Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey

Characterizing the HIV care continuum among children and adolescents with HIV in eastern and southern Africa in the era of "Universal Test and Treat": A systematic review and meta-analysis

INTRODUCTION

The "Universal Test and Treat" (UTT) era for antiretroviral therapy (ART) increased HIV service delivery to children and adolescents aged 0-19 with HIV. The goal is to reach ≥95% of people with HIV diagnosed, receiving ART and virally suppressed. We conducted a systematic review and meta-analysis to describe the care continuum among children and adolescents with HIV during the UTT era in the UNAIDS eastern and southern African region.

METHODS

We searched PubMed, EMBASE and African Index Medicus databases for peer-reviewed articles published from 1 January 2010 to 1 June 2023. We included studies reporting ≥1 care continuum proportion in ≥1 country in the study region during the country's UTT implementation. We extracted summary proportions and pooled them using random-effects logistic regression.

RESULTS

Of 10,281 studies screened, 190 met the inclusion criteria. Studies came from 16 countries; many from South Africa (n = 37) and Ethiopia (n = 32). The meta-analysis pooled proportions (95% confidence intervals) for children aged 0-14 were: 72% (60%, 81%) aware of HIV diagnosis; 95% (89%, 97%) on ART among diagnosed; 88% (76%, 95%) retained in HIV care after 12 months on ART; 77% (68%, 84%) self-/caregiver-reported ART adherence; 90% (79%, 95%) had a viral load test after ART initiation; and 76% (72%, 79%) viral suppression (<1000 copies/ml) while on ART with a viral load test. Similar proportions were estimated among adolescents aged 15-19: 73% (66%, 79%) diagnosed; 93% (92%, 94%) on ART; 80% (54%, 93%) retained; 74% (63%, 83%) adherent; 90% (79%, 95%) viral load test; and 78% (74%, 81%) viral suppression.

DISCUSSION

Estimates from this study on diagnosis, ART initiation and viral suppression were consistent with UNAIDS official estimates. Estimates on retention, adherence and viral suppression were similar to previous meta-analyses conducted before UTT.

CONCLUSIONS

Consistent with UTT expectations, most children and adolescents with HIV in eastern and southern Africa have initiated ART, but challenges remain on other care continuum indicators. Future planning for HIV programmes should consider locally informed, community-supported approaches to consistently support children and adolescents with HIV throughout the HIV care continuum.

Achieving the fast track 90-90-90 and 95-95-95 targets in sub-Saharan Africa: A rapid review

Background

The Joint United Nations Programme on HIV/AIDS (UNAIDS) set targets for 95% of people living with human immunodeficiency virus (HIV) infection to know their status, 95% to receive antiretroviral therapy (ART) and 95% to achieve viral suppression. These targets mirror the 90-90-90 targets that were aimed to be met by 2020 to end AIDS as a public health threat by 2030.

Aim

The study aims to synthesise evidence on recommendations, best practices and challenges in achieving 90-90-90 escalated to 95-95-95 fast-track targets in sub-Saharan Africa.

Setting

The review included empirical evidence from sub-Saharan Africa.

Method

We followed Arksey and O'Malley's methodological framework for this scoping review. A systematic search of relevant articles was conducted using electronic databases such as Scopus, EBSCOHost, PubMed, Science Direct and Sabinet. The results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Results

There were 6943 relevant study titles that were identified from the five databases. Following duplicates removal, title and abstract screening, 31 articles were included for full-text review. A combination of qualitative, quantitative and mixed methods studies were included.

Conclusion

The 90-90-90 targets have been achieved in part, but challenges remain, particularly for key and vulnerable populations. Even as successes and challenges towards '90-90-90 by 2020' are outlined, new fast-track '95-95-95 by 2030' targets have been established because of concerns that the original targets may not have achieved epidemic control.

Contribution

The findings of this review have implications for policy and practice related to interventions to facilitate the realisation of HIV epidemic control as outlined by the UNAIDS 95-95-95 treatment cascade.

Outcomes of Loop Electrosurgical Excision Procedures Performed for Severe Cervical Dysplasia in Botswana

PURPOSE

In Botswana, a see-and-treat approach to cervical cancer screening is taken. Our objective was to determine the number of loop electrosurgical excision procedures (LEEPs) performed for cervical intraepithelial neoplasia (CIN) 2/3 in Botswana, and follow-up rates and outcomes, among women with positive cervical margins.

METHODS

Data (patient age, HIV status, margin status, follow-up, and recurrence) from women who underwent LEEP with histologically confirmed CIN 2/3 between January 2014 and December 2015 were analyzed retrospectively. Histopathologic reports were reviewed at a central laboratory in Gaborone, Botswana. Follow-up and recurrence rates were summarized descriptively and compared according to HIV and margin statuses using chi-squared tests.

RESULTS

In total, 779 women (median age, 39.2 years) underwent LEEP showing CIN2/3; 638 (81.9%) women had CIN3 and 390 (50.1%) had positive LEEP margins (ectocervical, 186 [47.7%]; endocervical [including with ectocervical], 204 [52.4%]). Margin positivity was not associated with HIV status. Of women with positive endocervical margins followed at ≤1 and >1 year, 9.6% and 48.3%, respectively, had persistent CIN2/3 on repeat LEEP. Forty percent (90 of 204) of women with positive endocervical margins had no re-excision documented.

CONCLUSION

Most women who underwent LEEP had CIN3 and positive margins. Almost half with positive margins followed at >1 year after initial LEEP had CIN2/3 recurrence warranting further treatment; two thirds were not followed. Resources are needed to improve post-LEEP follow-up for women with margin positivity who require additional ablative/excisional procedures to reduce the cervical cancer burden in Botswana.

Community health workers' knowledge of Ubuntu informed care in tuberculosis, HIV, and AIDS in Gauteng province

BACKGROUND

 Community health workers (CHWs) work with community members who experience various health problems. They assist community members to lead a healthy life and achieve an acceptable health status. To achieve this, there is a need for CHWs to apply Ubuntu philosophy when providing care related tuberculosis (TB), Human Immunodeficiency Virus (HIV), and acquired immunodeficiency syndrome (AIDS).

OBJECTIVES

 The aim of this study was to assess CHW's knowledge of Ubuntu-informed Care in tuberculosis, HIV, and AIDS Services in Gauteng province, South Africa.

METHOD

 A total of 380 CHWs were recruited from a district in Gauteng province to participate in a training on the management of TB, HIV and AIDS. A questionnaire with 40 multiple choice questions was administered to the CHWs before the training. SPSS version 28 was used to analyse the data.

RESULTS

 The scores ranged from 9 to 33 out of 40 (M = 21.6, s.d. = 4.2). Out of the 380 participants, 274 (72.1%) passed the pretest while 106 participants (27.9%) failed. The highest mean scores were achieved by female participants (M = 21.6, s.d. = 4.3), participants aged 21-30 years (M = 21.8, s.d. = 4.1) and participants with additional course qualification after Grade 12 (M = 23.5, s.d. = 3.4).

CONCLUSION

 The findings highlight the need for targeted training interventions to improve the knowledge of CHWs on TB, HIV and AIDS.Contribution: This study adds to the literature on the need for inclusion of Ubuntu when caring for people living with HIV and TB.

Family Social Support Mediates the Relationship Between the COVID-19 Pandemic and Psychosocial well-being in a Cohort of Young South Africans Newly Diagnosed with HIV

Poor psychosocial well-being, including depression, anxiety, low self-esteem, and high anticipated stigma, complicates young South Africans' engagement with HIV care. During the COVID-19 pandemic, the psychosocial well-being of young South Africans with HIV may have been impacted by changing levels of social support. This analysis sought to examine whether social support mediates the relationship between the pandemic and psychosocial well-being in young South Africans with HIV. This secondary analysis compared baseline data from two cohorts of young people ages 18-24 who tested HIV positive either before or during South Africa's COVID-19 State of Disaster. Baseline sociodemographic, social support-related, and psychosocial data were analyzed using linear regression and mediation analyses. We found that self-esteem was higher (χ2 = 9.955, p < 0.01) and anticipated stigma (χ2 = 22.756, p < 0.001) was lower in the cohort recruited during the pandemic. Perceived family social support was higher in the cohort recruited during the COVID-19 pandemic (χ2 = 38.69, p < 0.001). Family social support partially mediated the relationship between study cohort and self-esteem (Sobel z=-3.04, p = 0.002), family- (Sobel z=-4.06, p < 0.001) and community-type (Sobel z =-3.44, p < 0.001) anticipated stigma, and depressive symptoms (Sobel z =-2.80, p = 0.005). Overall, compared to young people diagnosed with HIV before the pandemic, young people diagnosed during the pandemic reported higher self-esteem and lower anticipated stigma, an effect mediated by higher levels of family social support. Our findings add to the literature examining young people's psychosocial well-being during the COVID-19 pandemic and suggests that improvements in family support may have broadly positive effects on multiple indicators of psychosocial well-being.

Lesotho's progress towards UNAIDS 95-95-95 targets from 2016 to 2020: comparison of Population-based HIV Impact Assessments

BACKGROUND

Lesotho has made substantial efforts to control its HIV epidemic. We aimed to assess progress towards UNAIDS 95-95-95 targets in Lesotho by comparing data from the Lesotho Population-based HIV Impact Assessments conducted in 2016-17 (LePHIA 2016) and 2019-20 (LePHIA 2020).

METHODS

The LePHIA surveys used a cross-sectional, two-stage, stratified cluster sampling design to obtain a nationally representative sample of adults aged 15-59 years (LePHIA 2016) or aged 15 years and older (LePHIA 2020) from all ten districts of Lesotho. From November, 2016 to May, 2017 (LePHIA 2016) and from December, 2019 to March, 2020 (LePHIA 2020), consenting participants from randomly selected households provided demographic and clinical information and blood samples for household HIV testing according to national guidelines. HIV-reactive test results were confirmed by a laboratory assay. We estimated HIV status awareness and antiretroviral therapy (ART) use on the basis of self-reports or detection of antiretroviral drugs in blood samples. Viral load suppression was defined as HIV-1 RNA less than 1000 copies per mL. We applied Poisson regression models using survey weights and estimated variances using the Taylor series linearisation approach.

