Factors associated with self-reported repeat HIV testing after a negative result in Durban, South Africa

Effectiveness of provider-initiated versus client-initiated HIV testing by different health facility departments in Northern Tanzania

BACKGROUND

HIV prevalence in Tanzania is still high at 4.7% among adults. Regular HIV testing is consistently advocated in the country to increase the level of awareness of HIV status, thus contributing to national HIV prevention. We report findings from three years of implementation of an HIV Test and Treat project utilizing provider-initiated and client-initiated testing and counselling (PITC and CITC). This study compared the effectiveness of PITC versus CITC in HIV case detection by the different departments of health facilities.

METHOD

This retrospective cross-sectional study used health facility-based HIV testing data collected from adults aged 18 years and above between June 2017 - July 2019 in the Shinyanga region, Tanzania. Chi-square and logistic regression analysis were used to assess determinants of yield (HIV positivity).

RESULTS

A total of 24,802 HIV tests were performed of which 15,814 (63.8%) were by PITC and 8,987 (36.2%) by CITC. Overall HIV positivity was 5.7%, higher among CITC at 6.6% than PITC at 5.2%. TB and IPD departments had the highest HIV positivity 11.8% and 7.8% respectively. Factors associated with a positive test were testing at a department in the facility compared to CITC, first-time test, and being or having been married compared to being single.

CONCLUSION

Success in identifying HIV + patients was highest among people visiting the clinic for HIV testing (CITC) and first-time testers. With PITC, HIV + patient detection differed between departments, suggesting divergent risk profiles of respective clients and/or divergent HIV alertness of staff. This underscores the importance of increased targeting for PITC to identify HIV + patients.

Is long-acting reversible contraceptive method use associated with HIV testing frequency in KwaZulu-Natal, South Africa and Lusaka, Zambia? Findings from the CUBE study

Objectives

To assess differences in HIV testing at 6-months intervals over 24 months among intramuscular depot medroxyprogesterone acetate (DMPA-IM) injectable, levonorgestrel implant, or copper intrauterine devices (IUD) users in KwaZulu-Natal, South Africa, and Lusaka, Zambia. Testing at recommended intervals has not been previously assessed in long-acting reversible contraceptive (LARC) users (implant and IUD users) compared to those using effective but shorter-acting methods (such as DMPA-IM) in sub-Saharan Africa.

Study design

As part of the longitudinal contraceptive use beyond ECHO (CUBE) study, we measured HIV testing over 24 months. Participants were considered continuous users of DMPA-IM, levonorgestrel implant, or copper IUD if they used the same method across all months of their study participation, or not continuous users of their baseline CUBE method if they switched or discontinued their method. We used multivariable logistic regression models with generalized estimating equations and robust standard errors, stratified by country, to assess differences in HIV testing.

Results

Among the 498 participants, HIV testing rates were higher in Zambia for all methods compared to South Africa. In bivariate analyses, continuous implant or IUD users (the LARC users) were significantly less likely to report having received HIV testing at the 6-months and 24-months surveys, compared to continuous DMPA-IM users. In adjusted longitudinal models, continuous IUD users (adjusted odds ratio: 0.42, 95% CI: 0.24, 0.74), continuous implant users (adjusted odds ratio: 0.23, 95% CI: 0.12, 0.42) in South Africa had significantly lower odds of HIV testing compared to continuous DMPA-IM users. There were no significant differences in Zambia in the adjusted models.

Conclusion

LARC use may reduce opportunities for HIV testing and users should be counseled on regular HIV testing and the option of HIV self-testing.

Implications

Due to infrequent clinical contacts which may lead to lower rates of HIV testing at recommended intervals, LARC users should be provided opportunities to test for HIV at home or when seeking other health services.

Prevalence and factors associated with self-reported HIV testing among adolescent girls and young women in Rwanda: evidence from 2019/20 Rwanda Demographic and Health Survey

BACKGROUND

HIV/AIDS remains a major public health problem globally. The majority of people living with HIV are from Sub-Saharan Africa, particularly adolescent girls and young women (AGYW) aged 15-24 years. HIV testing is crucial as it is the gateway to HIV prevention, treatment, and care; therefore this study determined the prevalence and factors associated with self-reported HIV testing among AGYW in Rwanda.

