Population impacts of conditional financial incentives and a male-targeted digital decision support application on the HIV treatment cascade in rural KwaZulu Natal: findings from the HITS cluster randomized clinical trial

INTRODUCTION

In South Africa, the HIV care cascade remains suboptimal. We investigated the impact of small conditional financial incentives (CFIs) and male-targeted HIV-specific decision-support application (EPIC-HIV) on the HIV care cascade.

METHODS

In 2018, in uMkhanyakude district, 45 communities were randomly assigned to one of four arms: (i) CFI for home-based HIV testing and linkage to care within 6 weeks (R50 [US$3] food voucher each); (ii) EPIC-HIV which are based on self-determination theory; (iii) both CFI and EPIC-HIV; and (iv) standard of care. EPIC-HIV consisted of two components: EPIC-HIV 1, provided to men through a tablet before home-based HIV testing, and EPIC-HIV 2, offered 1 month later to men who tested positive but had not yet linked to care. Linking HITS trial data to national antiretroviral treatment (ART) programme data and HIV surveillance programme data, we estimated HIV status awareness after the HITS trial implementation, ART status 3 month after the trial and viral load suppression 1 year later. Analysis included all known individuals living with HIV in the study area including those who did not participated in the HITS trial.

RESULTS

Among the 33,778 residents in the study area, 2763 men and 7266 women were identified as living with HIV by the end of the intervention period and included in the analysis. After the intervention, awareness of HIV-positive status was higher in the CFI arms compared to non-CFI arms (men: 793/908 [87.3%] vs. 1574/1855 [84.9%], RR = 1.03 [95% CI: 0.99-1.07]; women: 2259/2421 [93.3%] vs. 4439/4845 [91.6%], RR = 1.02 [95% CI: 1.00-1.04]). Three months after the intervention, no differences were found for linkage to ART between arms. One year after the intervention, only 1829 viral test results were retrieved. Viral suppression was higher but not significant in the EPIC-HIV intervention arms among men (65/99 [65.7%] vs. 182/308 [59.1%], RR = 1.11 [95% CI: 0.88-1.40]).

CONCLUSIONS

Small CFIs can contribute to achieve the first step of the HIV care cascade. However, neither CFIs nor EPIC-HIV was sufficient to increase the number of people on ART. Additional evidence is needed to confirm the impact of EPIC-HIV on viral suppression.

Effect of a male-targeted digital decision support application aimed at increasing linkage to HIV care among men: Findings from the HITS cluster randomized clinical trial in rural South Africa

Introduction

Linkage to HIV care remains suboptimal among men. We investigated the effectiveness of a male-targeted HIV-specific decision support app, Empowering People through Informed Choices for HIV (EPIC-HIV), on increasing linkage to HIV care among men in rural South Africa.

Methods

Home-Based Intervention to Test and Start (HITS) was a multi-component cluster-randomized controlled trial among 45 communities in uMkhanyakude, KwaZulu-Natal. The development of EPIC-HIV was guided by self-determination theory and human-centered intervention design to increase intrinsic motivation to seek HIV testing and care among men. EPIC-HIV was offered in two stages: EPIC-HIV 1 at the time of home-based HIV counseling and testing (HBHCT), and EPIC-HIV 2 at 1 month after positive HIV diagnosis. Sixteen communities were randomly assigned to the arms to receive EPIC-HIV, and 29 communities to the arms without EPIC-HIV. Among all eligible men, we compared linkage to care (initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 1 year of a home visit, which was ascertained from individual clinical records. Intention-to-treat analysis was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., financial incentives) and clustering at the community level. We also conducted a satisfaction survey for EPIC-HIV 2.

Results

Among all 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, resulting in 122 HIV-positive tests. Among these, 54 men linked to care within 1 year after HBHCT. Additionally, of the 13,765 eligible participants who did not receive HBHCT or received HIV-negative results, 301 men linked to care within 1 year. Overall, only 13 men received EPIC-HIV 2. The proportion of linkage to care did not differ in the arms assigned to EPIC-HIV compared to those without EPIC-HIV (adjusted risk ratio=1.05; 95% CI:0.86-1.29). All 13 men who used EPIC-HIV 2 reported the app was acceptable, user-friendly, and useful for getting information on HIV testing and treatment.

Conclusion

Reach was low although acceptability and usability of the app was very high among those who engaged with it. Enhanced digital support applications could form part of interventions to increase knowledge of HIV treatment for men. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

The impact of a conditional financial incentive on linkage to HIV care: Findings from the HITS cluster randomized clinical trial in rural South Africa

Introduction

HIV elimination requires innovative approaches to ensure testing and immediate treatment provision. We investigated the effectiveness of conditional financial incentives on increasing linkage to HIV care in a 2×2 factorial cluster randomized controlled trial-Home-Based Intervention to Test and Start (HITS) - in rural South Africa.

