Background: Patient disengagement from HIV care and treatment programs is a major barrier to treatment optimization in sub-Saharan Africa. While initial studies show that patient re-engagement in care is possible, very little is known about re-engagement patterns, associated factors and how they lead to return to care. Study Objective: The goal of this study is to understand the patterns, predictors and mechanisms of re- engagement in HIV care among adult HIV patients in Zambia in order to inform interventions to support return and subsequent retention.
Specific Aims : I. Among a representative, longitudinal cohort of disengaged patients in Zambia, identify time to return and individual (e.g. demographics), relational (e.g. disclosure), household (e.g. wealth), and facility-level (e.g. staffing) factors that predict return to HIV care, comparing disengaged patients who re-engaged in HIV care to those who did not re-engage after being traced. II. Develop a refined conceptual model of the mechanisms of patient re-engagement to guide patient re-engagement support interventions. Approach: The sequential, mixed methods study builds on the applicant?s significant past experience living and contributing to research in Zambia. It leverages the data and infrastructure of an on-going parent study on which the applicant is a co-investigator. The parent study is tracing 5,000 randomly sampled, lost adult HIV patients from 31 health facilities across 4 provinces in Zambia to determine their outcomes: deceased, engaged in care elsewhere or disengaged from care.
Aim 1 will be a secondary data analysis of the estimated 1,000 disengaged patients from the parent study, among whom an estimated 25% (n=250) will re-engage in care over 15 months. Survival analysis will be used to estimate time to return and identify multi-level predictors of return across a social ecological framework. Sub-Aim 1a will examine the impact of tracing (peer educator outreach to lost patients) on return.
Aim 2 will collect in-depth interview data from disengaged patients who returned to HIV care. Drawing on the factors identified in Aim 1 and grounded theory to allow other factors to emerge, Aim 2 seeks to explain the mechanisms through which factors associated with re-engagement operate. Final results will be triangulated to develop a refined conceptual model of HIV care re-engagement that can guide the design and testing of interventions to facilitate return. Fellowship Information: The proposed research will serve as the doctoral dissertation of Ms. Laura Beres, a current PhD student in the Department of International Health at Johns Hopkins University. The training is guided by one Sponsor, two Co-sponsors and a Scientific Advisor who offer complementary expertise in HIV and analytic skills required for the study. Training includes coursework, field research and other opportunities to prepare Ms. Beres to become a leading independent researcher in global HIV prevention and care.

Public Health Relevance

While patient disengagement from HIV care threatens the effectiveness of HIV treatment to reduce morbidity, mortality and onward transmission, very little is known about patterns of disengaged patient return to care, factors associated with return, and how those factors lead to return. This mixed methods study will examine length of time to return and predictors of re-engagement in HIV care among previously disengaged adult HIV patients in a randomly sampled cohort in Zambia. The study will result in a refined conceptual model of re- engagement, which will inform the design and testing of interventions to support patient retention.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Predoctoral Individual National Research Service Award (F31)
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Special Emphasis Panel (ZRG1)
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Stoff, David M
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Johns Hopkins University
Public Health & Prev Medicine
Schools of Public Health
United States
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