Uptake and Retention Among Marginalized Populations Workshop Wednesday 20 th July 1100am 1230pm Understanding the underserved Minorities within the majority Ingrid T Katz MD MHS ID: 686091
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Slide1
Reaching the UnreachedService Uptake and Retention Among Marginalized Populations
Workshop
Wednesday
20
th
July
11:00am – 12:30pmSlide2
Understanding the underserved: Minorities within the majority
Ingrid T. Katz, MD, MHS
Assistant Professor, Harvard Medical School
Associate Physician, Brigham & Women’s HospitalResearch Scientist, Center for Global Health, Massachusetts General HospitalSlide3
DisclosureI have no financial conflicts of interestI receive salary and research support from:Connors Center for Women’s Health and Gender Biology
Burke Fellowship
Harvard University
Center for AIDS ResearchNational Institute of Mental HealthK23 MH 097667R34 MH 10839301Slide4
Key points for synergy Understanding how “Key Populations” may mean different things in different contexts
“Key” - refers to
specific or heightened vulnerabilities
and 'risks' in terms of HIVUltimately need to create programs and interventions that address this risk/vulnerability through addressing individual / social / structural factorsSlide5
Goals for this PresentationGaps and losses in care throughout the pre-ART and early-ART phases of the continuum in South Africa
Defining this key population
: Individuals presenting for testing who do not initiate ART – What is Treatment Refusal
Data from our recent cohort analyses: Defining key populations and discussing risk factorsWhere to go from here: The Treatment Ambassador ProgramSlide6
GaPs in careSlide7
Treatment Coverage for HIV-infected Individuals in Sub-Saharan Africa by Percent, 2010
Source: Katz IT et al, New
Engl
and Journal of Medicine, 2013Slide8
CD4 Trends in ART Initiation in Sub-Saharan Africa 2002-2013
Siedner
M, Ng C, Bassett IV, Katz IT,
Bansgberg
D, Tsai AC,
CID
, 2015Slide9
Source: UNICEF, 2014
Test and Treat StrategySlide10
Defining the key populationSlide11
Adults Presenting for Voluntary Counseling and Testing (VCT) in Soweto
Source: Katz IT et al, AIDS, 2011
20% of Adults Presenting
for Testing in Soweto
Refused TreatmentSlide12
Understanding treatment refusal among adults presenting for HIV-testing in Soweto, South Africa: a qualitative study
Katz IT et al, AIDS
Behav
, 2015Slide13
Risks Perceived in Starting TreatmentLosing health or beauty
“They said, ‘You are HIV positive,’ and I said, ‘I am not HIV positive.’ [...] I told myself that I am beautiful and they say I am HIV positive. Are they sick? I said, no, they are mad. How can they say that? I am very healthy.”
− Female, Sustained RefuserSlide14
Risks Perceived in Starting TreatmentStigma associated with disclosure
“In a rural area, it’s a small place even though you trust the nurses and stuff like that. People who are in the clinic, they know that you go to
that
door when you are HIV positive. You come in
this way, so they will notice, ‘Wow, she is HIV positive.’ So they will start talking.”
− Female, Initial RefuserSlide15
Risks Perceived in Starting TreatmentIncreased Financial Burdens
“My problem is that sometimes I do not have food to eat at all. How can I take [ARVs] when I don
’
t have food to eat? So now that means that I will default, but if I
knew that I had money then I would take them.”
− Female, False AcceptorSlide16
Protective Factors Offsetting Risks of Starting TreatmentCoping, Resilience and the importance of Social Support
“In rural areas, we have fields where there is no one. I went there and wrote a suicidal letter. It was addressed to my grandmother and aunts. But then I thought of people who love me. I thought my teacher wouldn't
’
t like this. She wouldn't
’t be proud of me, because she knows that I am a fighter. I am a hard-worker, and if I do this she will be disappointed. I just cried and cried and then said, let me just pull myself together. I lost my mother. I got shot and survived. So why am I not going to survive this HIV thing?”
