Pathways to Engagement in HIV-Care for Newly-Diagnosed South Africans

描述（申请人提供）：随着全球努力扩大治疗方案，并增加资源有限国家艾滋病毒阳性者获得抗逆转录病毒治疗（ART）的机会，了解人们如何与艾滋病毒初级保健联系起来至关重要，因为许多人进入护理太迟，无法从ART中受益。但相对较少注意到一个人接受艾滋病毒+诊断后的这段时间。由于对艾滋病毒阳性者的大多数研究都是在已经登记接受护理的人中进行的，因此对新诊断者中登记接受艾滋病毒初级护理和寻求护理的促进因素和障碍了解有限。拟在南非夸祖鲁-纳塔尔进行的四年期研究旨在填补这一空白。我们的目标是确定对艾滋病毒护理的登记和保留（无论ART资格如何）的最显着影响，如果得到解决，可以优化资源有限环境中新诊断的男性和女性的服务使用;并与关键利益相关者合作确定有希望的干预措施，以进一步开发和测试。具体目标是（1a）描述“登记时间”累积发病率曲线，估计艾滋病毒初级保健登记比例，并确定在多个影响层面-社会结构层面-登记和继续接受保健的促进因素和障碍（污名化、贫穷、性别不平等）、卫生系统（组织、策略、提供商）和个人（心理健康、社会认知、健康相关行为）;（1b）探讨有关披露和登记/保留护理的决策，以及耻辱、贫困、性别不平等和卫生系统因素如何影响这些过程，通过对队列参与者的子样本进行重复深入访谈;（1c）确定其他关键问题，包括新诊断个体对心理健康、生殖和其他艾滋病毒相关辅助服务的需求和使用。我们将对550名新诊断的女性和男性进行为期8个月的前瞻性队列研究，在基线进行结构化评估，4个月和8个月随访，重复深入访谈，子样本为30人，并进行额外的评估活动，以评估卫生系统和社会结构层面的理论兴趣变量，利用GPS绘图，健康和社区服务清单，媒体跟踪和分析，以及结构化的辅导员评估。为了推进干预措施的发展，我们将审查和整合研究结果，并通过互动式社区反馈会议，与政府官员、非政府组织成员和工作人员、卫生保健提供者和艾滋病毒阳性个人讨论基于这些结果的有希望的干预措施;并举办能力建设干预发展讲习班，以提高各机构和社区成员迅速制定有效、积极的回应。 公共卫生相关性：为了最大限度地扩大艾滋病毒检测的好处，并通过促进早期与初级艾滋病毒护理和其他支持服务联系的干预措施优化扩大抗逆转录病毒疗法的结果，本研究旨在确定对新诊断的女性和男性艾滋病毒初级护理的登记和保留的最显著影响在艾滋病毒污名化和贫困普遍存在、性别不平等普遍存在、卫生服务受到限制以及政策和方案不断变化的背景下，在艾滋病毒治疗寻求包括使用西方和传统的方式;并确定与社区组织，卫生保健提供者，政府官员和艾滋病毒+个人合作有前途的干预措施，以进一步发展和测试。

DESCRIPTION (provided by applicant): With the global effort to scale-up treatment programs and increase access to antiretroviral therapy (ART) for HIV+ people in resource-constrained nations, it is vital to understand how people become linked to HIV primary care, as many are entering care too late to benefit from ART. There is now significant momentum to promote HIV testing as a way to increase early enrollment in care, but relatively little attention to address the period immediately after a person receives an HIV+ diagnosis. As most studies of HIV+ individuals have been conducted among those already enrolled in care, there is limited knowledge concerning facilitators of and impediments to enrolling in HIV primary care and care-seeking more generally among those newly-diagnosed. The proposed four-year study, to be conducted in Kwa-Zulu-Natal, South Africa, seeks to fill this gap. Our goals are to determine the most salient influences on enrollment and retention in HIV care (regardless of ART eligibility) that, if addressed, could optimize use of services among newly diagnosed men and women in resource-constrained settings; and to identify collaboratively with key stakeholders promising interventions for further development and testing. The Specific Aims are to (1a) describe the "time to enrollment" cumulative incidence curve, estimate the proportion that enrolls in HIV primary care, and determine the facilitators of and barriers to enrollment and retention in care at multiple levels of influence - social structural (stigma, poverty, gender inequalities), health systems (organization, policies, providers), and individual (mental health, social cognitions, health-related behaviors); (1b) Explore decision-making around disclosure and enrollment/retention in care, and how stigma, poverty, gender inequalities, and health system factors shape these processes, through repeat in-depth interviews with a sub-sample of cohort participants; and (1c) Identify additional critical issues, including need for and use of mental health, reproductive, and other HIV-related ancillary services among newly diagnosed individuals. We will conduct a prospective Cohort Study following 550 newly- diagnosed women and men for eight months with structured assessments at Baseline, 4- and 8-month follow- up, repeat In-Depth Interviews with a subsample of 30, and additional assessment activities to evaluate variables of theoretical interest at the health system and social structural levels, utilizing GPS mapping, an Inventory of Health and Community Services, Media Tracking and Analysis, and structured Counselor Assessments. To advance intervention development, we will review and integrate study findings and discuss promising interventions based on these findings with public officials, non-governmental organization (NGO) members and staff, health care providers, and HIV+ individuals through Interactive Community Feedback sessions; and conduct capacity-building Intervention Development Workshops to enhance agencies' and community members' capacity to rapidly formulate effective, pro-active responses. PUBLIC HEALTH RELEVANCE: To maximize the benefits of expanded HIV testing and optimize the outcomes of ART scale-up with interventions that promote early linkage with primary HIV care and other supportive services, this study aims to determine the most salient influences on enrollment and retention in HIV primary care among newly diagnosed women and men (regardless of ART eligibility) in a context where HIV stigma and poverty are widespread, gender inequality prevails, health services are constrained and policies and programs are in flux, and where HIV care seeking includes the use of both Western and traditional modalities; and to identify collaboratively with community organizations, health care providers, public officials, and HIV+ individuals promising interventions for further development and testing.