Resource-poor settings bear the greatest burden of HIV-associated malignancies, with high background prevalence of HIV and oncogenic viruses. HIV-associated Kaposi?s sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Incidence has decreased with more widespread use of antiretroviral therapy (ART), but remains higher than prostate cancer in the United States. Survival after a diagnosis with HIV-associated KS in sub-Saharan Africa, even in the ART era, remains poor, with almost half of patients dead by two years. One reason for poor outcomes is that by the time patients seek care for their skin lesions, the disease has progressed to an advanced stage. Even after diagnosis, a substantial number of patients have delays in starting appropriate treatment. My own work has shown that 17-29% of KS patients do not receive timely initiation of ART and that nearly half of those with indications for chemotherapy never receive it. In order ultimately to improve survival, we first need to better understand the gaps in KS care. The KS care cascade includes a series time intervals separated by discrete events: noting symptoms, presenting to healthcare, receiving a diagnosis, and finally starting and completing treatment. Identifying personal and health system barriers at each step of the cascade is critical to designing and implementing interventions that improve outcomes for this vulnerable population. I am a PhD-trained epidemiologist and board certified dermatologist, with a career goal of becoming an independent investigator in the global health epidemiology of HIV- associated malignancies and associated skin conditions, and implementation of interventions to improve the treatment of these conditions in resource-poor settings. I will draw upon the methodological training of the K23 award and leverage the existing research infrastructure of my co-mentors and collaborators in a large NIH- sponsored cohort of HIV patients from the International Epidemiology Databases to Evaluate AIDS (IeDEA) in western Kenya to accomplish the following specific aims: (1) Evaluate the determinants of advanced disease stage at KS diagnosis and associated attributable risk, as well as the distribution and determinants of time intervals leading up to diagnosis, (2) Among patients newly diagnosed with KS, evaluate the timing and determinants of ART initiation and, where indicated, chemotherapy initiation and adherence after a diagnosis of KS and (3) Develop and pilot test a multi-level intervention including both patient and healthcare provider- centered components to promote prompt, appropriate treatment for KS. Building on my quantitative background in HIV epidemiology, this award will provide training in qualitative methods, behavioral theory based in intervention design, and implementation science. This combination, along with mentorship from a multidisciplinary team of experts in global health, HIV epidemiology, oncology, global dermatology, and implementation science, will ideally position me to launch my career as an independent investigator in HIV- associated malignancies with a focus on interventions to improve outcomes in resource-limited settings.
Early diagnosis, linkage to care, initiation of evidence-based treatment, and retention in care for people with HIV-associated malignancies are of critical public health importance in improving survival for vulnerable patients in resource-limited settings. I propose to evaluate this cascade of care for HIV-associated Kaposi?s sarcoma (KS), which can serve as a prototype for other cancers for people living with HIV in sub-Saharan Africa. The proposed research, in a large HIV primary care network in Kenya, will identify barriers to optimal care for KS patients and their healthcare providers, in order to develop novel interventions to improve health outcomes for patients with HIV-associated malignancies in resource-poor settings. !