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Browsing by Author "McMahon, Devon E."
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Item Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi's sarcoma in Kenya: a qualitative study(Springer, 2022-07-06) McMahon, Devon E.; Singh , Rhea; Chemtai, Linda; Semeere, Aggrey; Byakwaga, Helen; Grant , Merridy; Laker-Oketta , Miriam; Lagat, Celestine; Collier , Sigrid; Maurer , Toby; Martin , Jeffrey; Bassett , Ingrid V.; Butler , Lisa; Kiprono , Samson; Busakhala , Naftali; Freeman, Esther E.; Dermatology, School of MedicineBackground Kaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal. Methods 57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care. Results Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy. Conclusion Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.Item Beyond T Staging in the “Treat All” Era: Severity and Heterogeneity of Kaposi’s Sarcoma in East Africa(Wolters Kluwer, 2021) Freeman, Esther E.; Semeere, Aggrey; McMahon, Devon E.; Byakwaga, Helen; Laker-Oketta, Miriam; Regan, Susan; Wenger, Megan; Kasozi, Charles; Semakadde, Matthew; Bwana, Mwebesa; Kanyesigye, Michael; Kadama-Makanga, Philippa; Rotich, Elyne; Kisuya, Job; Wools-Kaloustian, Kara; Bassett, Ingrid V.; Busakhala, Naftali; Martin, Jeffrey; Medicine, School of MedicineBackground: Although many patients with Kaposi sarcoma (KS) in sub-Saharan Africa are diagnosed with AIDS Clinical Trials Group (ACTG) T1 disease, T1 staging insufficiently captures clinical heterogeneity of advanced KS. Using a representative community-based sample, we detailed disease severity at diagnosis to inform KS staging and treatment in sub-Saharan Africa. Methods: We performed rapid case ascertainment on people living with HIV, aged 18 years or older, newly diagnosed with KS from 2016 to 2019 at 3 clinic sites in Kenya and Uganda to ascertain disease stage as close as possible to diagnosis. We reported KS severity using ACTG and WHO staging criteria and detailed measurements that are not captured in the current staging systems. Results: We performed rapid case ascertainment within 1 month for 241 adults newly diagnosed with KS out of 389 adult patients with suspected KS. The study was 68% men with median age 35 years and median CD4 count 239. Most of the patients had advanced disease, with 82% qualifying as ACTG T1 and 64% as WHO severe/symptomatic KS. The most common ACTG T1 qualifiers were edema (79%), tumor-associated ulceration (24%), extensive oral KS (9%), pulmonary KS (7%), and gastrointestinal KS (4%). There was marked heterogeneity within T1 KS, with 25% of patients having 2 T1 qualifying symptoms and 3% having 3 or more. Conclusion: Most of the patients newly diagnosed with KS had advanced stage disease, even in the current antiretroviral therapy "treat-all" era. We observed great clinical heterogeneity among advanced stage patients, leading to questions about whether all patients with advanced KS require the same treatment strategy.Item Identifying Gaps in Global Health Dermatology: A Survey of GLODERM Members(Oxford University Press, 2021) McMahon, Devon E.; Oyesiku, Linda; Amerson, Erin; Beltraminelli, Helmut; Chang, Aileen Y.; Forrestel, Amy; Hay, Roderick; Knapp, Alexia; Kovarik, Carrie; Maurer, Toby; Norton, Scott A.; Rehmus, Wingfield; Van Hees, Colette; Wanat, Karolyn A.; Williams, Victoria L.; Fuller, L. Claire; Freeman, Esther E.; Dermatology, School of MedicineItem The role of dermatology in Kaposi sarcoma diagnosis across three regions in sub-Saharan Africa(Elsevier, 2020) Seth, Divya; Williams, Victoria L.; McMahon, Devon E.; Regan, Susan; Busakhala, Naftali; Wools-Kaloustian, Kara; Mosoajane, Karen; Ralefala, Tlotlo B.; Kayembe, Mukendi; Iregbu, Kenneth; Kwaghe, Vivian; Jedy-Agba, Elima; Oyesiku, Linda; Maurer, Toby; Jaquet, Antoine; Bassett, Ingrid V.; Martin, Jeff; Grover, Surbhi; Freeman, Esther E.; Medicine, School of MedicineItem Telling the story of intersectional stigma in HIV-associated Kaposi's sarcoma in western Kenya: a convergent mixed-methods approach(Wiley, 2022) Collier, Sigrid; Singh, Rhea; Semeere, Aggrey; Byakwaga, Helen; Laker-Oketta, Miriam; McMahon, Devon E.; Chemtai, Linda; Grant, Merridy; Butler, Lisa; Bogart, Laura; Bassett, Ingrid V.; Kiprono, Samson; Maurer, Toby; Martin, Jeffrey; Busakhala, Naftali; Freeman, Esther E.; Dermatology, School of MedicineIntroduction: The experience of stigma can be multifaceted for people with HIV and cancer. Kaposi's sarcoma (KS), one of the most