FINDINGS

11 682 participants were enrolled in LePHIA 2016 and 12 718 participants were enrolled in LePHIA 2020. Overall HIV incidence decreased significantly from 1·10% (95% CI 0·68-1·52) in 2016 to 0·50% (0·26-0·74) in 2020 (p=0·026). Among adults who tested positive for HIV, awareness of HIV status improved from 81·0% (79·6-82·3) in 2016 to 89·6% (88·3-90·8) in 2020 (p<0·0001). Furthermore, between the two surveys, the proportion on ART among those aware of their HIV status increased from 91·8% (90·5-93·0) to 96·9% (95·9-97·6; p<0·0001) and the prevalence of viral load suppression among those on ART increased from 87·7% (86·1-89·1) to 90·8% (89·5-91·9; p<0·0020). After adjusting for demographic covariates, adults living with HIV were significantly more likely in 2020 than in 2016 to know their HIV status (adjusted prevalence ratio 1·09, 95% CI 1·07-1·12, p<0·0001), to be on ART if aware of their status (1·05, 1·03-1·07, p<0·0001), and to be virally suppressed if on ART (1·03, 1·01-1·06, p=0·0045).

INTERPRETATION

Between 2016 and 2020, Lesotho made significant progress towards the UNAIDS 95-95-95 targets, surpassing the second target (ART coverage) and showing improvements in HIV status awareness and viral load suppression (the first and third targets) as well as declines in HIV prevalence and incidence. Lesotho's experience provides valuable insights for other countries working to control their HIV epidemics.

FUNDING

The US President's Emergency Plan for AIDS Relief.

Leadership, cohesion, and stress in primary care facilities and retention in chronic care in rural northeast South Africa before and during the COVID-19 pandemic: A longitudinal study

Background

Human immunodeficiency virus (HIV) and hypertension are major contributors to morbidity and mortality in South Africa. Effective management of these conditions is critical to population health, yet patient management and retention varies by facility for reasons that are not fully understood. We assessed whether measures of clinic leadership, cohesion, and stress were associated with retention for HIV and hypertension in a cohort of patients in northeast South Africa before and during the Coronavirus disease 2019 pandemic.

Methods

We quantified nursing capacity and service readiness within primary health care facilities in the Bushbuckridge sub-district in Mpumalanga province South Africa. We administered brief scales on facility leadership, cohesion, and stress from January to March 2019, and tested scales for individual and facility-level agreement. We extracted clinical records for patients with HIV and/or hypertension from 2019 to 2021 and quantified treatment retention by quarter. We used generalised estimating equations to assess individual and clinic factors associated with retention in each treatment programme prior to (2019-first quarter 2020) and during (second quarter 2020-2021) the pandemic.

Results

The nine facilities had a median of 12 nurses on staff and scored 0.83 out of 1.0 on basic service readiness. We collected responses to leadership, cohesion, and stress scales from 54 nurses and counsellors. Scales showed high inter-item agreement and moderate within-facility agreement. From 2019 to 2021, 19 445 individuals were treated for HIV and/or hypertension across seven participating facilities. Two-year retention was 91% for those with both conditions, 82% for those in treatment for HIV alone and 77% for those in treatment for hypertension alone, with 10-15% differences between facilities and high retention during the pandemic period. In addition to those with both conditions, women and adults aged 60-69 were more likely to be retained. Clinic factors were inconsistently associated with patient retention.

Conclusions

While measures of clinic leadership, cohesion, and stress were generally reliable at individual and facility levels, we found limited evidence supporting a link between these factors and better retention in care. Retention was stable during the Coronavirus disease 2019 pandemic. Men, the youngest and oldest adults, and those without known multimorbidity should be prioritised for retention interventions.

Comparison of a novel expanded social network recruitment intervention with risk network recruitment to HIV testing: locating undiagnosed cases in South Africa

OBJECTIVE

To ascertain whether a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention recruits men and individuals with previously undiagnosed HIV at higher rates than risk network recruitment.

DESIGN

Initial "seed" participants were prospectively randomly assigned to the E-SNRHT intervention or to risk network recruitment. Their network members were included in the study arm of their recruiter.

SETTING

Three Department of Health clinics and two drug treatment centers (DTCs) in the Msunduzi municipality of KwaZulu-Natal, South Africa.

PARTICIPANTS

Clinics and DTCs referred 110 newly HIV-diagnosed adult "seeds" to the study from June 2022 to February 2023. E-SNRHT seeds were asked to recruit network members as described below; risk network recruitment arm seeds were asked to recruit recent sex and/or injection partners. Presenting a recruitment coupon (from clinic/DTC staff or another participant) was required for eligibility.

INTERVENTION

E-SNRHT seeds were shown educational material about HIV transmission risks and then asked to recruit anyone they know (e.g., friends, family) whom they thought could benefit from HIV testing.

MAIN OUTCOME MEASURES

Rates of recruiting men to HIV testing and locating individuals with previously undiagnosed HIV.

RESULTS

E-SNRHT recruited significantly higher proportions of men to HIV testing (70.3 vs. 40.4%; χ2  = 16.33; P  < 0.0005) and located significantly more previously undiagnosed cases of HIV per seed than risk network recruitment (rate ratio = 9.40; P  < 0.0001). E-SNRHT also recruited significantly higher proportions of women with previously undiagnosed HIV (29.0 vs. 10.7%; χ2  = 3.87; P  = 0.049).

CONCLUSION

E-SNRHT is an important strategy to expand the reach of HIV testing among men and undiagnosed cases of HIV in KwaZulu-Natal.

Relationship between social capital and post-partum antiretroviral therapy adherence among women living with HIV in the Eastern Cape, South Africa

BACKGROUND

Adherence to antiretroviral therapy (ART) is crucial for preventing vertical transmission of HIV and maternal deaths. While the literature is replete with studies on ART adherence, the role of social capital in adherence to ART is less studied. Drawing from the social cognitive theory, this study examines the relationship between social capital and post-partum adherence to ART.

METHODS

We analysed data from 481 post-partum women with HIV in the Eastern Cape, South Africa. Adherence to ART was measured using a validated scale, capturing self-reported medication-taking behaviours. Social capital was assessed using a pre-validated tool, encompassing indicators of social engagement, support networks and community connectedness. We used logistic regression models to examine social capital and ART adherence associations, while controlling for relevant covariates.

RESULTS

Participants mean age was 32.9 (SD ± 5.76) years. After adjusting for age, education level, alcohol use, status disclosure to partner, marital status, desire for more children, employment status and living arrangements, social capital was significantly associated with higher odds of ART adherence (p = 0.004, AOR 1.09; 95% CI 1.03-1.16).

CONCLUSION

We found evidence in support of the role of social capital in ART adherence. Strengthening social support networks and addressing psychosocial factors could improve adherence to ART. As such, policymakers and programme managers should consider the role of social capital in designing interventions to improve ART adherence. Future research should explore the mechanisms through which social capital impacts ART adherence.

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis

PURPOSE

Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs.

METHODS

This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status.

RESULTS

A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72 h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs.

CONCLUSION

The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Changes in Stigma and Social Support among Participants in a Randomized Trial of a Novel Expanded Social Network-based HIV Testing Intervention in KwaZulu-Natal, South Africa

HIV-related stigma is a well-documented barrier to HIV testing in South Africa, and may be particularly likely to create reluctance to test among South African men, who have reported feeling blamed for HIV by their partners and communities. The present study presents a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention explicitly designed to reduce stigma as a barrier to testing by asking people to recruit anyone they know to testing, thus allowing them to avoid the potential for increased stigma and/or blame associated with direct risk partner recruitment, and helping to normalize openly discussing HIV among social networks. We examined baseline and 6-10-week follow-up data from a 2022-2023 randomized trial in KwaZulu-Natal, South Africa that recruited 110 individuals who had been newly diagnosed with HIV and randomly assigned them to recruit people to HIV testing either via the E-SNRHT intervention or via risk network recruitment. Participants in the E-SNRHT intervention reported significant decreases in anticipated and enacted HIV-related stigma between baseline and follow-up; and the E-SNRHT intervention was more effective at decreasing enacted HIV-related stigma than was risk network recruitment. Individuals newly diagnosed with HIV by the E-SNRHT intervention reported significant increases in social support between intervention enrollment and follow-up, and all of these individuals reported participating in positive conversations about HIV services with peers in the 6-10 weeks after intervention enrollment. These findings suggest that E-SNRHT is a potentially important strategy to reduce HIV-related stigma as a barrier to HIV testing among peer networks in KwaZulu-Natal.

The HIV Care Cascade for Older Adults in Rural South Africa: A Longitudinal Cohort Study (2014-2019)

BACKGROUND

As people with HIV grow older, stable engagement in care is essential for healthy aging. We evaluate the HIV care cascade for older adults in rural South Africa at 2 time points cross-sectionally and assess movement in the cascade over time.

SETTING

We evaluated the cascade stage at waves 1 (2014-2015) and 2 (2018-2019) of Health and Aging in Africa: A Longitudinal Study of an INDPETH Community in South Africa, a population-based longitudinal cohort study in Mpumalanga Province, South Africa.

METHODS

Biomarker screening defined cascade stages [HIV+/no antiretroviral therapy (ART); ART+/unsuppressed viral load; ART+/suppressed viral load]. Between-wave probability of death, cascade progression, regression, cascade transitions, and sociodemographic predictors were assessed with Poisson regression. The impact of death was considered using the Fine and Gray competing risk model.