− Female, Initial RefuserSlide17
cohort analysisSlide18
Prospective Cohort StudyDetermine rates of ART refusal among PLWH at the point of
eligibility and over a 6 month period
Assessed
modifiable socio-behavioral factors associated with treatment refusal and viral load suppressionSlide19
Study Sites: Soweto and GugulethuSlide20
Participant EligibilityRecruitment500 ART-eligible participants between July 2014 and June 2015
ART eligibility changed during study
Pre-Jan 2015: CD4
≤ 350 cells/mm3Jan 2015: CD4
≤ 500 cells/mm3Pregnant women and children excluded Slide21
The Theory of Triadic Influence: Informing Measure Selection
Social Factors
Structural Factors
Individual Factors
Social
support
Social norms
Perceived stigma
Access
to
care
Perceived
quality of care
Food insecurity
Self-assessed
health
Self-efficacy
Coping
skills
Fatalism
Denial
Primary:
Rates of ART Refusal at baseline, 3 months and 6 months
Secondary:
Factors associated with ART refusal
HIV-1 RNA suppression at six months
Measure
Domain
OutcomeSlide22
Study Recruitment
360 (34%) lost after testing
[Median CD4: 194]
[IQR: 160–355]
711 (66%) presented for CD4 results
[Median CD4: 262]
[IQR: 141–
372]
1071 adults presented for VCT and eligible for ART
500 enrolled in studySlide23
Baseline Characteristics
Variable
Total
(n=500)
Median Age
35 years
Female
63 %
Median CD4
+
244 cells/mm
3
Unemployed
57%
Repeat testers
62%
Repeat testers with a prior positive test
60%Slide24
Baseline (point of testing )6.6% of ART-eligible individuals who presented for testing reported they were not planning to start treatment.Significantly higher odds of fatalistic beliefsSlide25
Multivariable Model of Factors Associated ART Refusal at Baseline, stratified by social support (n=483)*
Low Social Support
n=133
High
Social Support
n=350
Variable
Adjusted
Odds Ratio
95% CI
Adjusted Odds Ratio
95% CI
Age ≥
35
1.49
0.35—6.30
1.20
0.47—3.07
Baseline CD4 < 350
1.02
0.22—4.81
1.31
0.39—4.34
Less High School
Education
1.66
0.25—11.17
1.08
0.29—3.97
Female Gender
1.11
0.22—5.47
0.96
0.36—2.53
Denial
0.75
0.48—1.16
1.16
0.90—1.49
Stigma
1.32
0.84—2.08
1.14
0.88—1.47
Fatalism
1.40
1.05—1.86
1.12
0.96—1.30
* n=483 due to seventeen participants refusal
t
o answer questions on social support, coping, stigma, or fatalismSlide26
Treatment RefusalAt 6 months: 1.8%
(
n=9)
died within 6 months44.4% (n=222) had yet to initiateVerified through the National Health Laboratory Service or clinic records
Perceptions of low ART efficacy was significantly associated with sustained refusalSlide27
Viral Load Suppression Ultimately, only 25% of our cohort (125 participants) were virally suppressed within nine months of learning eligibility.Participants who refused ART at 6 months were significantly more likely to be unable to suppress their viral load at 9 months (p<0.001)
Slide28
Long-term outcomeLow rates of viral load suppression among this high-risk key population
Treatment refusal is significantly associated with a lack of viral load suppressionSlide29
Where to go from hereSlide30
Treatment Ambassador Program (TAP)Slide31
Thank YouDavid Bangsberg, Glenda Gray, Catherine Orrell, Norma Ware, Laura Bogart,
Ingrid Bassett
,
Janan Dietrich, Marya Gwadz, Garrett Fitzmaurice, Kathy GogginFrom MGH Center for Global Health & the Connors Center for Gender
BiologyRAs:
Holly Zanoni, Dominick Leone, Ingrid Courtney, Gugu TshabalalaFunders
: NIMH, Burke Family, CFAR, Mike Stirratt (Program
Officer)Participants: From the Republic of South Africa