Publications by authors named "Ingrid T Katz"

59 Publications

From Vaccine Nationalism to Vaccine Equity - Finding a Path Forward.

N Engl J Med 2021 04 3;384(14):1281-1283. Epub 2021 Apr 3.

From the Department of Medicine, Brigham and Women's Hospital (I.T.K., R.W.), Harvard Medical School (I.T.K., R.W., A.M.B.), Massachusetts General Hospital Center for Global Health (I.T.K.), and Ariadne Labs (R.W.) - all in Boston; the Harvard Global Health Institute (I.T.K., A.M.B.), and Harvard University (A.M.B.) - both in Cambridge, MA; and the Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa (L.-G.B.).

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http://dx.doi.org/10.1056/NEJMp2103614DOI Listing
April 2021

Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study.

J Acquir Immune Defic Syndr 2021 04;86(5):562-567

Harvard Medical School, Boston, MA.

Background: Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care.

Methods: The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models.

Results: Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1).

Discussion: Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.
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http://dx.doi.org/10.1097/QAI.0000000000002605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938906PMC
April 2021

"You are not alone": a qualitative study to explore barriers to ART initiation and implications for a proposed community-based youth treatment club among young adults newly diagnosed with HIV in South Africa.

AIDS Care 2021 07 21;33(7):952-961. Epub 2020 Dec 21.

Harvard Medical School, Boston, MA, USA.

In South Africa, despite universal antiretroviral therapy (ART) availability, 60% of persons living with HIV (PLWH) ages 15-24 are not on treatment. This qualitative study aimed to identify barriers to ART initiation and the implications for a proposed community-based Youth Treatment Club to improve ART initiation for young PLWH in limited-resource, high HIV-prevalence communities in Cape Town, South Africa. Recruiting participants at community testing sites from 2018 to 2019, we conducted semi-structured interviews, informed by Social Action Theory (SAT), with 20 young adults, ages 18- to 24-years-old, newly diagnosed with HIV, along with 10 healthcare providers. Through systematic qualitative analysis, we found that young PLWH face barriers to treatment initiation in three SAT domains: (1) stigmatizing social norms (social regulation processes); (2) challenges coping with a new diagnosis (self-regulation processes); and (3) anticipated stigma in the clinic environment (contextual factors). Participants shared that a proposed community-based Youth Treatment Club for newly diagnosed youth would be an acceptable strategy to promote ART initiation. They emphasized that it should include supportive peers, trained facilitator support for counseling and education, and a youth-friendly environment.
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http://dx.doi.org/10.1080/09540121.2020.1861179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215080PMC
July 2021

The Treatment Ambassador Program: A Highly Acceptable and Feasible Community-Based Peer Intervention for South Africans Living with HIV Who Delay or Discontinue Antiretroviral Therapy.

AIDS Behav 2021 Apr 30;25(4):1129-1143. Epub 2020 Oct 30.

Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA.

We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, 3- and 6-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by 3 months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen's h = 0.41). Among those previously on ART (off for > 6 months), 33.3% initiated ART by 3 months in the intervention vs. 14.3% in the control arm (Cohen's h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART.
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http://dx.doi.org/10.1007/s10461-020-03063-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979476PMC
April 2021

Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind.

Curr HIV/AIDS Rep 2020 10;17(5):458-466

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Purpose Of Review: Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions.

Recent Findings: There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.
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http://dx.doi.org/10.1007/s11904-020-00522-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497373PMC
October 2020

Reckoning with mortality: global health, HIV, and the politics of data.

Lancet 2020 07 3;396(10246):288-290. Epub 2020 Jul 3.

Center for Innovation in Global Health, Georgetown University, Washington, DC, USA; School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

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http://dx.doi.org/10.1016/S0140-6736(20)31046-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333989PMC
July 2020

Transforming Global Health with AI.

N Engl J Med 2020 Feb;382(9):791-793

From Harvard Global Health Institute, Cambridge, and Harvard Medical School (M.C.M., I.T.K., A.K.J.), Partners Healthcare International (M.C.M.), Brigham and Women's Hospital (I.T.K.), and Harvard T.H. Chan School of Public Health (A.K.J.), Boston - all in Massachusetts.

