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Tanser FC, Kim HY, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, Wyke S, McGrath N, Adeagbo O, Sartorius B, Yapa HM, Zuma T, Zeitlin A, Blandford A, Dobra A, Bärnighausen T. Home-Based Intervention to Test and Start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa. J Int AIDS Soc 2021; 24:e25665. [PMID: 33586911 PMCID: PMC7883477 DOI: 10.1002/jia2.25665] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction The uptake of HIV testing and linkage to care remains low among men, contributing to high HIV incidence in women in South Africa. We conducted the “Home‐Based Intervention to Test and Start” (HITS) in a 2x2 factorial cluster randomized controlled trial in one of the World’s largest ongoing HIV cohorts in rural South Africa aimed at enhancing both intrinsic and extrinsic motivations for HIV testing. Methods Between February and December 2018, in the uMkhanyakude district of KwaZulu‐Natal, we randomly assigned 45 communities (clusters) (n = 13,838 residents) to one of the four arms: (i) financial incentives for home‐based HIV testing and linkage to care (R50 [$3] food voucher each); (ii) male‐targeted HIV‐specific decision support application, called EPIC‐HIV; (iii) both financial incentives and male‐targeted HIV‐specific decision support application and (iv) standard of care (SoC). EPIC‐HIV was developed to encourage and serve as an intrinsic motivator for HIV testing and linkage to care, and individually offered to men via a tablet device. Financial incentives were offered to both men and women. Here we report the effect of the interventions on uptake of home‐based HIV testing among men. Intention‐to‐treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster levels. Results Among all 13,838 men ≥ 15 years living in the 45 communities, the overall population coverage during a single round of home‐based HIV testing was 20.7%. The uptake of HIV testing was 27.5% (683/2481) in the financial incentives arm, 17.1% (433/2534) in the EPIC‐HIV arm, 26.8% (568/2120) in the arm receiving both interventions and 17.8% in the SoC arm. The probability of HIV testing increased substantially by 55% in the financial incentives arm (risk ratio (RR)=1.55, 95% CI: 1.31 to 1.82, p < 0.001) and 51% in the arm receiving both interventions (RR = 1.51, 95% CI: 1.21 to 1.87 p < 0.001), compared to men in the SoC arm. The probability of HIV testing did not significantly differ in the EPIC‐HIV arm (RR = 0.96, 95% CI: 0.76 to 1.20, p = 0.70). Conclusions The provision of a small financial incentive acted as a powerful extrinsic motivator substantially increasing the uptake of home‐based HIV testing among men in rural South Africa. In contrast, the counselling and testing application which was designed to encourage and serve as an intrinsic motivator to test for HIV did not increase the uptake of home‐based testing.
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Affiliation(s)
- Frank C Tanser
- Africa Health Research Institute, Durban, South Africa.,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Hae-Young Kim
- Africa Health Research Institute, Durban, South Africa.,Department of Population Health, New York University School of Medicine, New York, NY, USA.,KwaZulu-Natal Innovation and Sequencing Platform, KwaZulu-Natal, South Africa
| | | | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa.,Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sally Wyke
- University of Glasgow, Glasgow, United Kingdom
| | - Nuala McGrath
- Africa Health Research Institute, Durban, South Africa.,University of Southampton, Southampton, United Kingdom
| | - Oluwafemi Adeagbo
- Africa Health Research Institute, Durban, South Africa.,Department of Sociology, University of Johannesburg, Johannesburg, South Africa.,Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, SC, USA
| | - Benn Sartorius
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Handurugamage Manisha Yapa
- Africa Health Research Institute, Durban, South Africa.,The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | - Anya Zeitlin
- Institute for Global Health, University College London, London, United Kingdom
| | - Ann Blandford
- University College London Interaction Centre, University College London, London, United Kingdom
| | | | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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Mathenjwa T, Adeagbo O, Zuma T, Dikgale K, Zeitlin A, Matthews P, Seeley J, Wyke S, Tanser F, Shahmanesh M, Blandford A. Development and Acceptability of a Tablet-Based App to Support Men to Link to HIV Care: Mixed Methods Approach. JMIR Mhealth Uhealth 2020; 8:e17549. [PMID: 33231558 PMCID: PMC7723744 DOI: 10.2196/17549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Background The poor engagement of men with HIV care is attributed to a number of factors: fear of stigma, masculine representations, concerns related to confidentiality, and the time commitment needed to visit public health clinics. Digital technologies are emerging as an approach to support the engagement of men with care. Objective This study aims to deliver a usable and engaging tablet-based app, called EPIC-HIV 2 (Empowering People through Informed Choices for HIV 2), to support men in making informed decisions about engaging with HIV care in rural KwaZulu Natal, South Africa. Methods We employed a mixed methods, iterative, and three-phased design that was guided by self-determination theory (SDT), a person-based approach, and human-computer interaction techniques. We reviewed related literature and conducted secondary analyses of existing data to identify barriers and facilitators to linkage to care and inform content development