METHODS

We conducted secondary data analysis on the AGYW using data extracted from the nationally representative population-based 2019/2020 cross-sectional Rwanda Demographic and Health Survey (DHS). We described the characteristics of study participants and determined the prevalence of HIV testing and associated factors using the multivariable logistic regression model. We adjusted all our analyses for unequal sampling probabilities using survey weights.

RESULTS

There were a total of 5,732 AGYW, with the majority (57%) aged 15-19 years, 83% were not living with a man, 80% were from rural areas, 29% were from the East region, and 20% had a history of pregnancy. Self-reported HIV testing prevalence was 55.4% (95%CI: 53.7 to 57.0%). The odds of ever having an HIV test were significantly higher for those aged 20-24 years (aOR 2.87, 95%CI: 2.44 to 3.37); with higher education (aOR 2.41, 95%CI:1.48 to 3.93); who were rich (aOR 2.06, 95%CI:1.57 to 2.70); with access to at least one media (aOR 1.64, 95%CI: 1.14 to 2.37); who had ever been pregnant (aOR 16.12, 95%CI: 9.60 to 27.07); who ever had sex (aOR 2.40, 95%CI: 1.96 to 2.95); and those who had comprehensive HIV knowledge (aOR 1.34, 95%CI: 1.17 to 1.54).

CONCLUSIONS

We report an unmet need for HIV testing among AGYW in Rwanda. We recommend a combination of strategies to optimize access to HIV testing services, especially among the 15-19 years adolescent girls, including facility-based testing, school and community outreach, awareness campaigns on HIV testing, and home-based testing through HIV self-testing.

HIV testing criteria to reduce testing volume and increase positivity in Botswana

OBJECTIVE

We used data from a routine HIV testing program to develop risk scores to identify patients with undiagnosed HIV infection while reducing the number of total tests performed.

DESIGN

Multivariate logistic regression.

METHODS

We included demographic factors from HIV testing data collected in 134 Botswana Ministry of Health & Wellness facilities during two periods (1 October 2018- 19 August 2019 and 1 December 2019 to 30 March 2020). In period 2, the program collected additional demographic and risk factors. We randomly split each period into prediction/validation datasets and used multivariate logistic regression to identify factors associated with positivity; factors with adjusted odds ratios at least 1.5 were included in the risk score with weights equal to their coefficient. We applied a range of risk score cutoffs to validation datasets to determine tests averted, test positivity, positives missed, and costs averted.

RESULTS

In period 1, three factors were significantly associated with HIV positivity (coefficients range 0.44-0.87). In period 2, 12 such factors were identified (coefficients range 0.44-1.37). In period 1, application of risk score cutoff at least 1.0 would result in 50% fewer tests performed and capture 61% of positives. In period 2, a cutoff at least 1.0 would result in 13% fewer tests and capture 96% of positives; a cutoff at least 2.0 would result in 40% fewer tests and capture 83% of positives. Costs averted ranged from 12.1 to 52.3%.

CONCLUSION

Botswana's testing program could decrease testing volume but may delay diagnosis of some positive patients. Whether this trade-off is worthwhile depends on operational considerations, impact of testing volume on program costs, and implications of delayed diagnoses.

Determinants of HIV testing behaviour among male South African construction workers

The global trend of poorer outcomes across the HIV treatment cascade for men has drawn attention to the importance of engaging men in prevention and treatment services. The South African construction industry is one of the economic sectors most adversely affected by HIV/AIDS. Previous research on HIV testing behaviour among workers in the industry has revealed that male workers are less likely to be tested than female workers. Given this gender differential, this study employed a field-administered survey to gather data from 450 site-based, male construction workers in Western Cape, South Africa. An integrated model comprising demographic, cognitive, and behavioural factors was then hypothesised to explain HIV testing behaviour. Bivariate analysis and structural equation modelling were then used to test the model. Findings indicate that HIV knowledge, having previously had an STI, and possessing a positive attitude towards HIV testing are terminal predictors of testing behaviour. As a strategy for positively influencing testing behaviour, employers should ensure that effective communication about HIV testing is established with workers across all levels of education and ethnic groups. Interventions relating to risky sexual behaviour need particular attention, and where possible HIV testing should be coupled with general STI screening.

Financial incentives and deposit contracts to promote HIV retesting in Uganda: A randomized trial

BACKGROUND

Frequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV.

METHODS AND FINDINGS

In peri-urban Ugandan communities from October to December 2018, we randomized HIV-negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior.