Methods

Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 communities were randomly assigned to the arms to receive financial incentives for home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks (R50 [US$3] food voucher each) and 29 communities to the arms without financial incentives. We examined linkage to care (i.e., initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 6 weeks of a home visit, the eligibility period to receive the second financial incentive. Linkage to care was ascertained from individual clinical records. Intention-to-treat analysis (ITT) was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., male-targeted HIV-specific decision support app) and clustering of standard errors at the community level.

Results

Among 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, which resulted in 122 HIV-positive tests. Of these, 27 linked to care within 6 weeks of HBHCT. Additionally, of eligible men who did not receive HBHCT, 66 linked to care. In the ITT analysis, the proportion of linkage to care among men did not differ in the arms which received financial incentives and those without financial incentives (adjusted Risk Ratio [aRR]=0.78, 95% CI: 0.51-1.21). Among 19,884 eligible women, 29.1% received HBHCT, which resulted in 375 HIV-positive tests. Of these, 75 linked to care. Among eligible women who did not receive HBHCT, 121 linked to care within 6 weeks. Women in the financial incentive arms had a significantly higher probability of linkage to care, compared to those in the arms without financial incentives (aRR=1.50; 95% CI: 1.03-2.21).

Conclusion

While a small once-off financial incentive did not increase linkage to care among men during the eligibility period of 6 weeks, it significantly improved linkage to care among women over the same period. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

AIDS impact special issue 2023: two-way associations between relationship quality and uptake of couples health screening including HIV testing and counselling together: quantitative analysis of a couples cohort in rural South Africa

In the context of a couples cohort established to evaluate an optimised couples-focused behavioural intervention in rural South Africa, we examined: (1) Is couples' relationship quality (RQ) associated with couples HIV testing and counselling (CHTC) uptake? (2) Does CHTC uptake or the intervention components uptake improve subsequent RQ? Enrolled couples, (n = 218), previously naïve to couples HIV testing, were invited to two group sessions and offered four couples counselling sessions (CS1-CS4), as part of the intervention and administered a questionnaire individually at baseline, four weeks, and four months, which included item-scales to measure RQ: satisfaction, intimacy, dyadic trust, conflict, and mutual constructive communication. Logistic models indicated that no baseline RQ measures were significantly associated with CHTC uptake. Linear regression models showed that CHTC uptake before four weeks assessment significantly improved couples' satisfaction and trust at four weeks, and intimacy at four months. Attending at least one CS was associated with increased satisfaction, intimacy, and decreased conflict within couples at four weeks; the improvement in intimacy was sustained at four months. Consistent with the theoretical interdependence model, our findings suggest that CHTC and CS seemed to strengthen aspects of relationship quality, possibly leading to further collaboration in managing lifestyle changes and treatment adherence.

Prevalence of Curable Sexually Transmitted Infections in a Population-Representative Sample of Young Adults in a High HIV Incidence Area in South Africa

BACKGROUND

Recent population-representative estimates of sexually transmitted infection (STI) prevalence in high HIV burden areas in southern Africa are limited. We estimated the prevalence and associated factors of 3 STIs among adolescents and young adults (AYA) in rural South Africa.

METHODS

Between March 2020 and May 2021, a population-representative sample of AYA aged 16 to 29 years were randomly selected from a Health and Demographic Surveillance Site in rural KwaZulu-Natal, South Africa, for a 2 × 2 factorial randomized controlled trial. Participants in 2 intervention arms were offered baseline testing for gonorrhea, chlamydia, and trichomoniasis using GeneXpert. Prevalence estimates were weighted for participation bias, and logistic regression models were used to assess factors associated with STIs.

RESULTS

Of 2323 eligible AYA, 1743 (75%) enrolled in the trial. Among 863 eligible for STI testing, 814 (94%) provided specimens (median age of 21.8 years, 52% female, and 71% residing in rural areas). Population-weighted prevalence estimates were 5.0% (95% confidence interval [CI], 4.2%-5.8%) for gonorrhea, 17.9% (16.5%-19.3%) for chlamydia, 5.4% (4.6%-6.3%) for trichomoniasis, and 23.7% (22.2%-25.3%) for any STI. In multivariable models, female sex (adjusted odds ratio [aOR], 2.24; 95% CI, 1.48-3.09) and urban/periurban (vs. rural) residence (aOR, 1.48; 95% CI, 1.02-2.15) were associated with STIs; recent migration was associated with lower odds of STI (aOR, 0.37; 95% CI, 0.15-0.89). Among those with an STI, 53 (31.0%) were treated within 7 days; median time to treatment was 11 days (interquartile range, 6-77 days).

