Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana

Author:

Martei Yehoda M1ORCID,Obasohan Modesty2,Mokokwe Lebogang34,Ralefala Tlotlo5,Mosepele Mosepele4,Gross Robert6,Barg Frances K7

Affiliation:

1. Department of Medicine (Hematology-Oncology), University of Pennsylvania , Philadelphia, PA , USA

2. Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA

3. Botswana University of Pennsylvania Partnership , Gaborone , Botswana

4. Faculty of Medicine, University of Botswana , Gaborone , Botswana

5. Princess Marina Hospital , Gaborone , Botswana

6. Department of Medicine (Infectious Diseases), University of Pennsylvania , Philadelphia, PA , USA

7. Department of Family Medicine and Community Health, University of Pennsylvania , Philadelphia, PA , USA

Abstract

Abstract Background Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer. Methods We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach. Results We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively. Conclusion We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.

Funder

National Institutes of Health

Publisher

Oxford University Press (OUP)

Subject

Cancer Research,Oncology

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