RESULTS

We observed a higher prevalence of antiretroviral therapy with viral suppression over time (50% in wave 1 vs. 70% in wave 2). Among those alive, the oldest age group (70+ years old) was most likely to have cascade progression [adjusted risk ratio for treatment initiation vs. 40-49 years old: 1.38 (95% confidence interval: 1.02 to 1.86)]. However, there was a significant risk of death and cascade regression. Death between waves reached 40% for 70+-year-olds who were ART+/unsuppressed. In competing risk models, older age was associated with equivalent or less cascade progression.

CONCLUSION

Older age groups who were unsuppressed on treatment and men had poorer cascade outcomes. Improvements observed in HIV treatment coverage over time for older adults must be interpreted in the context of the high risk of death for older HIV-positive adults, especially among those failing treatment.

A multidisciplinary approach for people with HIV failing antiretroviral therapy in South Africa

Background

South Africa (SA) has the largest antiretroviral therapy (ART) programme worldwide. Multiple factors contribute to virological failure (VF), including poor adherence and viral resistance mutations. A multidisciplinary team (MDT) clinic dedicated to those with VF may be of benefit; however, very little data from SA exist.

Objectives

To assess whether an MDT approach achieved virological suppression (VS) in patients failing second-line-ART (2LART); assess the number of MDT sessions required to achieve VS; assess local resistance mutation patterns and whether the MDT reduced the number of genotypic resistance testing (GRT) required.

Method

An observational, retrospective, cross-sectional chart review study was conducted between January 2018 and December 2019 at a Target High Viral Load (VL) MDT clinic in KwaZulu-Natal, SA.

Results

Ninety-seven medical records were eligible. Women accounted for 63% of patients, with a mean age of 37 years. A significant reduction in the first VL measurement following the MDT was seen (median reduction 2374 c/mL; P < 0.001). This was maintained at the second VL measurement post-MDT (median reduction 2957 c/mL; P < 0.001). Patients attended a mean of 2.71 MDT sessions and 73.2% achieved VS, resulting in 61.86% fewer GRTs required. Of the GRTs performed, nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitor-related mutations were noted most frequently.

Conclusion

The MDT approach resulted in a significant reduction in VL, with most participants achieving VS. The MDT was successful in reducing the need for GRT. Resistance mutations were similar to those found in other studies conducted across SA.

The effect of care interruptions on mortality in adults resuming antiretroviral therapy

OBJECTIVE

To estimate the relative rate of all-cause mortality amongst those on antiretroviral treatment (ART) with a history of interruptions compared with those with no previous interruptions in care.

DESIGN

Retrospective cohort study.

METHODS

We used data from four South African cohorts participating in the International epidemiology Databases to Evaluate AIDS Southern Africa collaboration. We included adults who started ART between 2004 and 2019. We defined a care interruption as a gap in contact longer than 180 days. Observation time prior to interruption was allocated to a 'no interruption' group. Observation time after interruption was allocated to one of two groups based on whether the first interruption started before 6 months of ART ('early interruption') or later ('late interruption'). We used Cox regression to estimate hazard ratios.

RESULTS

Sixty-three thousand six hundred and ninety-two participants contributed 162 916 person-years of observation. There were 3469 deaths. Most participants were female individuals (67.4%) and the median age at ART initiation was 33.3 years (interquartile range: 27.5-40.7). Seventeen thousand and eleven (26.7%) participants experienced care interruptions. Those resuming ART experienced increased mortality compared with those with no interruptions: early interrupters had a hazard ratio of 4.37 (95% confidence interval (CI) 3.87-4.95) and late interrupters had a hazard ratio of 2.74 (95% CI 2.39-3.15). In sensitivity analyses, effect sizes were found to be proportional to the length of time used to define interruptions.

CONCLUSION

Our findings highlight the need to improve retention in care, regardless of treatment duration. Programmes to encourage return to care also need to be strengthened.

Socio-Behavioural Barriers to Viral Suppression in the Older Adult Population in Rural South Africa

South Africa has the largest share of people living with HIV in the world and this population is ageing. The social context in which people seek HIV care is often ignored. Apart from clinical interventions, socio-behavioural factors impact successful HIV care outcomes for older adults living with HIV. We use cross-sectional data linked with demographic household surveillance data, consisting of HIV positive adults aged above 40, to identify socio-behavioural predictors of a detectable viral load. Older adults were more likely to have a detectable viral load if they did not disclose their HIV positive status to close family members (aOR 2.56, 95% CI 1.89-3.46), resided in the poorest households (aOR 1.98, 95% CI 1.23-3.18), or were not taking medications other than ART (aOR 1.83, 95% CI 1.02-1.99) likely to have a detectable. Clinical interventions in HIV care must be supported by understanding the socio-behavioural barriers that occur outside the health facility. The importance of community health care workers in bridging this gap may offer more optimum outcomes for older adults ageing with HIV.

HIV infection and ART use are associated with altered plasma clot characteristics in Black South Africans

BACKGROUND

Human immunodeficiency virus (HIV) and antiretroviral treatment (ART) are both associated with hypercoagulability. Altered clot properties could be a potential mechanism thereof. We aimed to investigate the association of HIV and ART, with fibrinogen and plasma clot properties in a group of Black South Africans.

METHODS

At baseline, 151 newly diagnosed people living with HIV (PLWH) and 176 controls were recruited. Some PLWH subsequently commenced with ARTs (n = 70) while others remained ART-naïve (n = 81). Fibrinogen and clot properties (turbidity assay) were investigated from baseline to 5-year follow-up. A sub-group of 21 women (n = 10 ART-treated; n = 11 ART-naïve) with HIV was systematically selected and matched with 12 controls, and additional clot properties (rheometry, permeability and fibre diameter) were investigated.

RESULTS

Fibrinogen was lower in the HIV groups compared to the controls, while % γ' fibrinogen was higher. PLWH had shorter lag times and lower maximum absorbance than the controls (p<0.05). Their CLTs on the other hand were longer. Most variables increased over time in all groups, but differences in the degree of change over time was observed for lag time (p = 0.024) and permeability (p = 0.03). Participants who commenced with ART had a tendency of delayed clot formation (p = 0.08) and increased clot permeability (p = 0.005).

CONCLUSION

PLWH had lower total fibrinogen concentration and formed less dense clots. They also formed clots that were more difficult to lyse, which likely not resulted from altered clot properties. ART use (NNRTI's) had a moderately protective effect, delaying clot formation, and increasing clot permeability.

Longitudinal Trajectories of Antiretroviral Treatment Adherence and Associations With Durable Viral Suppression Among Adolescents Living With HIV in South Africa

BACKGROUND

Compared with other age groups, adolescents living with HIV (ALHIV) are estimated to have lower levels of adherence to antiretroviral treatment. Despite this, we lack evidence on adolescents' adherence patterns over time to inform the customization of intervention strategies.

SETTING

Eastern Cape province, South Africa.

METHODS

We analyzed data from a cohort of ALHIV (N = 1046, aged 10-19 years at baseline) recruited from 53 public health facilities. The cohort comprised 3 waves of data collected between 2014 and 2018 and routine viral load data from the National Institute for Communicable Disease data warehouse (2014-2019). Durable viral suppression was defined as having suppressed viral load (<1000 copies/mL) at ≥2 consecutive study waves. Group-based multitrajectory model was used to identify adherence trajectories using 5 indicators of self-reported adherence. Logistic regression modeling evaluated the associations between adherence trajectories and durable viral suppression.

RESULTS

Overall, 933 ALHIV (89.2%) completed all 3 study waves (55.1% female, mean age: 13.6 years at baseline). Four adherence trajectories were identified, namely, "consistent adherence" (49.8%), "low start and increasing" (20.8%), "gradually decreasing" (23.5%), and "low and decreasing" (5.9%). Adolescents experiencing inconsistent adherence trajectories were more likely to be older, live in rural areas, and have sexually acquired HIV. Compared with the consistent adherence trajectory, the odds of durable viral suppression were lower among adolescents in the low start and increasing (adjusted odds ratio [aOR]: 0.62, 95% CI: 0.41 to 0.95), gradually decreasing (aOR: 0.40, 95% CI: 0.27 to 0.59), and the low and decreasing adherence (aOR: 0.25, 95% CI: 0.10 to 0.62) trajectories.

CONCLUSIONS

Adherence to antiretroviral treatment remains a challenge among ALHIV in South Africa. Identifying adolescents at risk of nonadherence, based on their adherence trajectories may inform the tailoring of adolescent-friendly support strategies.

The impact of non-disclosure of HIV status and antiretroviral therapy on HIV recency testing and incidence algorithms

BACKGROUND AND OBJECTIVES

Accurate HIV incidence estimates among blood donors are necessary to assess the effectiveness of programs aimed at limiting transfusion-transmitted HIV. We assessed the impact of undisclosed HIV status and antiretroviral (ARV) use on HIV recency and incidence estimates using increasingly comprehensive recent infection testing algorithms.

MATERIALS AND METHODS

Using 2017 donation data from first-time and lapsed donors, we populated four HIV recency algorithms: (1) serology and limiting-antigen avidity testing, (2) with individual donation nucleic amplification testing (ID-NAT) added to Algorithm 1, (3) with viral load added to Algorithm 2 and (4) with ARV testing added to Algorithm 3. Algorithm-specific mean durations of recent infection (MDRI) and false recency rates (FRR) were calculated and used to derive and compare incidence estimates.

RESULTS

Compared with Algorithm 4, progressive algorithms misclassified fewer donors as recent: Algorithm 1: 61 (12.1%); Algorithm 2: 14 (2.8%) and Algorithm 3: 3 (0.6%). Algorithm-specific MDRI and FRR values resulted in marginally lower incidence estimates: Algorithm 1: 0.19% per annum (p.a.) (95% confidence interval [CI]: 0.13%-0.26%); Algorithm 2: 0.18% p.a. (95% CI: 0.13%-0.22%); Algorithm 3: 0.17% p.a. (95% CI: 0.13%-0.22%) and Algorithm 4: 0.17% p.a. (95% CI: 0.13%-0.21%).