CONCLUSIONS

We identified a high prevalence of curable STIs among AYA in rural South Africa. Improved access to STI testing to enable etiologic diagnosis and rapid treatment is needed.

'I accept his manhood is on life-support': A qualitative understanding of the impact of diabetes on sexual relationships among men and women living with type 2 diabetes and their partners in South Africa

AIMS

To explore the impact of diabetes on sexual relationships among men and women living with type 2 diabetes People living with type 2 diabetes (PLWD) and their partners in Cape Town, South Africa.

METHODS

As part of a larger study developing an intervention to improve type 2 diabetes mellitus (T2DM) self management, we conducted in-depth individual interviews with 10 PLWD and their partners without diabetes about experiences living with T2DM, between July 2020 and January 2021. We used inductive thematic analysis.

RESULTS

Both PLWD and partners felt that their sexual relationships and desires changed post-diagnosis, in ways beyond biomedical issues. Although couples' reports on the quality of their sexual relationships were concordant, most participants had not communicated their sexual desires and concerns with each other, causing unhappiness and fears of disappointing or losing their partner. Participants felt uninformed about sexual dysfunction but had not discussed this with their healthcare provider, leading to increased anxiety.

CONCLUSION

PLWD and their partners need more informational support to increase their understanding of diabetes-associated sexual dysfunction and to decrease fears and anxiety. Strengthening communication within couples on sexual issues may empower them to find solutions to problems experienced. This may improve couples' relationships and quality of life, and indirectly result in better self management of T2DM.

The prevalence of hypertension and hypertension control among married Namibian couples

BACKGROUND

Previous studies suggest that having a marital partner with hypertension is associated with an individual's increased risk of hypertension, however this has not been investigated in sub-Saharan Africa despite hypertension being a common condition; the age-standardised prevalence of hypertension was 46.0% in 2013 in Namibia.

OBJECTIVE

To explore whether there is spousal concordance for hypertension and hypertension control in Namibia.

METHODS

Couples data from the 2013 Namibia Demographic and Health Survey were analysed. Bivariable and multivariable logistic regression models were used to explore the odds of individual's hypertension based on their partner's hypertension status, 492 couples. and the odds of hypertension control in individuals based on their partner's hypertension control (121 couples), where both members had hypertension. Separate models were built for female and male outcomes for both research questions to allow independent consideration of risk factors to be analysed for female and males.

RESULTS

The unadjusted odds ratio of 1.57 (CI 1.10-2.24) for hypertension among individuals (both sexes) whose partner had hypertension compared to those whose partner did not have hypertension, was attenuated to aOR 1.35 (CI 0.91-2.00) for females (after adjustment for age, BMI, diabetes, residence, individual and partner education) and aOR 1.42 (CI 0.98-2.07) for males (after adjustment for age and BMI). Females and males were significantly more likely to be in control of their hypertension if their partner also had controlled hypertension, aOR 3.69 (CI 1.23-11.12) and aOR 3.00 (CI 1.07-8.36) respectively.

CONCLUSIONS

Having a partner with hypertension was positively associated with having hypertension among married Namibian adults, although not statistically significant after adjustment. Partner's hypertension control was significantly associated with individual hypertension control. Couples-focused interventions, such as routine partner screening of hypertensive individuals, could be developed in Namibia.

Impact of family networks on uptake of health interventions: evidence from a community-randomized control trial aimed at increasing HIV testing in South Africa

INTRODUCTION

While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network.

METHODS

The "Home-Based Intervention to Test and Start" (HITS) was a 2×2 factorial community-randomized controlled trial in Umkhanyakude, KwaZulu-Natal, South Africa, embedded in the Africa Health Research Institute's population-based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro-incentive and a male-targeted HIV-specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro-incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co-residents, a socio-centric family network was constructed among HITS-eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level.

RESULTS

Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3-7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9-22.3). The difference in efficacy was statistically significant (21.1-6.5 = 14.6%; 95% CI: 9.3-19.9).

CONCLUSIONS

Micro-incentives appear to have synergistic effects when distributed within family networks. These effects support family network-based approaches for the design of health interventions.

Intervention development of 'Diabetes Together' using the person-based approach: a couples-focused intervention to support self-management of type 2 diabetes in South Africa

OBJECTIVES

Type 2 diabetes (T2D) is a growing concern in South Africa, where many find self-management challenging. Behaviour-change health interventions are enhanced by involving partners of patients. We aimed to develop a couples-focused intervention to improve self-management of T2D among adults in South Africa.

