The expansion of access to antiretroviral therapies (ART) in sub-Saharan Africa (SSA) has resulted in dramatic reductions in HIV-related morbidity and mortality. Despite expanded access to both HIV testing and ART, many with HIV are delayed in accessing care causing increased mortality and strain on the health care system. Active outreach in communities through home-based counseling and testing (HBCT) is an accepted strategy for testing populations and has successfully identified and diagnosed individuals earlier in the stage of infection as compared to voluntary counseling and testing (VCT) and other testing modalities. Data on linkage to care following HBCT are limited, however, and the individual, psychosocial, and structural barriers to timely linkage are largely unknown in resource-limited settings. Until we understand the barriers and facilitators of accessing care following HBCT, it will not be possible to design evidence-based interventions to promote linkage to care and optimize the individual and population effectiveness of HBCT and ART in SSA. My long-term career goal is to become an independent researcher who successfully develops and implements multilevel interventions within healthcare systems designed to address the individual, social, and structural constraints on HIV outcomes in resource-limited settings. Toward this goal with this K01, I propose to gain expertise in improving linkage to care following HBCT, using a mixed-methods approach to develop and conduct a pilot feasibility study of a psychosocial intervention following HBCT. To be successful, I need further training in: 1) health services research;2) qualitative research methods;and 3) psychosocial interventions within health systems. This work will take place within the well-established consortium AMPATH (Academic Model Providing Access to Healthcare) in Eldoret, Kenya, with which Brown University has had a long and productive partnership, and has three specific aims: 1) to conduct retrospective and multilevel analyses to characterize linkage to care and the individual and structural determinants of linkage following HBCT;2) to perform a qualitative study to determine the psychosocial and structural facilitators and barriers to linking to care following HBCT;and 3) to design and pilot a psychosocial intervention to improve linkage to care following HBCT. To accomplish these aims, I will draw on the proposed training and guidance from my primary mentor, Dr. Ira Wilson, an expert in health services research and interventions designed to improve HIV clinical outcomes, and the Chair of the Department of Health Services, Policy &Practice at Brown University. My mentorship team also includes experts in HIV care delivery and program implementation, qualitative research, and the social and behavioral sciences. Completing these aims will provide the foundation for an R01 submitted during Year 4 to design and test a multilevel intervention to address the individual, psychosocial and structural constraints on linkage to HIV care in resource-limited settings. My prior training, experience conducting relevant research in SSA, and the strong mentoring team both in Kenya and at Brown strongly positions me to accomplish these aims.
The proposed research is relevant to public health because it will lead to an increased understanding of linkage to HIV care following home-based counseling and testing (HBCT) in resource-limited settings in sub- Saharan Africa, where only 49% of the more than 10 million people living with HIV receive the antiretroviral treatment they need. Improving linkage to care following HBCT will have profound implications on the success of antiretroviral medications to improve patient outcomes, prevent new infections at the population-level, as well as inform chronic disease management and primary care efforts for the rural poor in resource-limited settings. The objectives of this mixed methods research project are in line with the trans-NIH goal of reducing new HIV infections and improving outcomes for patients with HIV.
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