and design principles and used focus group discussions with members of the community advisory board and general community to evaluate a PowerPoint prototype of the app; used observations and guided questions with a convenience sample of potential users from the intervention community to iteratively test and refine a functioning interactive app; and conducted qualitative interviews and satisfaction surveys with actual users to evaluate acceptability. Results Phase 1 identified supply- and demand-side barriers to linkage to care. Specifically, clinics were feminized spaces unattractive to men with high social costs of attendance. Men did not feel vulnerable to HIV, preferred traditional medicine, and were afraid of the consequences of being HIV positive. Thus, the app needed to allow men to identify the long-term health benefits to themselves and their families of starting antiretroviral therapy early and remaining on it, and these benefits typically outweigh the social costs of attending and being seen at a clinic. SDT led to content design that emphasized long-term benefits but at the same time supported the need for autonomy, competence, and relatedness and informed decision making. Phase 2 indicated that we needed to use simpler text and more images to help users understand and navigate the app. Phase 3 indicated that the app was acceptable and likely to encourage men to link to care. Conclusions We found that iteratively developing the app with potential users using local narratives ensured that EPIC-HIV 2 is usable, engaging, and acceptable. Although the app encouraged men to link to HIV care, it was insufficient as a stand-alone intervention for men in our sample to exercise their full autonomy to link to HIV care without other factors such as it being convenient to initiate treatment, individual experiences of HIV, and support. Combining tailored digital interventions with other interventions to address a range of barriers to HIV care, especially supply-side barriers, should be considered in the future to close the present linkage gap in the HIV treatment cascade.
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Affiliation(s)
- Thulile Mathenjwa
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa
| | - Oluwafemi Adeagbo
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa.,Department of Sociology, University of Johannesburg, Johannesburg, South Africa.,Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC, United States
| | - Thembelihle Zuma
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa
| | - Keabetswe Dikgale
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa
| | - Anya Zeitlin
- UCL Interaction Centre, University College London, London, United Kingdom
| | - Philippa Matthews
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sally Wyke
- University of Glasgow, Glasgow, United Kingdom
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa.,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu Natal, Mtubatuba, South Africa.,Institute for Global Health, University College London, London, United Kingdom
| | - Ann Blandford
- UCL Interaction Centre, University College London, London, United Kingdom
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Zeitlin A, Frishman WH, Chang CJ. The association of vitamin b 12 and folate blood levels with mortality and cardiovascular morbidity incidence in the old old: the Bronx aging study. Am J Ther 1997; 4:275-81. [PMID: 10423620 DOI: 10.1097/00045391-199707000-00008] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE An elevated homocysteine level in the blood has been identified as an independent risk factor for vascular disease, including coronary atherosclerosis and venoembolic disease. A deficiency of vitamins B ( 6 ), B ( 12 ), or folate in the blood can cause increased blood levels of homocysteine. We set out to determine whether there was a relationship between blood levels of folate and B ( 12 ) and the subsequent development of cardiovascular disease and mortality in old old ambulatory men and women. DESIGN Four hundred forty subjects (mean age, 79 years; 64% female) were followed in the Bronx Longitudinal Aging Study, a prospective study of 10 years duration, designed to assess risk factors for cardiovascular and cerebrovascular diseases and dementia in an ambulatory old old cohort. METHODS Serum levels of vitamin B ( 12 ) and folate were measured and related to the incidence of total all-cause mortality, stroke, myocardial infarction, coronary heart disease, and cardiovascular disease. RESULTS No statistical gender- or age-related differences were found in the mean levels of folate or B ( 12 ). The concentration of folate in the blood was not related to the incidence of mortality, myocardial infarction, stroke, or overall cardiovascular disease. However, by logistical regression and Cox proportional-hazards regression analyses, there was an increased incidence of mortality and coronary heart disease in those subjects having increased vitamin B ( 12 ) levels in the blood. Each 100-pg increase in B ( 12 ) was associated with a 10% increase in mortality and coronary heart disease incidence. CONCLUSION These results suggest that in elderly subjects, vitamin B ( 12 ) supplementation should not be routinely provided unless there are clear indications for doing so (a deficiency state), and then only to replace enough B ( 12 ) to correct the deficiency. A suggested treatment paradigm is provided for managing vitamin deficiency states and hyperhomocysteinemia in elderly subjects.
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Affiliation(s)
- A Zeitlin
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
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