CONCLUSION

We confirmed significant misclassification of recent HIV cases when not including viral load and ARV testing. Context-specific MDRI and FRR resulted in progressively lower incidence estimates but did not fully account for the context-specific variability in incidence modelling. The inclusion of ARV testing, in addition to viral load and ID-NAT testing, did not have a significant impact on incidence estimates.

Designing Implementation Strategies for the Inclusion of Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, and Allied and Key Populations' Content in Undergraduate Nursing Curricula in KwaZulu-Natal, South Africa: Protocol for a Multimethods Research Project

BACKGROUND

Lesbian, gay, bisexual, transgender, intersex, queer, and allied (LGBTQIA+) individuals encounter challenges with access and engagement with health services. Studies have reported that LGBTQIA+ individuals experience stigma, discrimination, and health workers' microaggression when accessing health care. Compelling evidence suggests that the LGBTQIA+ community faces disproportionate rates of HIV infection, mental health disorders, substance abuse, and other noncommunicable diseases. The South African National Strategic Plan for HIV or AIDS, tuberculosis, and sexually transmitted infections, 2023-2028 recognizes the need for providing affirming LGBTQIA+ health care as part of the country's HIV or AIDS response strategy. However, current anecdotal evidence suggests paucity of LGBTQIA+ and key populations' health content in the undergraduate health science curricula in South Africa. Moreover, literature reveals a general lack of health worker training regarding the health needs of LGBTQIA+ persons and other key populations such as sex workers, people who inject drugs, and men who have sex with men.

OBJECTIVE

This study aimed to describe the design of a project that aims at facilitating the inclusion of health content related to the LGBTQIA+ community and other key populations in the undergraduate nursing curricula of KwaZulu-Natal, South Africa.

METHODS

A multimethods design encompassing collection of primary and secondary data using multiple qualitative designs and quantitative approaches will be used to generate evidence that will inform the co-design, testing, and scale-up of strategies to facilitate the inclusion of LGBTQIA+ and key populations content in the undergraduate nursing curricula in KwaZulu-Natal, South Africa. Data will be collected using a combination of convenience, purposive, and snowball sampling techniques from LGBTQIA+ persons; academic staff; undergraduate nursing students; and other key populations. Primary data will be collected through individual in-depth interviews, focus groups discussions, and surveys guided by semistructured and structured data collection tools. Data collection and analysis will be an iterative process guided by the respective research design to be adopted. The continuous quality improvement process to be adopted during data gathering and analysis will ensure contextual relevance and sustainability of the resultant co-designed strategies that are to be scaled up as part of the overarching objective of this study.

RESULTS

The proposed study is designed in response to recent contextual empirical evidence highlighting the multiplicity of health challenges experienced by LGBTQIA+ individuals and key populations in relation to health service delivery and access to health care. The potential findings of the study may be appropriate for contributing to the education of nurses as one of the means to ameliorate these problems. Data collection is anticipated to commence in June 2024.

CONCLUSIONS

This research has potential implications for nursing education in South Africa and worldwide as it addresses up-to-date problems in the nursing discipline as it pertains to undergraduate students' preparedness for addressing the unique needs and challenges of the LGBTQIA+ community and other key populations.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52250.

Geospatial and temporal mapping of detectable HIV-1 viral loads amid dolutegravir rollout in KwaZulu-Natal, South Africa

South Africa rolled out dolutegravir (DTG) as first-line antiretroviral therapy (ART) in December 2019 to overcome high rates of pretreatment non-nucleoside reverse transcriptase inhibitor drug resistance. In the context of transition to DTG-based ART, this study spatiotemporally analysed detectable HIV viral loads (VLs) prior to- and following DTG rollout in public-sector healthcare facilities in KwaZulu-Natal (KZN) province, the epicentre of the HIV epidemic in South Africa. We retrospectively curated a HIV VL database using de-identified routine VL data obtained from the National Health Laboratory Service for the period January 2018 to June 2022. We analysed trends in HIV viraemia and mapped median log10 HIV VLs per facility on inverse distance weighted interpolation maps. We used Getis-Ord Gi* hotspot analysis to identify geospatial HIV hotspots. We obtained 7,639,978 HIV VL records from 736 healthcare facilities across KZN, of which 1,031,171 (13.5%) had detectable VLs (i.e., VLs ≥400 copies/millilitre (mL)). Of those with detectable VLs, we observed an overall decrease in HIV VLs between 2018 and 2022 (median 4.093 log10 copies/mL; 95% confidence interval (CI) 4.087-4.100 to median 3.563 log10 copies/mL; CI 3.553-3.572), p<0.01 (median test). The downward trend in proportion of HIV VLs ≥1000 copies/mL over time was accompanied by an inverse upward trend in the proportion of HIV VLs between 400 and 999 copies/mL. Moreover, specific coastal and northern districts of KZN had persistently higher VLs, with emergent hotspots demonstrating spatial clustering of high median log10 HIV VLs. The overall decrease in HIV VLs over time shows good progress towards achieving UNAIDS 95-95-95 targets in KZN, South Africa. The DTG-transition has been associated with a reduction in VLs, however, there is a need for pre-emptive monitoring of low-level viraemia. Furthermore, our findings highlight that specific districts will need intensified HIV care despite DTG rollout.

Pilot Testing Two Versions of a Social Network Intervention to Increase HIV Testing and Case-finding among Men in South Africa's Generalized HIV Epidemic

Locating undiagnosed HIV infections is important for limiting transmission. However, there is limited evidence about how best to do so. In South Africa, men have been particularly challenging to reach for HIV testing due, in part, to stigma. We pilot-tested two versions of a network-based case-finding and care-linkage intervention. The first, TRIP, asked "seeds" (original participants) to recruit their sexual and/or injection partners. The second, TRIPLE, aimed to circumvent some stigma-related issues by asking seeds to recruit anyone they know who might be at risk of being HIV-positive-unaware. We recruited 11 (18% male) newly diagnosed HIV-positive (NDP) seeds from two clinics in KwaZulu-Natal, South Africa and randomly assigned them to either TRIP or TRIPLE. Network members were recruited two steps from each seed. The TRIP arm recruited 12 network members; the TRIPLE arm recruited 62. Both arms recruited NDPs at higher rates than local clinic testing, with TRIP (50.0%) outperforming (p = 0.012) TRIPLE (14.5%). However, TRIPLE (53.2%) was far superior to clinics (27.8%) and to TRIP (25.0%) at recruiting men. Given challenges around testing and treating men for HIV in this context, these findings suggest that the TRIPLE expanded network-tracing approach should be tested formally among larger samples in multiple settings.

HIV viral suppression at different thresholds and duration of treatment in the dolutegravir treatment era in Sierra Leone: a nationwide survey

INTRODUCTION

Viral load assessment for people living with HIV is key for monitoring treatment and achieving the 95-95-95. In this study, we aimed to assess the degree of viral suppression at different thresholds and treatment duration after the introduction of dolutegravir-based therapy in ten public hospitals in Sierra Leone.

METHODS

We used a cross-sectional study design to recruits patients aged 18 years or older between August 2022 and January 2023. Statistical analyses were performed using R-software. Logistic regression was used to assess factors independently associated with viral suppression. The level of significance was set at P < 0.05.

RESULTS

Of the 2,253 patients recruited, 1,720 (76%) were women and 1,705 (76%) were receiving a fixed dose combination of tenofovir, lamivudine and dolutegravir. The median age and duration of anti-retroviral therapy (ART) was 36.0 (IQR, 28.0-45.0) years and 40.9 (IQR, 14.4-79.6) months, respectively. Using a threshold of HIV RNA < 1000 copies/mL, 1,715 (88.4%) patients on ART for more than 6 months were virally suppressed. Viral suppression rates were higher with dolutegravir-based (1,277, 89.5%) than efavirenz-based (418, 86.2%) ART. HIV RNA was < 200 copies/mL in 1,643 (84.6%) patients or < 50 copies/mL in 1,487 (76.6%) patients or between 50 and 999 copies/mL in 228 (11.7%) patients. Viral suppression rates at different ART durations (months) were as follows: 84.2% (≤ 3), 88.8% (4-6), 90.9% (6-12), and 88.1% (> 12). Viral suppression rates were higher for patients aged 40 or older (40-50 years: aOR 2.05, 95%CI 1.41-3.04, P < 0.01; 50-60 years: aOR 2.51, 95%CI 1.53-4.35, P < 0.01; >60 years: aOR 2.69, 95%CI 1.28-6.63, P = 0.02). Men had 49% lower odds of viral suppression than women (aOR 0.50, 95% CI 0.38-0.67, P < 0.01).

CONCLUSION

We report a viral suppression rate of 88.4% among patients on treatment for at least 6 months, with higher rate of suppression with dolutegravir than efavirenz. Factors associated with virological suppression were age and gender, emphasizing the need for innovative differentiated ART delivery models to optimize viral suppression and achieve the 95% target.

Statistical methods applied for the assessment of the HIV cascade and continuum of care: a systematic scoping review

OBJECTIVES

This scoping review aims to identify and synthesise existing statistical methods used to assess the progress of HIV treatment programmes in terms of the HIV cascade and continuum of care among people living with HIV (PLHIV).

DESIGN

Systematic scoping review.

DATA SOURCES

Published articles were retrieved from PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Excerpta Medica dataBASE (EMBASE) databases between April and July 2022. We also strategically search using the Google Scholar search engine and reference lists of published articles.

ELIGIBILITY CRITERIA

This scoping review included original English articles that estimated and described the HIV cascade and continuum of care progress in PLHIV. The review considered quantitative articles that evaluated either HIV care cascade progress in terms of the Joint United Nations Programme on HIV and AIDS targets or the dynamics of engagement in HIV care.