DESIGN

We used the person-based approach (PBA): synthesising evidence from existing interventions; background research; theory; and primary qualitative interviews with 10 couples to ascertain barriers and facilitators to self-management. This evidence was used to formulate guiding principles that directed the intervention design. We then prototyped the intervention workshop material, shared it with our public and patient involvement group and ran iterative co-discovery think-aloud sessions with nine couples. Feedback was rapidly analysed and changes formulated to improve the intervention, optimising its acceptability and maximising its potential efficacy.

SETTING

We recruited couples using public-sector health services in the area of Cape Town, South Africa, during 2020-2021.

PARTICIPANTS

The 38 participants were couples where one person had T2D.

INTERVENTION

We developed the 'Diabetes Together' intervention to support self-management of T2D among couples in South Africa, focussing on: improved communication and shared appraisal of T2D; identifying opportunities for better self-management; and support from partners. Diabetes Together combined eight informational and two skills-building sections over two workshops.

RESULTS

Our guiding principles included: providing equal information on T2D to partners; improving couples' communication; shared goal-setting; discussion of diabetes fears; discussing couples' roles in diabetes self-management; and supporting couples' autonomy to identify and prioritise diabetes self-management strategies.Participants viewing Diabetes Together valued the couples-focus of the intervention, especially communication. Feedback resulted in several improvements throughout the intervention, for example, addressing health concerns and tailoring to the setting.

CONCLUSIONS

Using the PBA, our intervention was developed and tailored to our target audience. Our next step is to pilot the workshops' feasibility and acceptability.

Implementation and effectiveness of a linkage to HIV care intervention in rural South Africa (ANRS 12249 TasP trial)

BACKGROUND

Timely linkage to care and ART initiation is critical to decrease the risks of HIV-related morbidity, mortality and HIV transmission, but is often challenging. We report on the implementation and effectiveness of a linkage-to-care intervention in rural KwaZulu-Natal, South Africa.

METHODS

In the ANRS 12249 TasP trial on Universal Testing and Treatment (UTT) implemented between 2012-2016, resident individuals ≥16 years were offered home-based HIV testing every six months. Those ascertained to be HIV-positive were referred to trial clinics. Starting May 2013, a linkage-to-care intervention was implemented in both trial arms, consisting of tracking through phone calls and/or home visits to "re-refer" people who had not linked to care to trial clinics within three months of the first home-based referral. Fidelity in implementing the planned intervention was described using Kaplan-Meier estimation to compute conditional probabilities of being tracked and of being re-referred by the linkage-to-care team. Effect of the intervention on time to linkage-to-care was analysed using a Cox regression model censored for death, migration, and end of data follow-up.

RESULTS

Among the 2,837 individuals (73.7% female) included in the analysis, 904 (32%) were tracked at least once, and 573 of them (63.4%) were re-referred. Probabilities of being re-referred was 17% within six months of first referral and 31% within twelve months. Compared to individuals not re-referred by the intervention, linkage-to-care was significantly higher among those with at least one re-referral through phone call (adjusted hazard ratio [aHR] = 1.82; 95% confidence interval [95% CI] = 1.47-2.25), and among those with re-referral through both phone call and home visit (aHR = 3.94; 95% CI = 2.07-7.48).

CONCLUSIONS

Phone calls and home visits following HIV testing were challenging to implement, but appeared effective in improving linkage-to-care amongst those receiving the intervention. Such patient-centred strategies should be part of UTT programs to achieve the UNAIDS 95-95-95 targets.

Men’s motivations, barriers to and aspirations for their families’ health in the first 1000 days in sub-Saharan Africa: a secondary qualitative analysis

Introduction

The first 1000 days of life are a critical period of growth and development that have lasting implications for health, cognitive, educational and economic outcomes. In sub-Saharan Africa, gender and social norms are such that many men have little engagement with maternal and child health and nutrition during pregnancy and early childhood. This study explores how men perceive their role in three sites in sub-Saharan Africa.

Methods

Secondary qualitative analysis of 10 focus group discussions with 76 men in Burkina Faso, Ghana and South Africa. Data were thematically analysed to explore men’s perceptions of maternal and child health and nutrition.

Results

Men considered themselves ‘providers’ and 'advisors' within their families, particularly of finances, food and medicines. They also indicated that this advice was out of care and concern for their families’ health. There were similarities in how the men perceive their role. Differences between men living in rural and urban settings included health priorities, the advice and the manner in which it was provided. Across all settings, men wanted to be more involved with maternal and child health and nutrition. Challenges to doing so included stigma and proscribed social gender roles.

Conclusion

Men want a greater engagement in improving maternal and child health and nutrition but felt that their ability to do so was limited by culture-specified gender roles, which are more focused on providing for and advising their families. Involving both men and women in intervention development alongside policymakers, health professionals and researchers is needed to improve maternal and child health and nutrition.

