Social Networks, HIV Stigma, and the HIV Care Cascade in Rural Uganda

项目摘要 在撒哈拉以南非洲的2900万艾滋病毒感染者中，只有一半人知道自己的艾滋病病毒感染情况。 艾滋病毒/艾滋病感染者中，只有不到一半的人在接受艾滋病毒抗逆转录病毒治疗。平均CD 4 + 截至2012年，撒哈拉以南非洲抗逆转录病毒治疗开始时的T淋巴细胞计数为140个细胞/mm 3，表明 晚期疾病在就诊和开始抗逆转录病毒治疗时仍然是常态。的耻辱 艾滋病毒已被确定为改善这些艾滋病毒预防和治疗成果的关键障碍。艾滋病毒 在整个撒哈拉以南非洲地区仍然受到严重的污名化，目前的情况只得到部分缓解， 干预措施。本R 01应用程序的科学目标是应用社交网络方法来了解 艾滋病毒污名的社会生产，其传播随着时间的推移，通过社会网络，及其因果关系的影响 艾滋病毒预防和治疗成果。我们的中心假设是，强制性规范（即，现行 社会网络内关于什么构成批准或不批准行为的态度）具有因果关系 影响自己的信念，这种影响是由预期的耻辱（即，一个人所认为的 普遍的态度）。我们进一步假设，强制性规范，预期的耻辱，和一个人自己的信念， 对艾滋病毒感染风险人群的艾滋病毒预防和艾滋病毒治疗产生独立的因果影响 艾滋病毒感染者之间的结果。这些假设是根据我们强有力的初步数据提出的 来自乌干达农村的研究表明，强制性规范与一个人自己的消极态度有关， 艾滋病毒污名化与广泛的艾滋病毒预防和治疗不利有关 结果。我们最近完成了一项基于人群的，以社会为中心的社会网络研究，研究对象为N= 1，814名成年人， 乌干达农村。这个R 01应用程序将把我们的试点研究扩展到一个队列中，跟踪这些相同的参与者 以及任何新的移民，以便我们能够实现以下具体目标：（1）估计 强制性规范对艾滋病消极态度的因果效应;（2）估计 强制性规范、预期污名和对艾滋病毒感染者接受自愿咨询的消极态度 艾滋病毒抗体阴性者和艾滋病患者中的艾滋病毒感染问题 未知的血清状态;（3）估计强制性规范的因果关系，预期的耻辱， 抑郁症的内在耻辱感，与护理的联系，ART依从性，病毒抑制，护理保留， 艾滋病毒感染者的二次传播风险。我们的关键创新在于我们使用基于身份的 验证收集纵向的，以社会为中心的社交网络数据，我们应用分析方法， 确定因果效应和因果中介效应。这项研究将对公众健康产生重大影响。 通过为制定更有效的反污名干预措施奠定基础， 在成见形成的动态过程中，可以最有战略性地采取这些干预措施。

PROJECT SUMMARY Of the 29 million persons living with HIV (PLHIV) in sub-Saharan Africa, only half are aware of their seropositivity, and among these, less than half are on HIV antiretroviral therapy (ART). The average CD4+ T-lymphocyte cell count at ART initiation in sub-Saharan Africa was 140 cells/mm3 as of 2012, demonstrating that late-stage disease at presentation to care and at ART initiation remain the norm. The stigma attached to HIV has been identified as a critical barrier to improving these HIV prevention and treatment outcomes. HIV remains heavily stigmatized throughout sub-Saharan Africa and has only been partially mitigated by current interventions. The scientific objective of this R01 application is to apply social network methods to understand the social production of HIV stigma, its propagation over time through the social network, and its causal effects on HIV prevention and treatment outcomes. Our central hypothesis is that injunctive norms (i.e., the prevailing attitude within the social network about what constitutes approved or disapproved conduct) have a causal effect on one's own beliefs, and that the effect is mediated by anticipated stigma (i.e., what one perceives to be the prevailing attitude). We further hypothesize that injunctive norms, anticipated stigma, and one's own beliefs exert independent causal effects on HIV prevention among those at risk for HIV infection and on HIV treatment outcomes among PLHIV. These hypotheses have been formulated on the basis of our strong preliminary data from rural Uganda showing that injunctive norms are associated with one's own negative attitudes toward PLHIV, and that HIV stigma is associated with a wide range of adverse HIV prevention and treatment outcomes. We recently completed a population-based, sociocentric social network study of N=1,814 adults in rural Uganda. This R01 application will extend our pilot study into a cohort, following these same participants and any new in-migrants over time, so that we can accomplish the following specific aims: (1) Estimate the causal effect of injunctive norms on negative attitudes toward PLHIV; (2) Estimate the causal effects of injunctive norms, anticipated stigma, and negative attitudes toward PLHIV on uptake of voluntary counseling and testing, condomless sexual intercourse, and HIV infection among HIV-negative persons and persons of unknown serostatus; and (3) Estimate the causal effects of injunctive norms, anticipated stigma, and internalized stigma on depression, linkage to care, ART adherence, viral suppression, retention in care, & secondary transmission risk among PLHIV. Our key innovation is that we use photograph-based identity verification to collect longitudinal, sociocentric social network data, and we apply analytic methods designed to identify causal effects and causal mediation effects. The proposed study will have significant public health impact by laying a foundation for developing more effective anti-stigma interventions and by identifying where in the dynamic process of stigma formation these interventions can most strategically be deployed.