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http://dx.doi.org/10.1056/NEJMp1912079DOI Listing
February 2020

Economic vulnerability and non-initiation of antiretroviral therapy in India: a qualitative study.

AIDS Care 2021 04 13;33(4):423-427. Epub 2020 Jan 13.

Harvard Medical School, Boston, USA.

In India, many people living with HIV (PLHIV) do not successfully initiate antiretroviral therapy (ART) after diagnosis. We conducted a clinic-based qualitative study at the Y.R. Gaitonde Centre for AIDS Research in Chennai, Tamil Nadu to explore factors that influence ART non-initiation. We interviewed 22 men and 15 women; median age was 42 (IQR, 36-48) and median CD4+ was 395 (IQR, 227-601). Participants were distrustful of HIV care freely available at nearby government facilities. Faced with the perceived need to access the private sector and therefore pay for medications and transportation costs, non-initiators with high CD4+ counts often decided to postpone ART until they experienced symptoms whereas non-initiators with low CD4+ counts often started ART but defaulted quickly after experiencing financial stressors or side effects. Improving perceptions of quality of care in the public sector, encouraging safe serostatus disclosure to facilitate stronger social support, and alleviating economic hardship may be important in encouraging ART initiation in India.
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http://dx.doi.org/10.1080/09540121.2020.1713973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354892PMC
April 2021

Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa.

Stigma Health 2019 Nov 28;4(4):433-441. Epub 2019 Jan 28.

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Background: HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction.

Methods: We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest.

Results: Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78).

Conclusions: Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.
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http://dx.doi.org/10.1037/sah0000159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884335PMC
November 2019

PrEParing to End the HIV Epidemic - California's Route as a Road Map for the United States.

N Engl J Med 2019 Dec 27;381(26):2489-2491. Epub 2019 Nov 27.

From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center (D.S.K.), Harvard Medical School (D.S.K., I.T.K., A.K.J.), Brigham and Women's Hospital (I.T.K.), and the Harvard T.H. Chan School of Public Health (A.K.J.) - all in Boston; the University of California San Francisco Center for Vulnerable Populations, San Francisco (D.S.K.); and the Harvard Global Health Institute, Cambridge, MA (I.T.K., A.K.J.).

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http://dx.doi.org/10.1056/NEJMp1912293DOI Listing
December 2019

Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study.

AIDS 2019 06;33 Suppl 1:S71-S79

Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA.

Objective: Failure to initiate antiretroviral therapy (ART) and achieve virologic suppression are significant barriers to the United Nations 90-90-90 goals. Identifying resilience resources, or modifiable strength-based factors, among people living with HIV is critical for successful HIV treatment and prevention.

Design: Prospective cohort study.

Methods: From July 2014 to July 2015, 500 adults presenting for voluntary counseling and HIV testing who were diagnosed with HIV and were ART-eligible in South Africa (Soweto and Gugulethu) were enrolled and surveyed. Logistic regression models assessed resilience-related predictors of ART initiation within 6 months of voluntary counseling and HIV testing for HIV, and HIV-1 plasma RNA suppression within 9 months, adjusting for sociodemographic factors.

Results: Within 6 months, 62% initiated ART, and within 9 months, 25% had evidence of an undetectable HIV-1 plasma RNA (<50 copies/ml). Participants who initiated ART relied less on social support from friends [adjusted odds ratio (aOR) 0.94, 95% confidence interval (CI): 0.89-0.99], coped using self-distraction (aOR 1.05, 95% CI: 1.00-1.10) and avoided coping through substance use (aOR 0.79, 95% CI: 0.65-0.97), as compared with participants who did not initiate ART. Those who achieved plasma RNA suppression relied more on social support from a significant other/partner (aOR 1.04, 95% CI: 1.02-1.07), used positive religious coping (aOR 1.03, 95% CI: 1.00-1.07), and were less likely to engage in denial coping (aOR 0.84, 95% CI: 0.77-0.92), compared with those who initiated ART but did not achieve plasma RNA suppression.

