HIV Treatment Refusal Among Adults Presenting for Testing in Soweto, South Africa

描述（由申请人提供）：南非是全球艾滋病毒感染者最多的国家，拥有世界上最大的抗逆转录病毒治疗（ART）计划。超过一半的南非成年人至少接受过一次自愿咨询和检测。不幸的是，这些举措并没有转化为早期抗逆转录病毒疗法的启动。大幅 存在未满足的需求，估计200万艾滋病毒感染者中只有37%符合接受抗逆转录病毒疗法的条件。符合ART条件的个人数量只会增加，因为政府已经采用了新的WHO指南，将ART资格设定为CD 4 < 350个细胞/mm 3。到目前为止，很少有研究调查为什么南非数百万符合ART条件的人没有接受治疗。我们已经确定了一个高度关注的现象，直接影响ART在南非的吸收。在2009年期间，有7，287名成年人到索韦托的一个高容量自愿咨询和检测点就诊。10%（743）被发现是艾滋病毒感染，并有资格立即开始ART。我们发现，148（20%）这些客户拒绝启动ART后，了解他们的CD 4计数，尽管有一个中位数CD 4为110个细胞/mm 3。虽然VCT传统上被视为治疗的切入点，但这些数据强调了ART前护理中未被重视的挑战的重要性。为了确保艾滋病毒治疗扩展的成功，必须了解为什么有资格接受抗逆转录病毒治疗的人选择不开始治疗。我的K23奖项的目标是确定ART拒绝的可改变的决定因素，并设计有针对性的知情干预措施，以抵消索韦托的这种现象，并防止这一弱势群体的过早死亡。使用混合方法的方法，我将确定修改的心理社会决定因素的ART拒绝进行深入的定性访谈与40 ART合格的成年人提出的VCT，和10个医疗服务提供者，告知类别建设的一个假定的模型的基础上，安德森的模型的医疗保健利用。然后，我将通过在测试点和VCT后6个月的调查实施，在500名符合治疗条件的成年人中检查ART拒绝的相关性和结果。最后，我将开发一种干预措施，以促进新诊断的艾滋病毒感染者接受艾滋病毒治疗，并在100名符合治疗条件的人群中进行试点测试。拟议的研究领域涉及ART前护理的一个关键领域，提供了一种理论和方案方法，以提高南非高风险艾滋病毒阳性者对ART的吸收和接受。为K23奖提出的研究和培训组合将利用我在艾滋病毒治疗和护理以及全球卫生计划实施方面的现有技能。它将使我能够与哈佛大学和威特沃特斯兰德大学的多学科导师团队合作，并最终成为一名富有成效和有影响力的独立调查员，专注于提高ART的接受程度。

DESCRIPTION (provided by applicant): South Africa, the country with the most HIV-infected citizens globally, has the largest antiretroviral treatment (ART) program in the world. More than half of all South African adults have undergone voluntary counseling and testing (VCT) at least once. Unfortunately, these initiatives have not translated into early ART initiation. A substantial unmet need exists, with only 37% of the estimated 2 million HIV-infected ART-eligible individuals actually in care. The number of ART-eligible individuals will only increase, now that the government has adopted the new WHO guidelines, setting ART-eligibility at CD4 < 350 cells/mm3. To date, few studies have examined why millions of ART-eligible individuals in South Africa are not receiving treatment. We have identified a highly concerning phenomenon directly impacting ART uptake in South Africa. Over the course of 2009, 7,287 adults presented to a high-volume VCT site in Soweto. Ten percent (743) were found to be HIV-infected, and eligible to start immediate ART. We found that 148 (20%) of these clients refused to initiate ART upon learning their CD4 count, despite having a median CD4 of 110 cells/mm3. Though VCT is traditionally viewed as an entry point to treatment, these data underscore the importance of an unappreciated challenge in pre-ART care. To ensure the success of HIV treatment expansion, it will be essential to understand why individuals who qualify for ART choose not to initiate treatment. My goal with this K23 award is to identify modifiable determinants of ART-refusal, and design a targeted and informed intervention to counteract this phenomenon in Soweto, and prevent premature mortality in this vulnerable population. Using a mixed-methods approach, I will identify modifiable psycho-social determinants of ART-refusal by performing in-depth qualitative interviews with 40 ART-eligible adults presenting for VCT, and 10 healthcare providers, to inform category construction for a putative model based upon Anderson's Model of Healthcare Utilization. I will then examine correlates and outcomes of ART-refusal in 500 treatment-eligible adults, through survey implementation at the point of testing and for 6 months post-VCT. Finally, I will develop an intervention to promote HIV treatment acceptance among newly diagnosed HIV-infected individuals and pilot test it in a population of 100 treatment-eligible individuals. The proposed area of research addresses a critical area in pre-ART care, providing a theoretical and programmatic approach to improving ART uptake and acceptance among high-risk HIV-positive individuals in South Africa. The portfolio of research and training proposed for this K23 award will draw on my existing skills in HIV treatment and care, and global health program implementation. It will enable me to work with a multidisciplinary team of mentors across Harvard University and the University of Witwatersrand, and ultimately become a productive and influential independent investigator focused on improving ART acceptance.