的障碍 寻求、治疗启动和依从性。然而，很少有研究量化了耻辱感对结核病的影响 护理级联，很少有人使用经过验证的污名措施，没有人使用前瞻性的全面护理 级联研究设计。我们提出了一个4目标，严格，多层次，混合方法的研究。我们将执行家庭 这些调查将汇总成社区一级的数据，并纳入对所有目标的分析。目标1： 利用混合方法来确定和衡量个人和社区一级的耻辱和社会 与主动转诊的接触者中结核病检测相关的决定因素。我们会进行 一项在主动转诊进行检测的有症状HHC（n= 750）中进行的前瞻性研究， 结核病和艾滋病毒污名化与其他社会决定因素和吸收的多层次内部和之间的关系 结核病检测。目标2：利用混合方法确定和衡量个人和社区一级的耻辱感 以及与有症状个体返回检查结果相关的社会决定因素 肺结核我们将对被动参加研究的结核病症状个体进行前瞻性研究 临床和结核病测试（n= 1000），以调查结核病和艾滋病毒的多个层次之间的关系 耻辱和其他社会决定因素以及返回或获得测试结果。目标3：使用混合方法 确定和衡量个人和社区一级的耻辱感和与之相关的社会决定因素， 开始接受结核病治疗的个人的LTFU和治疗结果。我们将进行前瞻性的 在开始治疗的结核病患者（n= 1250）中进行的一项研究，旨在调查预期、实施和 内化结核病和艾滋病毒的耻辱感对长期随访和结核病治疗效果差。定性方法将探索 在治疗期间和治疗后，感知和经历的结核病污名的轨迹、持续性和影响。目标4： 利用混合方法来确定和衡量个人和社区一级的耻辱和社会 在合并感染者中，结核病治疗后艾滋病毒护理的LTFU相关的决定因素。 先前作为目标3的一部分收集的TB/HIV合并感染受试者的相关数据（n= ~600），以及其他 将使用艾滋病毒结果数据。通过这一点，我们将调查的存在和潜在的影响， 在完成结核病治疗后继续接受艾滋病毒护理的耻辱。这项研究将最终告知有针对性的， 多层次的干预措施，植根于社区的需求和挑战，理论上知情， 这一战略将在全球范围内实施，以应对南非的结核病危机，并为全球类似的干预措施提供信息。

PROJECT ABSTRACT In 2018, ~10 million individuals developed TB disease globally, of which ~1.5 million died; HIV was the leading cause of death. Ongoing transmission results from an estimated 4.3 million “missing” TB cases along with active TB cases not retained in care. We will conduct our study in South Africa (TB prevalence=852/100,000 population; HIV co-infection=>50%), where a recent TB cascade analysis and national TB program indicators report significant gaps along the entire TB care cascade. Qualitative studies suggest TB stigma as a barrier to case finding, care seeking, treatment initiation, and adherence. However, few studies have quantified the impact of stigma on the TB care cascade, fewer have used validated stigma measures, and none have employed prospective, full care cascade study designs. We propose a 4-aim, rigorous, multilevel, mixed-methods study. We will perform household surveys, which will be aggregated into community-level data and incorporated into the analysis of all aims. Aim 1: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with presentation for TB testing among actively referred contacts. We will conduct a prospective study amongst symptomatic HHCs actively referred for testing (n= 750) to investigate the relationships within and between the multiple levels of TB and HIV stigma and other social determinants and uptake of TB testing. Aim 2: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with returning for test results among symptomatic individuals tested for TB. We will conduct a prospective study of individuals with TB symptoms who passively present to a study clinic and are tested for TB (n= 1000) to investigate the relationships between the multiple levels of TB and HIV stigma and other social determinants and returning for or obtaining the test results. Aim 3: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with LTFU and treatment outcomes among individuals initiated on TB treatment. We will conduct a prospective study among TB patients initiating treatment (n= 1250) to investigate the association of anticipated, enacted and internalized TB and HIV stigma on LTFU and poor TB treatment outcomes. Qualitative methods will explore the trajectory, persistence, and impact of perceived and experienced TB stigma during and after treatment. Aim 4: Utilize mixed-methods to identify and measure individual- and community-level stigma and social determinants associated with LTFU from HIV care following TB treatment among co-infected individuals. Relevant data for TB/HIV co-infected participant previously collected as part of Aim 3 (n= ~600), and additional HIV outcome data will be used. Through this, we will investigate the presence and potential impact of intersecting stigmas on retention in HIV care following completion of TB treatment. This study will ultimately inform targeted, multi-level interventions, rooted in the needs and challenges of communities, theoretically informed, and fully contextualized, to address the TB crisis in South Africa, and inform similar interventions globally.