DATA EXTRACTION AND SYNTHESIS

The first author and the librarian developed database search queries and screened the retrieved titles and abstracts. Two independent reviewers and the first author extracted data using a standardised data extraction tool. The data analysis was descriptive and the findings are presented in tables and visuals.

RESULTS

This review included 300 articles. Cross-sectional study design methods were the most commonly used to assess the HIV care cascade (n=279, 93%). In cross-sectional and longitudinal studies, the majority used proportions to describe individuals at each cascade stage (276/279 (99%) and 20/21 (95%), respectively). In longitudinal studies, the time spent in cascade stages, transition probabilities and cumulative incidence functions was estimated. The logistic regression model was common in both cross-sectional (101/279, 36%) and longitudinal studies (7/21, 33%). Of the 21 articles that used a longitudinal design, six articles used multistate models, which included non-parametric, parametric, continuous-time, time-homogeneous and discrete-time multistate Markov models.

CONCLUSIONS

Most literature on the HIV cascade and continuum of care arises from cross-sectional studies. The use of longitudinal study design methods in the HIV cascade is growing because such methods can provide additional information about transition dynamics along the cascade. Therefore, a methodological guide for applying different types of longitudinal design methods to the HIV continuum of care assessments is warranted.

Epidemiology and aetiology of moderate to severe diarrhoea in hospitalised patients ≥5 years old living with HIV in South Africa, 2018-2021: A case-control analysis

Diarrhoea is a recognised complication of HIV-infection, yet there are limited local aetiological data in this high-risk group. These data are important for informing public health interventions and updating diagnostic and treatment guidelines. This study aimed to determine the pathogenic causes of diarrhoeal admissions in people living with HIV (PLHIV) compared to hospital controls between July 2018 and November 2021. Admitted diarrhoeal cases (n = 243) and non-diarrhoeal hospital controls (n = 101) ≥5 years of age were enrolled at Kalafong, Mapulaneng and Matikwana hospitals. Stool specimens/rectal swabs were collected and pathogen screening was performed on multiple platforms. Differences in pathogen detections between cases and controls, stratified by HIV status, were investigated. The majority (n = 164, 67.5%) of enrolled diarrhoeal cases with known HIV status were HIV-infected. Pathogens could be detected in 66.3% (n = 228) of specimens, with significantly higher detection in cases compared to controls (72.8% versus 50.5%, p<0.001). Amongst PLHIV, prevalence of Cystoisospora spp. was significantly higher in cases than controls (17.7% versus 0.0%, p = 0.028), while Schistosoma was detected more often in controls than cases (17.4% versus 2.4%, p = 0.009). Amongst the HIV-uninfected participants, prevalence of Shigella spp., Salmonella spp. and Helicobacter pylori was significantly higher in cases compared to controls (36.7% versus 12.0%, p = 0.002; 11.4% versus 0.0%, p = 0.012; 10.1% versus 0.0%, p = 0.023). Diarrhoeal aetiology differed by HIV status, with Shigella spp. (36.7%) and Salmonella spp. (11.4%) having the highest prevalence amongst HIV-uninfected cases and Shigella spp. (18.3%), Cystoisospora (17.7%), and Cryptosporidium spp. (15.9%) having the highest prevalence in cases amongst PLHIV. These differences should be considered for the development of diagnostic and treatment guidelines.

Provision of HIV prevention and care services to farmworkers in sub-Saharan African countries

OBJECTIVES

To summarise data on human immunodeficiency virus (HIV) services available to farmworkers in sub-Saharan Africa (SSA).

METHODS

We conducted a systematic review to understand which HIV prevention and care services were accessed by farm workers in SSA. MEDLINE (PubMed), Embase, CINAHL (EBSCO Host), Cochrane library, African Index Medicus, Scopus, Google Scholar, Open Grey, and Web of Science Proceedings Citation Index were searched. Studies were eligible for inclusion if they measured or reported on the presence of HIV workplace policy frameworks, guidelines, or programmes for HIV prevention, treatment and care services, and other treatment modalities specifically targeting farmworkers.

RESULTS

Nine studies published between 2005 and 2019 were included in the review. Six themes emerged from included studies, which include HIV policy, HIV prevention (awareness, education, and condom supply), voluntary counselling and testing, antiretroviral therapy (ART), linkage to care, and mobile clinic. Though availability of an HIV policy was inadequate, a significant positive impact of the HIV policy in influencing behaviour change was reported. Most of the farm workers could access HIV education and condom supply in their places of work. Access to ART, treatment support, and linkage to care was inadequate, but community outreach programmes and mobile clinics showed success in reaching a high number of workers with HIV testing and treatment. A majority of farm workers faced barriers in accessing government health facilities.

CONCLUSIONS

The findings suggest that there is poor access to HIV services for farmworkers in SSA. There is a dire need to scale up HIV services and programmes, including mobile health facilities, in agricultural settings. Due to high labour migration patterns among farmworkers, we recommend cross-country HIV programmes that allow continuity of care across borders.

Relationship Between Criminal and Status Offense Behaviors, Substance Use, and HIV Risk Among Adolescent Girls and Young Women in Cape Town, South Africa

This study aimed to examine the relationship between externalizing behaviors, substance use, and sexual risk among adolescent girls and young women (AGYW) in Cape Town, South Africa, who experience social disadvantage characterized by poverty and school dropout. We analyzed baseline data from 500 AGYW in a cluster-randomized trial who had dropped out of school. Multivariate logistic regression models explored associations between self-reported criminal behaviors and other status offenses, heavy episodic drinking, polydrug use, and condomless sex. Engagement in status offenses was associated with heavy episodic drinking (OR = 3.56, 95% CI: 2.05-6.20), while crimes against other people were associated with polydrug use (OR = 1.65, 95% CI: 1.03-2.63). Drug-related illegal behavior was associated with polydrug use (OR = 7.78, 95% CI: 3.53-8.69) and reduced odds of condom use during last sexual episode, after adjusting for drug use (OR = 0.56, 95% CI: 4.00-5.15). As externalizing behaviors are prevalent among this sample of AGYW and associated with greater likelihood of problem substance use and condomless sex, interventions to improve the physical and mental well-being of AGYW should assess for and address engagement in criminal and status offenses.

HIV infection

The AIDS epidemic has been a global public health issue for more than 40 years and has resulted in ~40 million deaths. AIDS is caused by the retrovirus, HIV-1, which is transmitted via body fluids and secretions. After infection, the virus invades host cells by attaching to CD4 receptors and thereafter one of two major chemokine coreceptors, CCR5 or CXCR4, destroying the host cell, most often a T lymphocyte, as it replicates. If unchecked this can lead to an immune-deficient state and demise over a period of ~2-10 years. The discovery and global roll-out of rapid diagnostics and effective antiretroviral therapy led to a large reduction in mortality and morbidity and to an expanding group of individuals requiring lifelong viral suppressive therapy. Viral suppression eliminates sexual transmission of the virus and greatly improves health outcomes. HIV infection, although still stigmatized, is now a chronic and manageable condition. Ultimate epidemic control will require prevention and treatment to be made available, affordable and accessible for all. Furthermore, the focus should be heavily oriented towards long-term well-being, care for multimorbidity and good quality of life. Intense research efforts continue for therapeutic and/or preventive vaccines, novel immunotherapies and a cure.

Motivations for blood donation by HIV-positive individuals on antiretrovirals in South Africa: A qualitative study

OBJECTIVES

We performed a mixed-methods study to explore the motivations associated with blood donation by donors with known, but undisclosed HIV-positive status and ARV use (HIV+/ARV+), seeking potential strategies to reduce such donations and mitigate risk for blood recipients. Here, we report predominantly the qualitative component.

BACKGROUND

A safe and sustainable blood supply is dependent in part, on effective pre-donation donor assessment. We previously described failure by HIV+/ARV+ blood donors to disclose their status. Such donations may lead to transfusion-transmitted HIV.

METHODS

The social ecological model provided the conceptual framework for this study. Previously identified HIV+/ARV+ donors were invited to complete a survey (including a validated stigma scale) and qualitative interview, which underwent inductive and deductive thematic analysis.

RESULTS

We uncovered two primary motivational paths to HIV+/ARV+ blood donations: privacy and altruism. The latter included a motivation not previously reported in the literature: donating specifically for other people living with HIV (PLWH). The other primary factor was a lack of privacy. These accounts often included donors encountering donation opportunities when accompanied by people to whom they had not and did not plan to disclose their HIV status. Most were highly confident their donations would be identified as HIV-positive and discarded.

CONCLUSION

We demonstrated a complex interaction between individual, social, cultural, and structural/policy factors in blood donations by PLWH who take ARV. Recommendations to limit HIV + ARV+ donations include: (1) Targeted communication strategies to increase knowledge among PLWH of their deferral from blood donation-without increasing stigma, and (2) development of procedures to assist those who feel unable to opt-out of donation due to privacy concerns.

Development of "Yima Nkqo," a community-based, peer group intervention to support treatment initiation for young adults with HIV in South Africa

AIMS

Half of young adults diagnosed with HIV in South Africa start antiretroviral therapy (ART). We developed and field tested a facilitator-guided peer support group called Yima Nkqo ("Standing Tall" in isiXhosa) to promote treatment initiation for young adults newly diagnosed with HIV in communities around Cape Town.

METHODS

Following an adapted version of the UK Medical Research Council's framework for developing complex interventions, we 1) identified evidence on previous interventions to improve ART uptake in sub-Saharan Africa; 2) collected and analyzed qualitative data on the acceptability of our proposed intervention; 3) proposed a theoretical understanding of the process of behavior change; and 4) developed an intervention manual and feedback tools. During field-testing, participant feedback on intervention acceptability, and team feedback on consistency of content delivery and facilitation quality, were analyzed using an iterative, rapid-feedback evaluation approach. In-depth written and verbal summaries were shared in weekly team meetings. Team members interpreted feedback, identified areas for improvement, and proposed suggestions for intervention modifications.

