Date of Award

9-8-2008

Document Type

Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Kaveh Khoshnood

Abstract

Injection drug users (IDUs) account for an estimated 44% of people living with HIV/AIDS in China and are the major driving force behind the expanding epidemic. Developing effective antiretroviral therapy (ART) adherence interventions in the Chinese IDU population is a major challenge. In conjunction with ART scale-up in Yunnan province, our goal was to gather patient perspectives on ART and ideas for feasible adherence support. Between December 2005 and March 2006, eight focus groups with a total of 55 HIV positive IDUs were conducted at three sites in Yunnan to ascertain ART knowledge, barriers to adherence, and acceptable adherence support methods. Focus groups included ART experienced and naïve participants, and HIV positive IDUs in methadone maintenance clinics. Discussions were audiotaped, notes were transcribed and coded for analyses. All participants were former or current IDUs and 31 were from the rural countryside (59.6%), and 19 (36.5%) resided in a small city. ART was viewed positively but the principal barriers for urban IDUs were stigma and discrimination, while geography was the main problem for rural IDUs. Major themes were stratified between four components: knowledge, motivation, cues to action, and access to care. Adherence tools that were spontaneously endorsed included watches, pill boxes, and diaries. Directly observed therapy (DOT) within methadone programs was acceptable but community-based DOT would need to address stigma issues in urban areas. Two separate HIV epidemics exist within IDUs in China, stratified between small-city urban and rural populations. No single model for adherence will work and interventions must be broad-based. This study provides an expanded conceptual framework for ART adherence in the HIV positive IDU population, which includes the unique barriers posed by the ecological context surrounding this doubly-discriminated population.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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