Conclusion: Interventions optimizing resilience resources and decreasing maladaptive coping strategies (e.g., substance use, denial) may present a feasible approach to maximizing ART-based HIV treatment strategies among South African people living with HIV.
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http://dx.doi.org/10.1097/QAD.0000000000002175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712569PMC
June 2019

Timing of Antiretroviral Therapy and Systemic Inflammation in Sub-Saharan Africa: Results From the META Longitudinal Cohort Study.

J Infect Dis 2019 08;220(7):1172-1177

Harvard Medical School, Boston.

Chronic inflammation predicts complications in persons with human immunodeficiency virus infection. We compared D-dimer, soluble CD14, and interleukin 6 levels before and 12 months after antiretroviral therapy (ART) initiation, among individuals starting ART during earlier-stage (CD4 T-cell count >350/µL) or late-stage disease (CD4 T-cell count <200/µL). Female sex, older age, viral load, and late-stage disease were associated with pre-ART biomarkers (n = 661; P < .05). However, there were no differences in biomarkers by disease stage after 12 months of ART (n = 438; P > .05), owing to loss from observation and greater declines in biomarkers in late-stage initiators (P < .001). Earlier initiation of ART is associated with decreased inflammation, but levels seem to converge between earlier and later initiators surviving to 12 months.
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http://dx.doi.org/10.1093/infdis/jiz259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6736121PMC
August 2019

Recreational ART use among individuals living with HIV/AIDS in South Africa: Examining longitudinal ART initiation and viral suppression.

Drug Alcohol Depend 2019 05 22;198:192-198. Epub 2019 Mar 22.

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA. Electronic address:

Background: South Africa has the highest number of people living with HIV (PLWH) and one of the largest antiretroviral therapy (ART) programs globally. High rates of substance use comorbidity exist, including speculation of recreational ART use (i.e., mixing ART with other illicit drugs). Recreational ART use may affect viral load among PLWH due to ART nonadherence and/or viral resistance; however, prior quantitative research has not examined rates of recreational ART use, nor associations with HIV treatment outcomes longitudinally.

Methods: Data were drawn from a prospective, observational cohort study (n = 500) of ART-eligible adults recruited from two HIV voluntary counseling and testing centers in Cape Town, and Johannesburg, South Africa. Multiple logistic regression models assessed recreational ART use as a predictor of ART initiation over six months and viral load suppression over nine months, above and beyond other substance use (binge drinking and illicit drug use).

Results: Approximately 5% (n = 24) reported recreational ART use, which was less frequent in Cape Town compared to Johannesburg (AOR = 0.025; 95%CI: 0.003-0.19; p < 0.001). Recreational ART use was not significantly associated with ART initiation or viral suppression. Other substance use, but not recreational ART use, was significantly associated with lower odds of ART initiation (AOR = 0.54; 95%CI: 0.33-0.87; p = .01) and viral suppression (AOR = 0.47; 95%CI: 0.25-0.89; p = .02).

Conclusions: Recreational ART use was infrequent and not uniquely associated with ART initiation or viral suppression. Findings suggest that comorbid use of other substances is ultimately what may make recreational ART use problematic for ongoing engagement in care and viral suppression.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6644059PMC
May 2019

ART adherence and viral suppression are high among most non-pregnant individuals with early-stage, asymptomatic HIV infection: an observational study from Uganda and South Africa.

J Int AIDS Soc 2019 02;22(2):e25232

Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA.

Introduction: The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS-free generation depend on high adherence in individuals initiating ART during early-stage HIV infection; however, adherence may be difficult in the absence of illness and associated support.

Methods: From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non-pregnant women with early-stage HIV infection (CD4 > 350 cells/μL), pregnant women with early-stage HIV infection and men and non-pregnant women with late-stage HIV infection (CD4 < 200 cells/μL). Socio-behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically.

Results: Adherence data were available for 869 participants: 322 (37%) early/non-pregnant, 199 (23%) early/pregnant and 348 (40%) late/non-pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non-pregnant versus early/pregnant or late/non-pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non-pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking.

Discussion: ART adherence among non-pregnant individuals with early-stage infection is as high or higher than with late-stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late-stage infection in South Africa and highlight the need for differentiated care delivery.
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http://dx.doi.org/10.1002/jia2.25232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371013PMC
February 2019

Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator.

J Int AIDS Soc 2018 10;21(10):e25198

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Introduction: Cross-sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV-1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations.