RESULTS

Based on our formative research, we developed three, 90-minute sessions with content including HIV and ART education, reflection on personal resources and strengths, practice disclosing one's status, strategies to overcome stressors, and goal setting to start treatment. A lay facilitator was trained to deliver intervention content. Two field testing groups (five and four participants, respectively) completed the intervention. Participants highlighted that strengths of Yima Nkqo included peer support, motivation, and education about HIV and ART. Team feedback to the facilitator ensured optimal consistency of intervention content delivery.

CONCLUSIONS

Iteratively developed in collaboration with youth and healthcare providers, Yima Nkqo is a promising new intervention to improve treatment uptake among young adults with HIV in South Africa. The next phase will be a pilot randomized controlled trial of Yima Nkqo (ClinicalTrials.gov Identifier: NCT04568460).

Dataset: A consolidated and harmonised Verbal Autopsy dataset from Health and Demographic Surveillance Sites in South Africa

This data note provides details of the development of a Verbal Autopsy (VA) dataset produced with the South African Population Research Infrastructure Network (SAPRIN) drawing on datasets from health and socio-demographic surveillance sites' (HDSS) ' covering a population of over 250,000 in two rural provinces in South Africa for the period 2012-2019. The purpose of the data set was to refine an analytical tool within VA, which provides unique information on care seeking and utilisation at and around the time of death complementary to that of medical cause of death. On an individual basis, the dataset includes demographic data, probable cause of death data, and data on care seeking and utilisation at or around the time of death drawn from longitudinal population cohorts. The purpose of this publication is to describe both the dataset and methods in formatting and processing the data for other researchers who may be interested in similar data. The data described in this paper are available to be requested from the respective HDSS repositories.

Realising radical potential: building community power in primary health care through Participatory Action Research

BACKGROUND

While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

METHODS

Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

RESULTS

Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

CONCLUSIONS

Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

HIV Related Behaviors Among Male Partners of Adolescent Girls and Young Women in Rural South Africa

Improving men's engagement in HIV prevention is not only essential for reducing their own HIV risk but also the risk of transmitting HIV to their female partners. We conducted a cross-sectional survey using a population-based sample of men (age 18-30) who reported being a partner of an adolescent girls and young women (AGYW) in South Africa (N = 2827). We used logit-binomial regression models to examine associations among men's partnership characteristics, HIV risk perceptions, and HIV-related behaviors and examine differences by male partner age (younger men (18-24) vs. older men (25-30)) and age difference between partners (age-concordant (< 5 years) vs. age-disparate (≥ 5 years)). Most men reported inconsistent condom use (85%) and nearly half reported engaging in transactional sex (48%). Older men were just as likely as younger men, and men with age-disparate and age-concordant partners, to inconsistently use condoms, engage in transactional sex, and perpetrate intimate partner violence. Most men also reported a very high interest in pre-exposure prophylaxis (PrEP) (77%) and half reported having an HIV test in the past year (50%). There were no differences by male partner age or age difference between partners in PrEP interest but older men and men in age-discordant relationships were more likely than younger men and men in age-concordant relationships to have an HIV test in the past year. Male partners of AGYW in South Africa are engaging in HIV-related behaviors and need HIV prevention interventions to reduce risk for themselves and their female partners.

Does a youth intern programme strengthen HIV service delivery in South Africa? An interrupted time-series analysis

INTRODUCTION

Since 2018, Youth Health Africa (YHA) has placed unemployed young adults at health facilities across South Africa in 1-year non-clinical internships to support HIV services. While YHA is primarily designed to improve employment prospects for youth, it also strives to strengthen the health system. Hundreds of YHA interns have been placed in programme (e.g. HIV testing and counselling) or administrative (e.g. data and filing) roles, but their impact on HIV service delivery has not been evaluated.

METHODS

Using routinely collected data from October 2017 to March 2020, we conducted an interrupted time-series analysis to explore the impact of YHA on HIV testing, treatment initiation and retention in care. We analysed data from facilities in Gauteng and North West where interns were placed between November 2018 and October 2019. We used linear regression, accounting for facility-level clustering and time correlation, to compare trends before and after interns were placed for seven HIV service indicators covering HIV testing, treatment initiation and retention in care. Outcomes were measured monthly at each facility. Time was measured as months since the first interns were placed at each facility. We conducted three secondary analyses per indicator, stratified by intern role, number of interns and region.

RESULTS

Based on 207 facilities hosting 604 interns, YHA interns at facilities were associated with significant improvements in monthly trends for numbers of people tested for HIV, newly initiated on treatment and retained in care (i.e. loss to follow-up, tested for viral load [VL] and virally suppressed). We found no difference in trends for the number of people newly diagnosed with HIV or the number initiating treatment within 14 days of diagnosis. Changes in HIV testing, overall treatment initiation and VL testing/suppression were most pronounced where there were programme interns and a higher number of interns; change in loss to follow-up was greatest where there were administrative interns.

CONCLUSIONS

Placing interns in facilities to support non-clinical tasks may improve HIV service delivery by contributing to improved HIV testing, treatment initiation and retention in care. Using youth interns as lay health workers may be an impactful strategy to strengthen the HIV response while supporting youth employment.

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa

OBJECTIVE

We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART).

DESIGN

I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation.

METHODS

Eighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status.

RESULTS

Overall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC.

CONCLUSION

Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs.

TRIAL REGISTRATION

NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

Thirteen cancers associated with HIV infection in a Black South African cancer patient population (1995-2016)

South Africa's HIV epidemic has evolved over time in terms of numbers of people living with HIV, access to antiretroviral treatment (ART) and age. These changes have profoundly influenced local cancer patterns. The Johannesburg Cancer Study has, over a period of 22 years (1995-2016), recruited over 20 000 incident black cancer patients who consented to provide answers to a questionnaire and blood samples (serum, DNA). This has presented a unique opportunity to examine the evolving association of HIV with cancer in Africa. We used logistic regression models to explore case-control associations between specific cancers and HIV, using participants with non-infection related cancers as controls. Using data of 20 835 cancer patients with confirmed HIV status, we found the following cancers to be associated with HIV: Kaposi's sarcoma (ORadj ; 95%CI): (99.1;72.6-135.1), non-Hodgkin lymphoma (11.3;9.3-13.6), cervical cancer (2.7;2.4-3.0), Hodgkin lymphoma (3.1;2.4-4.2), cancer of the eye/conjunctiva (18.7;10.1-34.7), anogenital cancers (anus [2.1;1.4-3.2], penis [5.4;2.7-10.5], vulva [4.8;3.5-6.4], vagina [5.5;3.0-10.2]), oropharyngeal cancer (1.6;1.3-1.9), squamous cell carcinoma of the skin (3.5;2.4-4.9), melanoma (2.0;1.2-3.5) and cancer of the larynx (1.7;1.3-2.4). Kaposi's sarcoma odds ratios increased from the pre-ART (1995-2004) to the early ART (2005-2009) period but declined in the late ART (2010-2016) period. Odds ratios for cancers of the eye/conjunctiva, cervix, penis and vulva continued to increase in recent ART periods. Our study confirms the spectrum of HIV-associated cancers found in other African settings. The odds ratios of conjunctival and HPV-related cancers continue to rise in the ART era as the HIV positive population ages.

Utility of a machine-guided tool for assessing risk behaviour associated with contracting HIV in three sites in South Africa

Introduction

Digital data collection and the associated mobile health technologies have allowed for the recent exploration of artificial intelligence as a tool for combatting the HIV epidemic. Machine learning has been found to be useful both in HIV risk prediction and as a decision support tool for guiding pre-exposure prophylaxis (PrEP) treatment. This paper reports data from two sequential studies evaluating the viability of using machine learning to predict the susceptibility of adults to HIV infection using responses from a digital survey deployed in a high burden, low-resource setting.

Methods

1036 and 593 participants were recruited across two trials. The first trial was a cross-sectional study in one location and the second trial was a cohort study across three trial sites. The data from the studies were merged, partitioned using standard techniques, and then used to train and evaluate multiple different machine learning models and select and evaluate a final model. Variable importance estimates were calculated using the PIMP and SHAP methodologies.

Results

Characteristics associated with HIV were consistent across both studies. Overall, HIV positive patients had a higher median age (34 [IQR: 29-39] vs 26 [IQR 22-33], p < 0.001), and were more likely to be female (155/703 [22%] vs 107/927 [12%], p < 0.001). HIV positive participants also had more commonly gone a year or more since their last HIV test (183/262 [70%] vs 540/1368 [39%], p < 0.001) and were less likely to report consistent condom usage (113/262 [43%] vs 758/1368 [55%], p < 0.001). Patients who reported TB symptoms were more likely to be HIV positive. The trained models had accuracy values (AUROCs) ranging from 78.5% to 82.8%. A boosted tree model performed best with a sensitivity of 84% (95% CI 72-92), specificity of 71% (95% CI 67-76), and a negative predictive value of 95% (95% CI 93-96) in a hold-out dataset. Age, duration since last HIV test, and number of male sexual partners were consistently three of the four most important variables across both variable importance estimates.

Conclusions

This study has highlighted the synergies present between mobile health and machine learning in HIV. It has been demonstrated that a viable ML model can be built using digital survey data from an low-middle income setting with potential utility in directing health resources.

HIV self-test reporting using mHealth platforms: A pilot study in Johannesburg, South Africa

Background

The main impediment to operational scale-up of HIV self-testing (HIVST) and counselling, is a dearth of information on utilisation, reporting, and linkage to care for HIV-positive individuals. To inform solutions to this issue, this study investigated the utility of self-testers reporting their results using a mobile-health (mHealth) platform, and whether seropositive users linked into care.

Method

Candidates who met the recruitment criteria across multiple sites within inner-city Johannesburg each received an HIVST kit. Using short message service (SMS) reminders (50% standard and 50% behavioural science), participants were prompted to self-report results on provided platforms. On the seventh day, users who did not make contact, were called, and surveyed via an interactive voice response system (IVRS). Multivariable regression was used in reporting by age and sex.