The mental wellbeing of prison staff in England during the COVID-19 pandemic: A cross-sectional study

Background

COVID-19 is likely to have had an impact on the mental wellbeing of prison staff because of the high risk for infectious disease outbreaks in prisons and the pre-existing high burden of mental health issues among staff.

Methods

A cross-sectional study of staff within 26 prisons in England was carried out between 20th July 2020 and 2nd October 2020. Mental wellbeing was measured using the Short-version of Warwick-Edinburgh Wellbeing Scale (SWEMWBS). Staff wellbeing was compared to that of the English population using indirectly standardised data from the Health Survey for England 2010-13 and a one-sample t-test. Multivariate linear regression modelling explored associations with mental wellbeing score.

Results

Two thousand five hundred and thirty-four individuals were included (response rate 22.2%). The mean age was 44 years, 53% were female, and 93% were white. The sample mean SWEMWBS score was 23.84 and the standardised population mean score was 23.57. The difference in means was statistically significant (95% CI 0.09-0.46), but not of a clinically meaningful level. The multivariate linear regression model was adjusted for age category, sex, ethnicity, smoking status, occupation, and prison service region. Higher wellbeing was significantly associated with older age, male sex, Black/Black British ethnicity, never having smoked, working within the health staff team, and working in certain prison regions.

Interpretation

Unexpectedly, prison staff wellbeing as measured by SWEMWBS was similar to that of the general population. Reasons for this are unclear but could include the reduction in violence within prisons since the start of the pandemic. Qualitative research across a diverse sample of prison settings would enrich understanding of staff wellbeing within the pandemic.

Moving our care home: A qualitative study of the views and experiences of residents, relatives and staff

INTRODUCTION

Involuntary relocation when care homes close can be detrimental to residents' health and well-being and is associated with increased mortality. There is little formal evidence to support whether planning can mitigate the impact of such moves. This study aimed to understand the experiences of a whole care home relocation where staff and residents relocated together using existing published guidance.

METHODS

A longitudinal qualitative research study using individual face-to-face semi-structured interviews was conducted between August 2018 and August 2019. Baseline interviews were conducted 6-8 weeks after relocation with follow-up interviews 10-12 months later. Interviews were recorded, transcribed and analysed using framework analysis.

RESULTS

27 interviews were conducted; 19 baseline interviews (4 residents, 7 family members, 8 staff) and 8 follow-up interviews (2 residents, 2 family members, 4 staff). Participants' feelings about the relocation were mixed: some reported apprehension before the move but others excitement. Residents and families felt variably involved in planning the move, whereas staff expressed lack of involvement. Time, family support and continuity of care helped participants settle in. The new environment shaped participants' experiences and abilities to adjust, especially the lack of a homely feeling with the new home, the larger size and changes in staff organisation and management.

CONCLUSIONS

Despite implementation of existing guidance, relocation was still challenging for residents, staff and family members. Future relocations should increase involvement of staff in the planning and design of the home; offer continuous support to those involved; and ensure continuity of care and management style.

Can a conditional financial incentive (CFI) reduce socio-demographic inequalities in home-based HIV testing uptake? A secondary analysis of the HITS clinical trial intervention in rural South Africa

In sub-Saharan Africa, home-based HIV testing interventions are designed to reach sub-populations with low access to HIV testing such as men, younger or less educated people. Combining these interventions with conditional financial incentives (CFI) has been shown to be effective to increase testing uptake. CFI are effective for one-off health behaviour change but whether they operate differentially on different socio-demographic groups is less clear. Using data from the HITS trial in South Africa, we investigated whether a CFI was able to reduce existing home-based HIV testing uptake inequalities observed by socio-demographic groups. Residents aged ≥15 years in the study area were assigned to an intervention arm (16 clusters) or a control arm (29 clusters). In the intervention arm, individuals received a food voucher (∼3.5 US dollars) if they accepted to take a home-based HIV test. Testing uptake differences were considered for socio-demographic (sex, age, education, employment status, marital status, household asset index) and geographical (urban/rural living area, distance from clinic) characteristics. Among the 37,028 residents, 24,793 (9290 men, 15,503 women) were included in the analysis. CFI increased significantly testing uptake among men (39.2% vs 25.2%, p < 0.001) and women (45.9% vs 32.0%, p < 0.001) with similar absolute increase between men and women. Uptake was higher amongst the youngest or least educated individuals, and amongst single (vs in union) or unemployed men. Absolute uptake increase was also significantly higher amongst these groups resulting in increasing socio-demographic differentials for home-based HIV testing uptake. However, because these groups are known to have less access to other public HIV testing services, CFI could reduce inequalities for HIV testing access in our specific context. Although CFI significantly increased home-based HIV testing uptake, it did not do so differentially by socio-demographic group. Future interventions using CFI should make sure that the intervention alone does not increase existing health inequities.