Methods: Longitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self-report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and HIV-1 RNA at nine months were extracted from the South Africa National Health Laboratory Service database. Two path analyses were estimated, one testing associations between internalized stigma, avoidant coping and ART initiation, and the other testing associations between internalized stigma, avoidant coping and HIV-1 RNA suppression.

Results: Participants were 36 years old, on average, and 63% identified as female, 18% as Zulu and 65% as Xhosa. The two path models fit the data well (ART initiation outcome: X (7) = 8.14, p = 0.32; root mean square error of approximation (RMSEA) = 0.02; comparative fit index (CFI) = 0.92; HIV-1 RNA suppression outcome: X (7)  = 6.58, p = 0.47; RMSEA = 0.00; CFI = 1.00). In both models, internalized stigma one week after diagnosis was associated with avoidant coping at three months, controlling for avoidant coping at one week. In turn, avoidant coping at three months was associated with lower likelihood of ART initiation at six months in the first model and lower likelihood of HIV-1 RNA suppression at nine months in the second model. Significant indirect effects were observed between internalized stigma with ART non-initiation and unsuppressed HIV-1 RNA via the mediator of avoidant coping.

Conclusions: Internalized stigma experienced soon after HIV diagnosis predicted lower likelihood of ART initiation and HIV-1 RNA suppression over the first year following HIV diagnosis. Avoidant coping played a role in these associations, suggesting that PLWH who internalize stigma engage in greater avoidant coping, which in turn worsens medication- and health-related outcomes. Interventions are needed to address internalized stigma and avoidant coping soon after HIV diagnosis to enhance treatment efforts during the first year after HIV diagnosis.
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http://dx.doi.org/10.1002/jia2.25198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6202800PMC
October 2018

Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries.

Soc Sci Med 2018 09 30;213:72-84. Epub 2018 May 30.

Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa; Africa Health Research Institute, KwaZulu-Natal, South Africa. Electronic address:

Background: Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation.

Methods: We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake.

Results: Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages.

Conclusions: Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.
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http://dx.doi.org/10.1016/j.socscimed.2018.05.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813776PMC
September 2018

Exploring Treatment Needs and Expectations for People Living with HIV in South Africa: A Qualitative Study.

AIDS Behav 2018 Aug;22(8):2543-2552

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

The UNAIDS 90-90-90 treatment targets aim to dramatically increase the number of people who initiate antiretroviral therapy (ART) by 2020. Greater understanding of barriers to ART initiation in high prevalence countries like South Africa is critical. Qualitative semi-structured interviews were conducted with 30 participants in Gugulethu Township, South Africa, including 10 healthcare providers and 20 people living with HIV (PLWH) who did not initiate ART. Interviews explored barriers to ART initiation and acceptability of theory-based intervention strategies to optimize ART initiation. An inductive content analytic approach was applied to the data. Consistent with the Theory of Triadic Influence, barriers to ART initiation were identified at the individual, social, and structural levels. Results suggested high acceptability for intervention strategies involving trained HIV-positive peers among South African PLWH and healthcare providers. Research is needed to evaluate their feasibility and efficacy in high HIV prevalence countries.
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http://dx.doi.org/10.1007/s10461-018-2101-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051887PMC
August 2018

The Global HIV Epidemic: What Will It Take to Get to the Finish Line?

JAMA 2018 03;319(11):1094-1095

ICAP at Columbia University, New York, New York.

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http://dx.doi.org/10.1001/jama.2018.2093DOI Listing
March 2018

Insurance status and cancer treatment mediate the association between race/ethnicity and cervical cancer survival.

PLoS One 2018 15;13(2):e0193047. Epub 2018 Feb 15.

Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America.