Results

Of the 9,505 participants, 2,467 (25.9%) participants answered any survey question, and of those, 1,933 (78.4%) were willing to self-report their HIV status. Men were more likely than women to make an inbound call (10.2% vs. 9.1%, p = 0.06) however, women were significantly more likely to self-report their test result (AOR = 1.12, 95%CI = 1.01-1.24, p = 0.025). Overall, self-reporting a test result was predicted by being younger and female. In addition, reporting HIV results was associated with age, 25-35 (AOR = 1.58, 95% CI = 1.24-2.02) and above 35 years (AOR = 2.12, 95% CI = 1.61-2.80). Out of 1,933 participants willing to report their HIV status, 314 reported a positive test, indicating a HIV prevalence of 16.2% (95% CI: 14.6%-18.0%) and of those 204 (65.0%) reported inclination to link to care.

Conclusion

While self-reporting HIVST results via an IVRS system yielded a higher response rate, behavioural SMSs were ineffective in increasing self-reporting.

Healthcare seeking patterns for TB symptoms: Findings from the first national TB prevalence survey of South Africa, 2017-2019

BACKGROUND

Although tuberculosis (TB) symptoms have limited sensitivity they remain an important entry point into the TB care cascade.

OBJECTIVES

To investigate self-reported healthcare seeking for TB symptoms in participants in a community-based survey.

METHODS

We compared reasons for not seeking care in participants reporting ≥1 of four TB screening symptoms (cough, weight loss, night sweats, fever) in the first South African national TB prevalence survey (2017-2019). We used logistic regression analyses to identify sociodemographic and clinical characteristics associated with healthcare seeking.

RESULTS

5,168/35,191 (14.7%) survey participants reported TB symptoms and 3,442/5168 had not sought healthcare. 2,064/3,442(60.0%) participants intended to seek care, 912 (26.5%) regarded symptoms as benign, 399 (11.6%) reported access barriers(distance and cost), 36 (1.0%) took other medications and 20(0.6%) reported health system barriers. Of the 57/98 symptomatic participants diagnosed with bacteriologically confirmed TB who had not sought care: 38(66.7%) intended to do so, 8(14.0%) regarded symptoms as benign, and 6(10.5%) reported access barriers. Among these 98, those with unknown HIV status(OR 0.16 95% CI 0.03-0.82), p = 0.03 and those who smoked tobacco products(OR 0.39, 95% CI 0.17-0.89, p = 0.03) were significantly less likely to seek care.

CONCLUSIONS

People with TB symptoms delayed seeking healthcare, many regarded symptoms as benign while others faced access barriers. Those with unknown HIV status were significantly less likely to seek care. Strengthening community-based TB awareness and screening programmes together with self-screening models could increase awareness of the significance of TB symptoms and contribute to improving healthcare seeking and enable many people with TB to enter the TB care cascade.

Exploring healthcare workers' experiences of managing patients returning to HIV care in Johannesburg, South Africa

Background

Retention of patients in HIV care is a critical barrier to reaching the UNAIDS 90–90-90 goals in South Africa. In January 2019, Anova Health Institute launched a campaign to encourage patients who had interrupted antiretroviral therapy to return to care. The Welcome Back campaign included training of health care workers and implementation of Médecins Sans Frontiers Welcome Services principles.

Objective

The aim of this study was to explore the experiences of healthcare workers managing patients reinitiating antiretroviral therapy following training, including barriers and facilitators to implementation.

Methods

Data were collected from six clinics. This study consisted of three components: 1) surveys; 2) semi-structured interviews and 3) reflexive feedback sessions. Each component covered staff attitudes and facility management of patients reinitiating antiretroviral therapy. A descriptive analysis was conducted of survey responses. A thematic approach was used to analyze interviews.

Results

Thirty-six healthcare workers completed the survey and interview. Following analysis, feedback sessions were conducted with 99 healthcare workers. Twenty-two (61%) participants were lay counsellors. The majority of healthcare workers reported managing patients returning to care appropriately. However, barriers persisted: 9 (25%) responded that patients were sent to the back of the queue and that service providers continued to insist on transfer letters. Twenty-five (69%) responded they had seen/heard other healthcare workers act poorly towards returning patients after training. Many poor behaviours from healthcare workers stemmed from frustration with the clinical flow and their overburdened work environment. Many participants (78%) believed that the Welcome Back approach helped improve client-provider relationships.

Conclusions

The Welcome Back approach supported healthcare workers to improve service provision for patients reinitiating antiretroviral therapy. Further support is needed to help providers consistently deliver services in line with the Welcome Back approach. Institutional level changes are required to implement patient-centred and trust-based models of care.

Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa

INTRODUCTION

Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses.

METHODS

In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care.

RESULTS

Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records.

CONCLUSION

At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics.

TRIAL REGISTRATION

The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.

COVID-19 hospital admissions and mortality among healthcare workers in South Africa, 2020-2021

Objectives

This study describes the characteristics of admitted HCWs reported to the DATCOV surveillance system, and the factors associated with in-hospital mortality in South African HCWs.

Methods

Data from March 5, 2020 to April 30, 2021 were obtained from DATCOV, a national hospital surveillance system monitoring COVID-19 admissions in South Africa. Characteristics of HCWs were compared with those of non-HCWs. Furthermore, a logistic regression model was used to assess factors associated with in-hospital mortality among HCWs.

Results

In total, there were 169 678 confirmed COVID-19 admissions, of which 6364 (3.8%) were HCWs. More of these HCW admissions were accounted for in wave 1 (48.6%; n = 3095) than in wave 2 (32.0%; n = 2036). Admitted HCWs were less likely to be male (28.2%; n = 1791) (aOR 0.3; 95% CI 0.3-0.4), in the 50-59 age group (33.1%; n = 2103) (aOR 1.4; 95% CI 1.1-1.8), or accessing the private health sector (63.3%; n = 4030) (aOR 1.3; 95% CI 1.1-1.5). Age, comorbidities, race, wave, province, and sector were significant risk factors for COVID-19-related mortality.

Conclusion

The trends in cases showed a decline in HCW admissions in wave 2 compared with wave 1. Acquired SARS-COV-2 immunity from prior infection may have been a reason for reduced admissions and mortality of HCWs despite the more transmissible and more severe beta variant in wave 2.

Gender Moderates Results of a Randomized Clinical Trial for the Khanya Intervention for Substance Use and ART Adherence in HIV Care in South Africa

Little is known about gender effects of alcohol and drug use (AOD) among people living with HIV (PLWH) in resource-limited settings. Using multilevel models, we tested whether gender moderated the effect of Khanya, a cognitive-behavioral therapy-based intervention addressing antiretroviral (ART) adherence and AOD reduction. We enrolled 61 participants from HIV care and examined outcomes at 3- and 6-months compared to enhanced treatment as usual (ETAU). Gender significantly moderated the effect of Khanya on ART adherence (measured using electronically-monitored and biomarker-confirmed adherence), such that women in Khanya had significantly lower ART adherence compared to men in Khanya; no gender differences were found for AOD outcomes. Exploratory trajectory analyses showed men in Khanya and both genders in ETAU had significant reductions in at least one AOD outcome; women in Khanya did not. More research is needed to understand whether a gender lens can support behavioral interventions for PLWH with AOD.Trial registry ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

Antiretroviral Drug Detection in a Community-Randomized Trial of Universal HIV Testing and Treatment: HPTN 071 (PopART)

Background

Antiretroviral therapy (ART) reduces human immunodeficiency virus (HIV) transmission risk. The primary aim of this study was to evaluate ART uptake in a trial in Zambia and South Africa that implemented a community-wide universal testing and treatment package to reduce HIV incidence.

Methods

Study communities were randomized to 3 arms: A, combination-prevention intervention with universal ART; B, combination-prevention intervention with ART according to local guidelines; and C, standard of care. Samples were collected from people with HIV (PWH) during a survey visit conducted 2 years after study implementation: these samples were tested for 22 antiretroviral (ARV) drugs. Antiretroviral therapy uptake was defined as detection of ≥1 ARV drug. Resistance was evaluated in 612 randomly selected viremic participants. A 2-stage, cluster-based approach was used to assess the impact of the study intervention on ART uptake.

Results

Antiretroviral drugs were detected in 4419 of 6207 (71%) samples (Arm A, 73%; Arm B, 70%; Arm C, 60%); 4140 (94%) of samples with ARV drugs had viral loads <400 copies/mL. Drug resistance was observed in 237 of 612 (39%) viremic participants (95 of 102 [93%] with ARV drugs; 142 of 510 [28%] without drugs). Antiretroviral therapy uptake was associated with older age, female sex, enrollment year, seroconverter status, and self-reported ART (all P < .001). The adjusted risk ratio for ART uptake was similar for Arm A versus C (1.21; 95% confidence interval [CI], .94-1.54; P = .12) and Arm B versus C (1.14; 95% CI, .89-1.46; P = .26).

Conclusions

At the 2-year survey, 71% of PWH were on ART and 94% of those participants were virally suppressed. Universal testing and treatment was not significantly associated with increased ART uptake in this cohort.

Socioeconomic inequalities in the 90-90-90 target, among people living with HIV in 12 sub-Saharan African countries - Implications for achieving the 95-95-95 target - Analysis of population-based surveys

Background

Inequalities undermine efforts to end AIDS by 2030. We examined socioeconomic inequalities in the 90-90-90 target among people living with HIV (PLHIV) -men (MLHIV), women (WLHIV) and adolescents (ALHIV).

Methods

We analysed the available Population HIV Impact Assessment (PHIA) survey data for each of the 12 sub-Saharan African countries, collected between 2015 and 2018 to estimate the attainment of each step of the 90-90-90 target by wealth quintiles. We constructed concentration curves, computed concentration indices (CIX) -a negative (positive) CIX indicated pro-poor (pro-rich) inequalities- and identified factors associated with, and contributing to inequality.

