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. 1
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.