CONCLUSIONS

Offering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02890459.

Predictors of retention in the prospective HIV prevention OKAPI cohort in Kinshasa

Retention is a key element in HIV prevention programs. In Sub-Saharan Africa most data on retention come from HIV clinical trials or people living with HIV attending HIV treatment and control programs. Data from observational cohorts are less frequent. Retention at 6-/12-month follow-up and its predictors were analyzed in OKAPI prospective cohort. From April 2016 to April 2018, 797 participants aged 15-59 years attending HIV Voluntary Counseling and Testing in Kinshasa were interviewed about HIV-related knowledge and behaviors at baseline and at 6- and 12-month follow-ups. Retention rates were 57% and 27% at 6- and 12-month follow up; 22% of participants attended both visits. Retention at 6-month was significantly associated with 12-month retention. Retention was associated with low economic status, being studying, daily/weekly Internet access, previous HIV tests and aiming to share HIV test with partner. Contrarily, perceiving a good health, living far from an antiretroviral center, daily/weekly alcohol consumption and perceiving frequent HIV information were inversely associated with retention. In conclusion, a high attrition was found among people attending HIV testing participating in a prospective cohort in Kinshasa. Considering the low retention rates and the predictors found in this study, more HIV cohort studies in Kinshasa need to be evaluated to identify local factors and strategies that could improve retention if needed.

Predictors of First-Time and Repeat HIV Testing Among HIV-Positive Individuals in Kenya

BACKGROUND

Despite a doubling of HIV testing coverage in Kenya over the past decade, approximately 2 in 10 people with HIV remained unaware of their infection in 2018. HIV testing is most effective in identifying people with undiagnosed HIV through frequent and strategic testing in populations at high risk. An assessment of testing frequency and predictors of first-time and repeat testing is critical for monitoring effectiveness of testing strategies.

METHODS

We conducted a cross-sectional analysis of adults aged ≥18 years who tested HIV-positive at 4 HIV testing and counseling clinics in Kenya from February 2015 to February 2016. We categorized individuals based on testing history, used Wilcoxon rank-sum tests to assess differences in intervals between the most recent and current HIV test, and used log-binomial regression to determine characteristics associated with first-time and repeat testing.

RESULTS

Among 1136 people testing HIV-positive, 336 (30%) had never tested before and 800 (70%) had, of whom 208 (26%) had previously tested positive. Among previously negative repeat testers, the median intertest interval was 414 days in key/priority populations (interquartile range = 179-1072) vs. 538 in the general population (interquartile range = 228-1299) (P = 0.09). Compared with previously negative repeat testers, being a first-time tester was associated with being age ≥40 years [vs. 18-24; adjusted risk ratio = 1.67, 95% confidence interval (CI): 1.23 to 2.26], men (vs. women; adjusted risk ratio = 1.45, 95% CI: 1.21 to 1.71), and testing through provider-initiated testing and counseling (vs. client initiated; 1.19, 95% CI: 1.00 to 1.40).

CONCLUSIONS

There is a need to increase HIV testing among older individuals and men, increase testing frequency in key/priority populations, and maintain provider-initiated and facility-based testing to reach first-time testers.

HIV retesting and risk behaviors among high-risk, HIV-uninfected adults in Uganda

There are limited data characterizing HIV retesting among high-risk adults in sub-Saharan Africa. From October-December 2018, we distributed recruitment cards offering health evaluations with HIV testing at venues frequented by individuals at-risk of HIV infection in Southwest Uganda. Those who attended were asked about their HIV testing history and risk factors: having >1 sexual partner, an HIV+ partner, STIs, and/or transactional sex. We defined "highest risk" as ≥3 risk factors and "frequent testing" as ≥3 tests within the past year. Of 1,777 cards distributed, 1,482 (83%) adults came to clinic: median age was 26(IQR: 22-31), 598 (40%) were men, and 334 (23%) were HIV+. Of 1,148 HIV-negative adults, 338 (29%) were highest risk and 205 (18%) were frequent testers. Frequent testing was similar in women (19%) and men (16%, p = 0.22). Among women, those at highest risk were more likely to report any testing (90% vs. 81%, p = 0.01) and frequent testing (25% vs. 18%, p = 0.06) than those at lower risk. Among men, any testing and frequent testing were similar between risk levels. Among adults recruited from high-risk venues in peri-urban Uganda, HIV risk behaviors were commonly reported, yet frequent retesting remained low. Interventions to promote retesting are needed, particularly among men.