Findings

Socioeconomic inequalities in achieving the 90-90-90 target components among PLHIV were noted in 11 of the 12 countries surveyed: not in Rwanda. Awareness of HIV positive status was pro-rich in 5/12 countries (Côte d'Ivoire, Tanzania, Uganda, Malawi, and Zambia) ranging from CIX=0·085 (p< 0·05) in Tanzania for PLHIV, to CIX = 0·378 (p<0·1) in Côte d'Ivoire for ALHIV. It was pro-poor in 5/12 countries (Côte d'Ivoire, Ethiopia, Malawi, Namibia and Eswatini), ranging from CIX = -0·076 (p<0·05) for PLHIV in Eswatini, and CIX = -0·192 (p<0·05) for WLHIV in Ethiopia. Inequalities in accessing ART were pro-rich in 5/12 countries (Cameroun, Tanzania, Uganda, Malawi and Zambia) ranging from CIX=0·101 (p<0·05) among PLHIV in Zambia to CIX=0·774 (p<0·1) among ALHIV in Cameroun and pro-poor in 4/12 countries (Tanzania, Zimbabwe, Lesotho and Eswatini), ranging from CIX = -0·072 (p<0·1) among PLHIV in Zimbabwe to CIX = -0·203 (p<0·05) among WLHIV in Tanzania. Inequalities in HIV viral load suppression were pro-rich in 3/12 countries (Ethiopia, Uganda, and Lesotho), ranging from CIX = 0·089 (p< 0·1) among PLHIV in Uganda to CIX = 0·275 (p<0·01) among WLHIV in Ethiopia. Three countries (Tanzania CIX = 0·069 (p< 0·5), Uganda CIX = 0·077 (p< 0·1), and Zambia CIX = 0·116 (p< 0·1)) reported pro-rich and three countries (Côte d'Ivoire CIX = -0·125 (p< 0·1), Namibia CIX = -0·076 (p< 0·05), and Eswatini CIX = -0·050 (p< 0·05) pro-poor inequalities for the cumulative CIX for HIV viral load suppression. The decomposition analysis showed that age, rural-urban residence, education, and wealth were associated with and contributed the most to inequalities observed in achieving the 90-90-90 target.

Interpretation

Some PLHIV in 11 of 12 countries were not receiving life-saving HIV testing, treatment, or achieving HIV viral load suppression due to socioeconomic inequalities. Socioeconomic factors were associated with and explained the inequalities observed in the 90-90-90 target among PLHIV. Governments should scale up equitable 95-95-95 target interventions, prioritizing the reduction of age, rural-urban, education and wealth-related inequalities. Research is needed to understand interventions to reduce socioeconomic inequities in achieving the 95-95-95 target.

Funding

This study was supported by the Swiss National Science Foundation (grant 202660).

Cohort profile: the South African National Health Laboratory Service (NHLS) National HIV Cohort

PURPOSE

South Africa's National Health Laboratory Service (NHLS) National HIV Cohort was established in 2015 to facilitate monitoring, evaluation and research on South Africa's National HIV Treatment Programme. In South Africa, 84.8% of people living with HIV know their HIV status; 70.7% who know their status are on ART; and 87.4% on ART are virologically suppressed.

PARTICIPANTS

The NHLS National HIV Cohort includes the laboratory data of nearly all patients receiving HIV care in the public sector since April 2004. Patients are included in the cohort if they have received a CD4 count or HIV RNA viral load (VL) test. Using an anonymised unique patient identifier that we have developed and validated to linked test results, we observe patients prospectively through their laboratory results as they receive HIV care and treatment. Patients in HIV care are seen for laboratory monitoring every 6-12 months. Data collected include age, sex, facility location and test results for CD4 counts, VLs and laboratory tests used to screen for potential treatment complications.

FINDINGS TO DATE

From April 2004 to April 2018, 63 million CD4 count and VL tests were conducted at 5483 facilities. 12.6 million unique patients had at least one CD4 count or VL, indicating they had accessed HIV care, and 7.1 million patients had a VL test indicating they had started antiretroviral therapy. The creation of NHLS National HIV Cohort has enabled longitudinal research on all lab-monitored patients in South Africa's national HIV programme, including analyses of (1) patient health at presentation; (2) care outcomes such as 'CD4 recovery', 'retention in care' and 'viral resuppression'; (3) patterns of transfer and re-entry into care; (4) facility-level variation in care outcomes; and (5) impacts of policies and guideline changes.

FUTURE PLANS

Continuous updating of the cohort, integration with available clinical data, and expansion to include tuberculosis and other lab-monitored comorbidities.

'Voice needs teeth to have bite'! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa

There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community 'voice' and initiating dialogue with the authorities, giving the voice 'teeth'. Achieving 'bite', however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative.

Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study

BACKGROUND

The population of people living with HIV in South Africa is rapidly ageing due to increased survivorship attributable to antiretroviral therapy (ART). We sought to understand how the combined effects of HIV and ART have led to differences in healthy longevity by HIV status and viral suppression in this context.

METHODS

In this observational cohort modelling study we use longitudinal data from the 2015 baseline interview (from Nov 13, 2014, to Nov 30, 2015) and the 2018 longitudinal follow-up interview (from Oct 12, 2018, to Nov 7, 2019) of the population-based study Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) to estimate life expectancy and disability-free life expectancy (DFLE) of adults aged 40 years and older in rural South Africa. Respondents who consented to HIV testing, responded to survey questions on disability, and who were either interviewed in both surveys or who died between survey waves were included in the analysis. We estimate life expectancy and DFLE by HIV status and viral suppression (defined as <200 copies per mL) using Markov-based microsimulation.

FINDINGS

Among the 4322 eligible participants from the HAALSI study, we find a clear gradient in remaining life expectancy and DFLE based on HIV serostatus and viral suppression. At age 45 years, the life expectancy of a woman without HIV was 33·2 years (95% CI 32·0-35·0), compared with 31·6 years (29·2-34·1) a woman with virally suppressed HIV, and 26·4 years (23·1-29·1) for a woman with unsuppressed HIV; life expectancy for a 45 year old man without HIV was 27·2 years (25·8-29·1), compared with 24·1 years (20·9-27·2) for a man with virally suppressed HIV, and 17·4 years (15·0-20·3) for a man with unsuppressed HIV. Men and women with viral suppression could expect to live nearly as many years of DFLE as HIV-uninfected individuals at ages 45 years and 65 years.

INTERPRETATION

These results highlight the tremendous benefits of ART for population health in high-HIV-prevalence contexts and reinforce the need for continued work in making ART treatment accessible to ageing populations.

FUNDING

National Institutes of Health.

Service delivery models for enhancing linkage to and retention in HIV care services for adolescent girls and young women and adolescent boys and young men: a protocol for an overview of systematic reviews

INTRODUCTION

Recent advances in the HIV care continuum have shown that an individual diagnosed with HIV should be initiated on antiretroviral therapy as soon as possible regardless of the CD4 count levels and retained in HIV care services. Studies have reported large losses in the HIV continuum of care, before and after the era of universal test and treat. Several systematic reviews have reported on the strategies for improving linkage to and retention in HIV treatment and care. The purpose of this overview of systematic reviews is to identify HIV care interventions or service delivery models (SDMs) and synthesise evidence on the effects of these to link adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM) to care and retain them in care. We also aim to highlight gaps in the evidence on interventions and SDMs to improve linkage and retention in HIV care of AGYW and ABYM.

METHODS AND ANALYSIS

An electronic search of four online databases: PubMed, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science will be performed to identify systematic reviews on the effects of linkage to and retention in HIV care interventions or SDMs for AGYW aged 15-24 years and ABYM aged 15-35 years. Our findings on the effects of interventions and SDMs will be interpreted considering the intervention and or SDMs' effectiveness by the time period, setting and population of interest. Two or more authors will independently screen articles for inclusion using a priori criteria.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study as only published secondary data will be used. Our findings will be disseminated through peer-reviewed publication, conference abstracts and through presentations to stakeholders and other community fora. The findings from this overview of systematic reviews will inform mixed-methods operations research on HIV intervention programming and delivery of HIV care services for AGYW and ABYM in South Africa.

PROSPERO REGISTRATION NUMBER

CRD42020177933.

Spatiotemporal Variation and Predictors of Unsuppressed Viral Load among HIV-Positive Men and Women in Rural and Peri-Urban KwaZulu-Natal, South Africa

Unsuppressed HIV viral load is an important marker of sustained HIV transmission. We investigated the prevalence, predictors, and high-risk areas of unsuppressed HIV viral load among HIV-positive men and women. Unsuppressed HIV viral load was defined as viral load of ≥400 copies/mL. Data from the HIV Incidence District Surveillance System (HIPSS), a longitudinal study undertaken between June 2014 to June 2016 among men and women aged 15−49 years in rural and peri-urban KwaZulu-Natal, South Africa, were analysed. A Bayesian geoadditive regression model which includes a spatial effect for a small enumeration area was applied using an integrated nested Laplace approximation (INLA) function while accounting for unobserved factors, non-linear effects of selected continuous variables, and spatial autocorrelation. The prevalence of unsuppressed HIV viral load was 46.1% [95% CI: 44.3−47.8]. Predictors of unsuppressed HIV viral load were incomplete high school education, being away from home for more than a month, alcohol consumption, no prior knowledge of HIV status, not ever tested for HIV, not on antiretroviral therapy (ART), on tuberculosis (TB) medication, having two or more sexual partners in the last 12 months, and having a CD4 cell count of <350 cells/μL. A positive non-linear effect of age, household size, and the number of lifetime HIV tests was identified. The higher-risk pattern of unsuppressed HIV viral load occurred in the northwest and northeast of the study area. Identifying predictors of unsuppressed viral load in a localized geographic area and information from spatial risk maps are important for targeted prevention and treatment programs to reduce the transmission of HIV.