common HIV-associated cancers in sub-Saharan Africa, often presents with visible skin lesions that may put people at risk for stigmatization. In this way, HIV-associated KS is unique, as people with KS can experience stigma associated with HIV, cancer, and skin disease simultaneously. The aim of this study is to characterize the intersectionality of HIV-related, cancer-related and skin disease-related stigma in people living with HIV and KS. Methods: We used a convergent mixed-methods approach nested within a longitudinal study of people with HIV-associated KS in western Kenya. Between February 2019 and December 2020, we collected quantitative surveys among all participants and conducted semi-structured interviews among a purposive sample of participants. Quantitative surveys were adapted from the abridged Berger HIV Stigma Scale to assess overall stigma, HIV-related stigma, cancer-related stigma, and skin disease-related stigma. Qualitative data were coded using stigma constructs from the Health Stigma and Discrimination Framework. Results: In 88 semi-structured interviews, stigma was a major barrier to KS diagnosis and treatment among people with HIV-associated KS. Participant's stories of stigma were dominated by HIV-related stigma, more than cancer-related or skin disease-related stigma. However, quantitative stigma scores among the 117 participants were similar for HIV-related (Median: 28.00; IQR: 28.0, 34.0), cancer-related (Median: 28.0; IQR: 28.0, 34.8), and skin disease-related stigma (Median: 28.0; IQR: 27.0, 34.0). In semi-structured interviews, cancer-related and skin disease-related stigma were more subtle contributors; cancer-related stigma was linked to fatalism and skin-related stigma was linked to visible disease. Participants reported resolution of skin lesions contributed to lessening stigma over time; there was a significant decline in quantitative scores of overall stigma in time since KS diagnosis (adjusted β = -0.15, p <0.001). Conclusions: This study highlights the role mixed-method approaches can play in better understanding stigma in people living with both HIV and cancer. While HIV-related stigma may dominate perceptions of stigma among people with KS in Kenya, intersectional experiences of stigma may be subtle, and quantitative evaluation alone may be insufficient to understand intersectional stigma in certain contexts.Item Understanding Diagnostic Delays for Kaposi Sarcoma in Kenya: A Qualitative Study(Wolters Kluwer, 2022-08-15) McMahon, Devon E.; Chemtai, Linda; Grant, Merridy; Singh, Rhea; Semeere, Aggrey; Byakwaga, Helen; Laker-Oketta, Miriam; Maurer, Toby; Busakhala, Naftali; Martin, Jeffrey; Bassett, Ingrid V.; Butler, Lisa; Freeman, Esther E.; Dermatology, School of MedicineBackground: Although HIV-associated Kaposi sarcoma (KS) is frequently diagnosed at an advanced stage in sub-Saharan Africa, reasons for diagnostic delays have not been well described. Methods: We enrolled patients >18 years with newly diagnosed KS between 2016–2019 into the parent study, based in Western Kenya. We then purposively selected 30 participants with diversity of disease severity and geographic locations to participate in semi-structured interviews. We employed two behavioral models in developing the codebook for this analysis: situated Information, Motivation and Behavior (sIMB) framework and Andersen model of total patient delay. We then analyzed the interviews using framework analysis. Results: The most common patient factors that delayed diagnosis were lack of KS awareness, seeking traditional treatments, lack of personal efficacy, lack of social support, and fear of cancer, skin biopsy, amputation, and HIV diagnosis. Health system factors that delayed diagnosis included prior negative healthcare interactions, incorrect diagnoses, lack of physical exam, delayed referral, and lack of tissue biopsy availability. Financial constraints were prominent barriers for patients to access and receive care. Facilitators for diagnosis included being part of an HIV care network, living near health facilities, trust in the healthcare system, desire to treat painful or disfiguring lesions, and social support. Conclusion: Lack of KS awareness among patients and providers, stigma surrounding diagnoses, and health system referral delays were barriers in reaching KS diagnosis. Improved public health campaigns, increased availability of biopsy and pathology facilities, and health provider training about KS are needed to improve early diagnosis of KS.