A pilot randomized trial of incentive strategies to promote HIV retesting in rural Uganda

Background

Retesting for HIV is critical to identifying newly-infected persons and reinforcing prevention efforts among at-risk adults. Incentives can increase one-time HIV testing, but their role in promoting retesting is unknown. We sought to test feasibility and acceptability of incentive strategies, including commitment contracts, to promote HIV retesting among at-risk adults in rural Uganda.

Methods

At-risk HIV-negative adults were enrolled in a pilot trial assessing feasibility and acceptability of incentive strategies to promote HIV retesting three months after enrollment. Participants were randomized (1:1:3) to: 1) no incentive; 2) standard cash incentive (~US$4); and 3) commitment contract: participants could voluntarily make a low- or high-value deposit that would be returned with added interest (totaling ~US$4 including the deposit) upon retesting or lost if participants failed to retest. Contracts sought to promote retesting by leveraging loss aversion and addressing present bias via pre-commitment. Outcomes included acceptability of trial enrollment, contract feasibility (proportion of participants making deposits), and HIV retesting uptake.

Results

Of 130 HIV-negative eligible adults, 123 (95%) enrolled and were randomized: 74 (60%) to commitment contracts, 25 (20%) to standard incentives, and 24 (20%) to no incentive. Of contract participants, 69 (93%) made deposits. Overall, 93 (76%) participants retested for HIV: uptake was highest in the standard incentive group (22/25 [88%]) and lowest in high-value contract (26/36 [72%]) and no incentive (17/24 [71%]) groups.

Conclusion

In a randomized trial of strategies to promote HIV retesting among at-risk adults in Uganda, incentive strategies, including commitment contracts, were feasible and had high acceptability. Our findings suggest use of incentives for HIV retesting merits further comparison in a larger trial.

Trial registration

ClinicalTrials.gov identifier: NCT:02890459

Challenges and barriers to HIV service uptake and delivery along the HIV care cascade in Cameroon

Introduction

The year 2017 marked a transition period with the end of the implementation of Cameroon´s 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target.

Methods

We conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access.

Results

A total of 137 staff and 642 people living with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04-4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16-7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs “HIV test kits (21%), antiretrovirals (ARVs) (71.4%), viral load testing reagents (100%)” are the major barriers to service delivery and uptake along the cascade.

Conclusion

We identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target.

Uptake and determinants for HIV postpartum re-testing among mothers with prenatal negative status in Njombe region, Tanzania

Background

Uptake of Human Immunodeficiency Virus (HIV) re-testing among postnatal mothers who had previously tested HIV-negative is crucial for the detection of recent seroconverters who are likely to have high plasma viral loads and an increased risk of mother-to-child HIV transmission. Tanzania set a target of 90% re-testing of pregnant mothers who had tested negative during the first test. However, there is no statistics on the implementation, coverage and the factors determining re-testing among pregnant women in Tanzania. This study determined the proportion of newly-delivered, previously HIV-negative mothers who returned for HIV re-testing, and assessed the determinants of re-testing in Njombe Region in Tanzania.

Methods

A cross-sectional study was conducted in four health facilities in Njombe and Wanging’ombe districts during December 2015–June 2016. All newly-delivered mothers (≤7 days from delivery) presenting at health facilities and who had previously tested HIV-negative during pregnancy were included. A structured questionnaire was used to collect data on the determinants for re-testing. Records on the previous HIV testing was verified using antenatal clinic card. A multiple logistic regression model was used to calculate the adjusted odds ratio (AOR) with their 95% confidence intervals (CI) to quantify the association.

Results

Of 668 mothers (median age = 25 years) enrolled, 203 (30.4%) were re-tested for their HIV status. Among these, 27 (13.3%) tested positive. Significant predictors for HIV re-testing were socio-demographic factors including having at least a secondary education [AOR = 1.9, 95% CI: 1.25–3.02] and being employed [AOR = 2.1, 95% CI: 1.06–4.34]; personal and behavioural factors, reporting symptoms of sexually transmitted infections [AOR = 4.9, 95% CI: 2.15–6.14] and use of condoms during intercourse [AOR = 1.7, 95% CI: 1.13–2.71]. Significant health system factors were having ≥4 ANC visits [AOR = 1.8, 95% CI: 1.21–2.69] and perceiving good quality of HIV counselling and testing service at the first ANC visit [AOR = 2.14, 95% CI: 1.53–3.04].