Protocol: evaluation of an optimised couples-focused intervention to increase testing for HIV in rural KwaZulu-Natal, South Africa, the Igugu Lethu (‘Our treasure’) cohort study

Background

Between 2012 and 2015, the Uthando Lwethu (UL) study demonstrated that a theory-based behavioural couples-focused intervention significantly increased participation in couples HIV testing and counselling (CHTC) among South African couples who had never previously tested for HIV together or mutually disclosed their HIV status, 42% compared to 12% of the control group at 9 months follow-up. Although effective, we were nonetheless concerned that in this high prevalence setting the majority (58%) of intervention couples chose not to test together. In response we optimised the UL intervention and in a new study, ‘Igugu Lethu’, we are evaluating the success of the optimised intervention in promoting CHTC.

Methods

One hundred eighty heterosexual couples, who have been in a relationship together for at least 6 months, are being recruited and offered the optimised couples-focused intervention. In the Igugu Lethu study, we have expanded the health screening visit offered to couples to include other health conditions in addition to CHTC. Enrolled couples who choose to schedule CHTC will also have the opportunity to undertake a random blood glucose test, blood pressure and BMI measurements, and self-sample for STI testing as part of their health screening. Individual surveys are administered at baseline, 4 weeks and 4 months follow-up. The proportion of couples who decide to test together for HIV will be compared to the results of the intervention arm in the UL study (historical controls). To facilitate this comparison, we will use the same recruitment and follow-up strategies in the same community as the previous UL study.

Discussion

By strengthening communication and functioning within the relationship, the Igugu Lethu study, like the previous UL study, aims to transform the motivation of individual partners from a focus on their own health to shared health as a couple. The Igugu Lethu study findings will answer whether the optimised couples-focused behavioural intervention and offering CHTC as part of a broader health screening for couples can increase uptake of CHTC by 40%, an outcome that would be highly desirable in populations with high HIV prevalence.

Trial registration

Retrospectively registered. ISRCTN Registry ISRCTN 46162564 Registered on 26th May 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13894-3.

A-39 Baseline And Initial Post-Injury Presentation Of Athletes With Self-Reported Neurodevelopmental Disorders As Measured By ImPACT

Purpose: To compare neurocognitive profiles of high school athletes with self-reported LD and/or ADHD neurodevelopmental disorders (ND) to controls at baseline (BL) and during initial post-injury (PI) testing with ImPACT. Methods: A sample of 155 (112 males, 43 females) high school athletes who completed BL and PI testing with ImPACT from 2019 to present was analyzed. Students who self-reported ND (n = 36) were compared to those who did not. ImPACT composites Verbal Memory (VM), Visual Memory (VisM), Visual Motor Speed (VMS), Reaction Time (RT), Impulse Control (IC), and Total Symptom Score (TSS) were measured as dependent variables. Data was analyzed using multiple one-way ANOVA’s accounting for gender and presence of ND as fixed factors. Results: One-way ANOVA (CI = 95%) revealed a five-point difference on BL-VMS between NDs and controls (p &lt; 0.001). ND students’ performance declined more after injury on VMS (p = 0.042). Analysis also showed ND PI-IC score about two points higher than controls (p = 0.014). With respect to gender, females reported greater symptoms on PI and more symptom increase than their male counterparts (p &lt; 0.001, p = 0.01; respectively). Lastly, ND males performed eight points lower on BL-VM than ND females (p = 0.031). Conclusions: The present study confirms that performance differences on ImPACT VMS may be expected between student-athletes with self-reported ND and their counterparts. Gender appears to contribute to performance on some measures of ImPACT; females endorse more symptoms than males PI, and ND males perform worse on BL-VM than ND females.

The association of exposure to DREAMS on sexually acquiring or transmitting HIV amongst adolescent girls and young women living in rural South Africa

OBJECTIVE

We investigate how risk of sexually acquiring or transmitting HIV in adolescent girls and young women (AGYW) changed following the real-world implementation of DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored and Safe) HIV prevention programme.

DESIGN

A representative population-based prospective cohort study of AGYW living in rural KwaZulu-Natal.

METHODS

Between 2017 and 2019, we interviewed a random sample of AGYW aged 13-22 years annually. We measured exposure to DREAMS as self-reported receipt of an invitation to participate and/or participation in DREAMS activities that were provided by DREAMS implementing organizations. HIV and herpes simplex virus type 2 (HSV-2) statuses were ascertained through blood tests on Dried Blood Spot (DBS). We used multivariable regression analysis to assess the association between exposure to DREAMS and risk of acquiring HIV: measured as incident HSV-2 (a proxy of sexual risk) and incident HIV;and the risk of sexually transmitting HIV: measured as being HIV positive with a detectable HIV viral load (≥50 copie/ml) on the last available DBS. We adjusted for sociodemographic, sexual relationship, and migration.