Cervical cancer outcomes remain poor among disadvantaged populations, including ethnic minorities, low-income, and underinsured women. The aim of this study was to evaluate the mechanisms that underlie the observed association between race/ethnicity and cervical cancer survival. We identified 13,698 women, ages 21 to 64 years, diagnosed with stages I-III primary cervical cancer between 2007-2013 in Surveillance, Epidemiology, and End Results (SEER). Multivariable Cox proportional hazards regression models evaluated associations between race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other) and cervical cancer-specific mortality. We conducted mediation analysis to calculate the mediation proportion and its 95% confidence interval. Non-Hispanic black women had an increased risk of cervical cancer-specific mortality (HR: 1.23, 95% CI: 1.08-1.39), and Hispanic women a decreased risk of dying from their disease (HR: 0.82, 95% CI: 0.72-0.93), compared with non-Hispanic white. The estimated proportion of excess cervical cancer mortality for non-Hispanic black women relative to non-Hispanic white women that was mediated by insurance was 18.6% and by treatment was 47.2%. Furthermore, non-Hispanic black women were more likely to receive radiation and less likely to receive surgery for early-stage disease. In this population-based study we found that some of the excess cervical cancer-specific mortality for non-Hispanic black women is mediated by factors such as insurance status and treatment. These findings suggest that enhancing existing insurance coverage and ensuring equal and adequate treatment in all women may be a key strategy for improving cervical cancer outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193047PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814056PMC
May 2018

Beyond Burnout - Redesigning Care to Restore Meaning and Sanity for Physicians.

N Engl J Med 2018 Jan;378(4):309-311

Drs. Wright and Katz are national correspondents for the Journal.

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http://dx.doi.org/10.1056/NEJMp1716845DOI Listing
January 2018

Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study.

PLoS Med 2017 Nov 14;14(11):e1002434. Epub 2017 Nov 14.

Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa.

Background: South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/μl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/μl.

Methods And Findings: We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28-41 years), almost 62% were female, and the median CD4+ count was 173 cells/μl (IQR 92-254 cells/μl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/μl versus 214 cells/μl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09-1.55). As such, it remains unclear if early attrition from care was due to a "healthy cohort" effect or to overcrowding as programs expanded to accommodate the broader guidelines for treatment. Our findings were limited by a lack of generalizability (given that these data were from a single high-volume site where testing and treatment were available) and an inability to formally investigate the effect of crowding on the main outcome.

Conclusions: Over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation, or early ART discontinuation. Those who started treatment in the later cohort appeared to be more likely to discontinue care early, and this outcome appeared to be independent of CD4+ count or WHO stage. Future interventions should focus on those most at risk for early loss from care as programs continue to expand in South Africa.
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http://dx.doi.org/10.1371/journal.pmed.1002434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685472PMC
November 2017

Effect of eliminating CD4-count thresholds on HIV treatment initiation in South Africa: An empirical modeling study.

PLoS One 2017 15;12(6):e0178249. Epub 2017 Jun 15.

Africa Health Research Institute, Somkhele and Durban, South Africa.

Background: The World Health Organization recommends initiating antiretroviral therapy (ART) regardless of CD4 count. We assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO's recommendations in South Africa.

Methods: We conducted an empirical analysis of cohort data using a regression discontinuity design, and then used this model for policy simulation. We enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. We estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds.

Findings: In 2013, 38.9% of patients diagnosed had a CD4 count ≥500. 8.0% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, we project that an additional 19.2% of patients with CD4 ≥500 would initiate ART; 72.8% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 26.7%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5.2% increase in patients receiving ART and 5.3% increase in programme costs.

Conclusions: Removing CD4 criteria alone will modestly increase timely uptake of ART. However, our results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0178249PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472329PMC
September 2017

Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave.

BMJ Glob Health 2016 24;1(3):e000004. Epub 2016 Oct 24.

Massachusetts General Hospital, Boston, Massachusetts, USA.

Context: South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression.

Objective: To determine the adolescent HIV continuum of care in South Africa.

Data Sources: We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015.

Data Extraction: We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15-24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression.

Results: Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed.

Limitations: This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents.

Conclusions: Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.
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http://dx.doi.org/10.1136/bmjgh-2015-000004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321340PMC
October 2016

Improved life expectancy of people living with HIV: who is left behind?

Lancet HIV 2017 08 10;4(8):e324-e326. Epub 2017 May 10.

Southern Africa Labour and Development Research Unit, University of Cape Town, South Africa.

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http://dx.doi.org/10.1016/S2352-3018(17)30086-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828160PMC
August 2017

Scientific Drought, Golden Eggs, and Global Leadership - Why Trump's NIH Funding Cuts Would Be a Disaster.