Conclusion

Uptake of the HIV re-testing was lower than the national target. Education level, employment status, having ≥4 ANC visits, reporting sexually-transmitted infections, condom use, and good perception of HIV tests were significant factors increased uptake for re-testing. Identified factors should be incorporated in the Prevention of the Mother-to-Child Transmission (PMTCT) programme strategies to prevent HIV infection in new-borns.

Correlates of Undiagnosed HIV Infection and Retesting Among Voluntary HIV Testing Clients at Mildmay Clinic, Uganda

Increasing HIV diagnosis is important for combatting HIV. We invited individuals aged ≥ 13 years seeking voluntary HIV testing at Mildmay Clinic in Uganda to undertake a computer or audio-computer-assisted self-interview to facilitate post-test counseling. We evaluated first-visit data from 12,233 consenting individuals between January 2011 and October 2013. HIV prevalence was 39.0%. Of those with HIV, 37.2% already knew they were infected. Undiagnosed infection was associated with not being single, screening positive for depression (aOR 1.16, 95% CI 1.04-1.28), and screening for harmful drinking behavior (aOR 1.23, 95% CI 1.10-1.39). The odds of retesting subsequent to HIV diagnosis were lower for males (aOR 0.80, 95% CI 0.70-0.92) and those screening positive for harmful drinking behavior (aOR 0.77, 95% CI 0.66-0.88). Retesting was also associated with higher education and perceived social status below 'better off'. Our findings reiterate the value of population-based HIV surveys to provide estimates of testing coverage.

Facilitating HIV/AIDS and HIV testing literacy for emergency department patients: a randomized, controlled, trial

Background

Although this has not been fully studied, videos and pictorial brochures might be equivalent methods of delivering HIV/AIDS and HIV testing information to emergency departments (ED) patients. It also is not known how well or for how long such knowledge is retained, if this information should be tailored according to patient health literacy, and if retention of this knowledge impacts future HIV testing behavior.

Methods

We will conduct a multi-site, randomized, controlled, longitudinal trial among 600 English- and 600 Spanish-speaking 18–64-year-old ED patients to investigate these questions. We will stratify our sample within language (English vs. Spanish) by health literacy level (lower vs. higher) and randomly assign patients to receive HIV/AIDS and HIV testing information by video or pictorial brochure. All patients will be tested for HIV in the ED. At 12-months post-enrollment, we will invite participants to be tested again for HIV. As primary aims, we will compare the efficacy of pictorial brochures and videos in improving short-term (in ED) HIV/AIDS and HIV testing knowledge and retaining this knowledge over 12 months. We will determine if and how short-term improvement and longer-term retention of knowledge interacts with information delivery mode (pictorial brochure or video), patient health literacy level (lower or higher), and language (English or Spanish). As secondary aims, using the Information-Motivation-Behavioral Skills (IMB) model as a heuristic framework, we will measure constructs from the IMB model relevant to our study, and assess their impact on HIV re-testing behavior; we will also examine the moderating influences of information delivery mode, language, and health literacy level. In addition, we will explore simplified screening strategies to identify ED patients with lower health literacy as ways to implement a tailored approach to HIV/AIDS and HIV testing information delivery in EDs.

Discussion

Study findings will guide ED-based delivery of HIV/AIDS and HIV testing information; that is, whether delivery modes (video or pictorial brochure) should be selected for patients by language and/or health literacy level. The results also will inform EDs when, how, and for whom information needs to be provided for those undergoing testing again for HIV within a one-year period.

Trial registration

ClinicalTrials.gov Identifier: NCT02284451. Posted November 6, 2014.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0172-7) contains supplementary material, which is available to authorized users.

A Framework for Health Communication Across the HIV Treatment Continuum

Supplemental Digital Content is Available in the Text.

Background:

As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum.

Conceptual Framework:

This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters.