RESULTS

Two thousand one hundred and eighty-four (86.4%) of those eligible agreed to participate and 2016 (92.3%) provided data for at least one follow-up time-point. One thousand and thirty (54%) were exposed to DREAMS;HIV and HSV-2 incidence were 2.2/100 person-years [95% confidence interval (CI) 1.66-2.86] and 17.3/100 person-years (95% CI 15.5-19.4), respectively. There was no evidence that HSV-2 and HIV incidence were lower in those exposed to DREAMS: adjusted rate ratio (aRR) 0.96 (95% CI 0.76-1.23 and 0.83 (95% CI 0.46-1.52), respectively. HIV viral load was detectable for 169 (8.9%) respondents;there was no evidence this was lower in those exposed to DREAMS with an adjusted risk difference, compared with those not exposed to DREAMS, of 0.99% (95% CI-1.52 to 3.82]. Participants who lived in peri-urban/ urban setting were more likely to have incident HIV and transmissible HIV. Both HSV-2 incidence and the transmissible HIV were associated with older age and ever having sex. Findings did not differ substantively by respondent age group.

CONCLUSION

DREAMS exposure was not associated with measurable reductions in risk of sexually acquiring or transmitting HIV amongst a representative cohort of AGYW in rural South Africa.

Protocol: Mapping social networks, social influence and sexual health among youth in rural KwaZulu-Natal, the Sixhumene cohort study

Background: Sexual behaviour and sexually transmitted infections are strongly affected by social connections, and interventions are often adapted more readily when diffused through social networks. However, evidence on how young people acquire ideas and change behaviour through the influence of important social contacts is not well understood in high-HIV-prevalence settings, with the result that past peer-led HIV-prevention interventions have had limited success.

Methods: We therefore designed a cohort study (named Sixhumene or ‘we are connected’) to follow young people in three rural and small-town communities in uMkhanyakude district, KwaZulu-Natal, South Africa, and the people that these youth identify as important in their lives. We will interview them five times over three years, at each visit collecting information on their socioeconomic, social and sexual health lives, and testing them for HIV and herpes simplex virus 2 (HSV-2). We will use this information to understand how these young people’s sexual health decisions are formed. This will include evaluating how poor sexual health outcomes are correlated across social networks, how youth mimic the attitudes and behaviours of those around them, who is at greatest risk of acquiring HIV and HSV-2, and who might be most influential within communities and thus best able to promote protective interventions.

Discussion: The information gathered through this study will allow us to describe social connection and influence spread through these real-world social networks, and how this leads to sexual health outcomes. Sixhumene will provide vital inputs for mathematical models of communities and spreading processes, as well as inform the development of effective interventions to protect the sexual health of community members through appropriate targeting with optimised messaging requiring fewer resources.

Antenatal couples' counselling in Uganda (ACCU): study protocol for a randomised controlled feasibility trial

BACKGROUND

Common avoidable factors leading to maternal, perinatal and neonatal deaths include lack of birth planning (and delivery in an inappropriate place) and unmet need for contraception. Progress has been slow because routine antenatal care has focused only on women. Yet, in Uganda, many women first want the approval of their husbands. The World Health Organization recommends postpartum family planning (PPFP) as a critical component of health care. The aim of this trial is to test the feasibility of recruiting and retaining participants in a trial of a complex community-based intervention to provide counselling to antenatal couples in Uganda.

METHODS

This is a two-group, non-blinded cluster-randomised controlled feasibility trial of a complex intervention. Primary health centres in Uganda will be randomised to receive the intervention or usual care provided by the Ministry of Health. The intervention consists of training village health teams to provide basic counselling to couples at home, encouraging men to accompany their wives to an antenatal clinic, and secondly of training health workers to provide information and counselling to couples at antenatal clinics, to facilitate shared decision-making on the most appropriate place of delivery, and postpartum contraception. We aim to recruit 2 health centres in each arm, each with 10 village health teams, each of whom will aim to recruit 35 pregnant women (a total of 700 women per arm). The village health teams will follow up and collect data on pregnant women in the community up to 12 months after delivery and will directly enter the data using the COSMOS software on a smartphone.

DISCUSSION

This intervention addresses two key avoidable factors in maternal, perinatal and neonatal deaths (lack of family planning and inappropriate place of delivery). Determining the acceptability and feasibility of antenatal couples' counselling in this study will inform the design of a fully randomised controlled clinical trial. If this trial demonstrates the feasibility of recruitment and delivery, we will seek funding to conduct a fully powered trial of the complex intervention for improving uptake of birth planning and postpartum family planning in Uganda.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR202102794681952 . Approved on 10 February 2021. ISRCTN Registry ISRCTN97229911. Registered on 23 September 2021.