N Engl J Med 2017 05 29;376(18):1701-1704. Epub 2017 Mar 29.

From the Division of Women's Health, Brigham and Women's Hospital (I.T.K.), the Center for Global Health, Massachusetts General Hospital (I.T.K.), Harvard Medical School (I.T.K., A.A.W.), and the Dana-Farber Cancer Institute (A.A.W.) - all in Boston.

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http://dx.doi.org/10.1056/NEJMp1703734DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5529046PMC
May 2017

Variation in Human Papillomavirus Vaccine Uptake and Acceptability Between Female and Male Adolescents and Their Caregivers.

J Community Health 2017 Jun;42(3):522-532

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

HPV vaccination coverage is suboptimal. Previous research largely focused on vaccinating girls. This study aimed to identify factors associated with HPV vaccination among male and female adolescents. We conducted secondary analyses using the National Immunization Survey-Teen. We specified parallel logistic models to examine associations of adolescent, caregiver, and provider characteristics with vaccination status among boys and girls. The primary outcome was HPV vaccination status defined as unvaccinated, initiated, or completed. Additionally, we analyzed caregivers' intent to initiate or complete the three-dose series. The vaccination completion rate was 26 %. Among teens aged 13-17 years, 19 % initiated, but did not complete the vaccine. Additionally, 14 % of males completed the 3-dose series as compared to 38 % of females. Vaccination rates were higher among teens receiving a provider recommendation [girls: adjusted odds ratio (AOR) = 3.33, 95 % confidence interval (CI) (2.44, 4.55); boys: AOR = 10.0, 95 % CI (7.69, 12.5)]. Moreover, provider recommendation was associated with caregivers' intent to initiate vaccination [girls: AOR = 2.32, 95 % CI (1.77, 3.02); boys: AOR = 2.76, 95 % CI (2.22, 3.43)]. Other associations differed by gender. Higher vaccine initiation rates were associated with younger age and residing in the mid-west for girls and racial/ethnic minority and eligibility for the "Vaccine for Children" program for boys. Provider recommendation for vaccination was the strongest predictor for both genders; however, it is insufficient to achieve high coverage rates, especially among boys. Factors associated with HPV vaccination were different for males and females. These findings suggest providers should consider gender bias with regard to HPV vaccination.
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http://dx.doi.org/10.1007/s10900-016-0284-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403619PMC
June 2017

Barriers to HPV immunization among blacks and latinos: a qualitative analysis of caregivers, adolescents, and providers.

BMC Public Health 2016 08 25;16(1):874. Epub 2016 Aug 25.

Harvard Medical School, Boston, Massachusetts, USA.

Background: Despite recommendations that 11-12-year-olds receive the full three-shot Human papillomavirus (HPV) vaccine series, national HPV immunization coverage rates remain low. Disparities exist, with Blacks and Latinos being less likely than Whites to complete the series. We aimed to identify and compare barriers to HPV immunization perceived by healthcare providers, Black and Latino adolescents, and their caregivers to inform a clinic-based intervention to improve immunization rates.

Methods: We conducted semi-structured interviews between March and July 2014 with Black and Latino adolescents (n = 24), their caregivers (n = 24), and nurses (n = 18), and 2 focus groups with 18 physicians recruited from two pediatric primary care clinics. Qualitative protocol topics included: general perceptions and attitudes towards vaccines; HPV knowledge; and perceived individual and systems-level barriers affecting vaccine initiation and completion.

Results: Themes were identified and organized by individual and systems-level barriers to HPV immunization. Adolescents and their caregivers, particularly Blacks, expressed concerns about HPV being an untested, "newer" vaccine. All families felt they needed more information on HPV and found it difficult to return for multiple visits to complete the vaccine series. Providers focused on challenges related to administering multiple vaccines simultaneously, and perceptions of parental reluctance to discuss sexually transmitted infections.

Conclusions: Optimizing HPV immunization rates may benefit from a multi-pronged approach to holistically address provider, structural, and individual barriers to care. Further research should examine strategies for providing multiple modalities of support for providers, including a routinized system of vaccine promotion and delivery, and for addressing families' concerns about vaccine safety and efficacy.
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http://dx.doi.org/10.1186/s12889-016-3529-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997748PMC
August 2016

Medical mistrust in the context of Ebola: Implications for intended care-seeking and quarantine policy support in the United States.