Discussion:

The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Community perceptions of repeat HIV-testing: experiences of the ANRS 12249 Treatment as Prevention trial in rural South Africa

In the context of the ANRS 12249 Treatment as Prevention (TasP) trial, we investigated perceptions of regular and repeat HIV-testing in rural KwaZulu-Natal (South Africa), an area of very high HIV prevalence and incidence. We conducted two qualitative studies, before (2010) and during the early implementation stages of the trial (2013-2014), to appreciate the evolution in community perceptions of repeat HIV-testing over this period of rapid changes in HIV-testing and treatment approaches. Repeated focus group discussions were organized with young adults, older adults and mixed groups. Repeat and regular HIV-testing was overall well perceived before, and well received during, trial implementation. Yet community members were not able to articulate reasons why people might want to test regularly or repeatedly, apart from individual sexual risk-taking. Repeat home-based HIV-testing was considered as feasible and convenient, and described as more acceptable than clinic-based HIV-testing, mostly because of privacy and confidentiality. However, socially regulated discourses around appropriate sexual behaviour and perceptions of stigma and prejudice regarding HIV and sexual risk-taking were consistently reported. This study suggests several avenues to improve HIV-testing acceptability, including implementing diverse and personalised approaches to HIV-testing and care, and providing opportunities for antiretroviral therapy initiation and care at home.

Level of viral suppression and the cascade of HIV care in a South African semi-urban setting in 2012

OBJECTIVE

In 2012, 7 years after the introduction of antiretroviral treatment (ART) in the South African township of Orange Farm, we measured the proportion of HIV-positive people who were virally suppressed, especially among high-risk groups (women 18-29 years and men 25-34 years).

DESIGN

A community-based cross-sectional representative survey was conducted among 3293 men and 3473 women.

METHODS

Study procedures included a face-to-face interview and collection of blood samples that were tested for HIV, 11 antiretroviral drugs and HIV-viral load.

RESULTS

HIV prevalence was 17.0% [95% confidence interval: 15.7-18.3%] among men and 30.1% [28.5-31.6%] among women. Overall, 59.1% [57.4-60.8%] of men and 79.5% [78.2-80.9%] of women had previously been tested for HIV. When controlling for age, circumcised men were more likely to have been tested compared with uncircumcised men (66.1 vs 53.6%; P < 0.001). Among HIV+, 21.0% [17.7-24.6%] of men and 30.5% [27.7-33.3%] of women tested positive for one or more antiretroviral drugs. Using basic calculations, we estimated that, between 2005 and 2012, ART programs prevented between 46 and 63% of AIDS-related deaths in the community. Among antiretroviral-positive, 91.9% [88.7-94.3%] had viral suppression (viral load <400 copies/ml). The proportion of viral suppression among HIV+ was 27.0% [24.3-29.9%] among women and 17.5% [14.4-20.9%] among men. These proportions were lower among the high-risk groups: 15.6% [12.1-19.7%] among women and 8.4% [5.0-13.1%] among men.

CONCLUSION

In Orange Farm, between 2005 and 2012, ART programs were suboptimal and, among those living with HIV, the proportion with viral suppression was still low, especially among the young age groups. However, our study showed that, in reality, antiretroviral drugs are highly effective in viral suppression at an individual level.

Reliability of reporting of HIV status and antiretroviral therapy usage during verbal autopsies: a large prospective study in rural Malawi

Objective

Verbal autopsies (VAs) are interviews with a relative or friend of the deceased; VAs are a technique used in surveillance sites in many countries with incomplete death certification. The goal of this study was to assess the accuracy and validity of data on HIV status and antiretroviral therapy (ART) usage reported in VAs and their influence on physician attribution of cause of death.

Design

This was a prospective cohort study.

Methods

The Karonga Health and Demographic Surveillance Site monitors demographic events in a population in a rural area of northern Malawi; a VA is attempted on all deaths reported. VAs are reviewed by clinicians, who, with additional HIV test information collected pre-mortem, assign a cause of death. We linked HIV/ART information reported by respondents during adult VAs to database information on HIV testing and ART use and analysed agreement using chi-square and kappa statistics. We used multivariable logistic regression to analyse factors associated with agreement.

Results

From 2003 to 2014, out of a total of 1,952 VAs, 80% of respondents reported the HIV status of the deceased. In 2013–2014, this figure was 99%. Of those with an HIV status known to the study, there was 89% agreement on HIV status between the VA and pre-mortem data, higher for HIV-negative people (92%) than HIV-positive people (83%). There was 84% agreement on whether the deceased had started ART, and 72% of ART initiation dates matched within 1 year.

Conclusions

In this population, HIV/ART information was often disclosed during a VA and matched well with other data sources. Reported HIV/ART status appears to be a reliable source of information to help classification of cause of death.

Repeated HIV Voluntary Counseling and Testing Increased Risk Behaviors Among Men Who Have Sex with Men in China: A Prospective Cohort Study

High risk MSM are recommended to take up HIV voluntary counseling and testing (VCT) once every 6 months. 809 HIV-negative MSM in Beijing, China entered the 18-month prospective cohort study; 228 joined an extended study at month 21. The majority (92.5 %) of the participants had taken up four rounds of VCT over the study period. HIV prevalence at months 0, 6, 12, 18 and 21 ranged from 2.5 to 6.3 %; HIV incidences for the four intervals between the five visits ranged from 5.00 to 14.28 per 100-person year. Despite experiencing repeated VCT, high levels of risk behaviors were reported at month 21. 18 % of the participants interviewed at month 21 self-reported increased in UAI and other risk behaviors, comparing recent and pre-baseline experiences. HIV transmission and risk behaviors had not been reduced by multiple rounds of VCT. Reasons behind apparent ineffectiveness and tailored repeated testing strategies need to be investigated.

Frequency of HIV-testing and factors associated with multiple lifetime HIV-testing among a rural population of Zambian men

BACKGROUND

Across sub-Saharan Africa, men's levels of HIV-testing remain inadequate relative to women's. Men are less likely to access anti-retroviral therapy and experience higher levels of morbidity and mortality once initiated on treatment. More frequent HIV-testing by men at continued risk of HIV-infection is required to facilitate earlier diagnosis. This study explored the frequency of HIV-testing among a rural population of men and the factors associated with more frequent HIV-testing.

METHODS

We conducted a secondary analysis of a population-based survey in three rural district in Zambia, from February-November, 2013. Households (N = 300) in randomly selected squares from 42 study sites, defined as a health facility and its catchment area, were invited to participate. Individuals in eligible households were invited to complete questionnaires regarding demographics and HIV-testing behaviours. Men were defined as multiple HIV-testers if they reported more than one lifetime test. Upon questionnaire completion, individuals were offered rapid home-based HIV-testing.

RESULTS

Of the 2376 men, more than half (61%) reported having ever-tested for HIV. The median number of lifetime tests was 2 (interquartile range = 1-3). Just over half (n = 834; 57%) of ever-testers were defined as multiple-testers. Relative to never-testers, multiple-testers had higher levels of education and were more likely to report an occupation. Among the 719 men linked to a spouse, multiple-testing was higher among men whose spouse reported ever-testing (adjusted prevalence ratio = 3.02 95% CI: 1.37-4.66). Multiple-testing was higher in study sites where anti-retroviral therapy was available at the health facility on the day of a health facility audit. Among ever-testers, education and occupation were positively associated with multiple-testing relative to reporting one lifetime HIV-test. Almost half (49%) of ever-testers accepted the offer of home-based HIV-testing.

DISCUSSION

Reported HIV-testing increased among this population of men since a 2011/12 survey. Yet, only 35% of all men reported multiple lifetime HIV-tests. The factors associated with multiple HIV-testing were similar to factors associated with ever-testing for HIV. Men living with HIV were less likely to report multiple HIV-tests and employment and education were associated with multiple-testing. The offer of home-based HIV-testing increased the frequency of HIV-testing among men.

CONCLUSION

Although men's levels of ever-testing for HIV have increased, strategies need to increase the lifetime frequency of HIV-testing among men at continued risk of HIV-infection.

Re-Testing and Seroconversion Among HIV Testing and Counseling Clients in Lesotho

HIV testing and counseling (HTC) is an essential component of comprehensive HIV programs. Retrospective HTC program data from 2006 to 2010 were examined to determine patterns of re-testing and seroconversion in Lesotho. Among 104,662 initially negative clients, 6,777 (6.5%) were re-testers. Predictors of re-testing included being male, age ≥ 25 years, divorced/separated, having more than a high school education, being tested as a couple, testing in the year 2006, testing in the capital city, and awareness of partner's recent testing behavior. Among re-testers who seroconverted (N = 259), predictors included being female and having less than a high school education. There is a critical need for more effectively targeting HIV retesting messages to align with WHO (2010) guidelines and identify persons at highest risk for HIV, to increase timely diagnoses and link persons to appropriate HIV prevention, care, and treatment services.