J Health Psychol 2019 02 1;24(2):219-228. Epub 2016 Jun 1.

1 Harvard Medical School, USA.

This investigation explores Ebola conspiracy beliefs, a form of medical mistrust, and their potential impact on health behavior. Results of an online survey in the United States in December 2014 demonstrated that 16 percent of 202 participants held conspiracy beliefs. Participants who were less knowledgeable about Ebola, more mistrustful of medical organizations, and more xenophobic more strongly endorsed conspiracy beliefs. Participants who more strongly endorsed conspiracy beliefs reported that they would be less likely to seek care for Ebola and were less supportive of quarantining people returning from West Africa. Results suggest that medical mistrust may influence health behaviors during infectious disease outbreaks.
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http://dx.doi.org/10.1177/1359105316650507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526737PMC
February 2019

Cervical Abnormalities in South African Women Living With HIV With High Screening and Referral Rates.

J Glob Oncol 2016 Dec 4;2(6):375-380. Epub 2016 May 4.

and , Brigham and Women's Hospital; , , and , Harvard Medical School; , Massachusetts General Hospital Center for Global Health; , Boston Children's Hospital; , Dana-Farber Cancer Institute; , Boston University, Boston, MA; , University of KwaZulu-Natal, Durban; , Western Cape Province Department of Health, Cape Town; , R.K. Khan Hospital, Chatsworth, South Africa; and , Canadian Red Cross, Ontario, Canada.

Purpose: To determine the prevalence of screening, cervical dysplasia, and malignancy on the basis of histologic diagnoses from colposcopy and large loop excision of the transformation zone among women living with HIV (WLWH) who attended an urban antiretroviral treatment (ART) clinic in KwaZulu-Natal, South Africa.

Materials And Methods: We performed a retrospective cohort study to examine a random sample of 462 WLWH during a 5-year period from 2004 to 2009. Women on ART for < 3 months were excluded. Data were abstracted from electronic records and paper charts to assess rates of cervical abnormalities detected on Pap smears as well as time to colposcopy.

Results: During the study period, 432 women (93.5%) had at least one evaluable Papanicolau test. At baseline, 237 women (54.9%) had an abnormal Papanicolau test, and of these patients, 181 (76.3%) had a Papanicolau test that qualified for further colposcopic evaluation. In addition, 115 women (63.5%) received colposcopy within a median of 39 days from referral. This yielded 74 evaluable histologic samples (64.3%), of which 21.6%, 27.0%, 27.0%, and 1.4% had cervical intraepithelial neoplasia (CIN) 1, CIN2, CIN3, and invasive cervical cancer, respectively.

Conclusion: In a large sample of WLWH who received ART in KwaZulu-Natal, South Africa, where Papanicolau test coverage and rates of referral for colposcopy and large loop excision of the transformation zone were high, > 75% of women with evaluable histologic samples had evidence of cervical dysplasia or malignancy. These findings underscore the importance of routine cervical screening upon entry into HIV care to optimize survival.
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http://dx.doi.org/10.1200/JGO.2015.002469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493244PMC
December 2016

Psychosocial correlates of alcohol and other substance use among low-income adolescents in peri-urban Johannesburg, South Africa: A focus on gender differences.

J Health Psychol 2017 09 1;22(11):1415-1425. Epub 2016 Mar 1.

2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Alcohol and other drug use is prevalent among peri-urban, South African adolescents. We identified correlates of alcohol and other drug use by gender among adolescents (age = 16-18 years; N = 822) in peri-urban Johannesburg. Interviewer-administered surveys assessed sexual activity, alcohol and other drug use, and relevant psychosocial factors. In separate logistic regression models of alcohol and other drug use stratified by gender, violence exposure and sexual activity were associated with alcohol use for both males and females. For females only, depressive symptoms were associated with drug use. For males only, being older and sexually active were associated with drug use. Substance use interventions for South African adolescents should consider psychological health, sexual health, and tailoring by gender.
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http://dx.doi.org/10.1177/1359105316628739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237616PMC
September 2017
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