Isisekelo Sempilo study protocol for the effectiveness of HIV prevention embedded in sexual health with or without peer navigator support (Thetha Nami) to reduce prevalence of transmissible HIV amongst adolescents and young adults in rural KwaZulu-Natal: a 2 × 2 factorial randomised controlled trial

Background

Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality, morbidity and incidence. Effective individual-level prevention modalities have not translated into population-level impact in southern Africa due to sub-optimal coverage among adolescents and youth who are hard to engage. We aim to investigate the feasibility, acceptability, and preliminary population level effectiveness of HIV prevention services with or without peer support to reduce prevalence of transmissible HIV amongst adolescents and young adults in KwaZulu-Natal.

Methods

We are conducting a 2 × 2 factorial trial among young men and women aged 16–29 years, randomly selected from the Africa Health Research Institute demographic surveillance area. Participants are randomly allocated to one of four intervention combinations: 1) Standard of Care (SOC): nurse-led services for HIV testing plus ART if positive or PrEP for those eligible and negative; 2) Sexual and Reproductive Health (SRH): Baseline self-collected vaginal and urine samples with study-organized clinic appointments for results, treatment and delivery of HIV testing, ART and PrEP integrated with SRH services; 3) Peer-support: Study referral of participants to a peer navigator to assess their health, social and educational needs and provide risk-informed HIV prevention, including facilitating clinic attendance; or 4) SRH + peer-support.

The primary outcomes for effectiveness are: (1) the proportion of individuals with infectious HIV at 12 months and (2) uptake of risk-informed comprehensive HIV prevention services within 60 days of enrolment. At 12 months, all participants will be contacted at home and the study team will collect a dried blood spot for HIV ELISA and HIV viral load testing.

Discussion

This trial will enable us to understand the relative importance of SRH and peer support in creating demand for effective and risk informed biomedical HIV prevention and preliminary data on their effectiveness on reducing the prevalence of transmissible HIV amongst all adolescents and youth.

Trial registration

Trial Registry: clincialtrials.gov. ClinicalTrials.gov Identifier NCT04532307. Registered: March 2020.

Social Influence and Uptake of Couples HIV Testing and Counselling in KwaZulu-Natal, South Africa

Social influences may create a barrier to couples HIV testing and counselling (CHTC) uptake in sub-Saharan Africa. This secondary analysis of data collected in the 'Uthando Lwethu' randomised controlled trial used discrete-time survival models to evaluate the association between within-couple average 'peer support' score and uptake of CHTC by the end of nine months' follow-up. Peer support was conceptualised by self-rated strength of agreement with two statements describing friendships outside of the primary partnership. Eighty-eight couples (26.9%) took up CHTC. Results tended towards a dichotomous trend in models adjusted only for trial arm, with uptake significantly less likely amongst couples in the higher of four peer support score categories (OR 0.34, 95% CI 0.18, 0.68 [7-10 points]; OR 0.53, 95% CI 0.28, 0.99 [≥ 11 points]). A similar trend remained in the final multivariable model, but was no longer significant (AOR 0.59, 95% CI 0.25, 1.42 [7-10 points]; AOR 0.88, 95% CI 0.36, 2.10 [≥ 11 points]). Accounting for social influences in the design of couples-focused interventions may increase their success.

Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis

OBJECTIVE

Peer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal.

METHODS

Between March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18-29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach.

RESULTS

Overall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake.

CONCLUSION

Both professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.

Antiretroviral therapy based HIV prevention targeting young women who sell sex: a mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa

Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13-22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15-24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%-15.7%) reported transactional sex and 10.6% (95%CI: 8.85-12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.

Reducing new chlamydia infection among young men by promoting correct and consistent condom use: Protocol for a randomised controlled trial. (Preprint)

Background

The health, social, and economic costs of sexually transmitted infections (STIs) represent a major public health concern. Young people are considered one of the groups most at risk for acquiring and transmitting STIs. Correct and consistent condom use has been shown to be the most effective method for reducing STIs; however, condoms are often not used properly. Evidence shows that brief behavior change interventions that focus on skills, communication, and motivation to acquire safe sex practices should be adopted into routine care to reduce STIs. Funding for sexual health services in England has declined dramatically, so novel ways of reducing clinic attendance are being sought. The home-based intervention strategy (HIS-UK) to promote condom use among young men has shown promise in feasibility and pilot studies by demonstrating high acceptability of the intervention in participant and health professional feedback, including aiding men to find condoms they like and feel more confident when using condoms.

Objective

The aim of this study is to determine the effectiveness and cost-effectiveness of HIS-UK when compared to usual condom distribution care among young men.

Methods

The 3 trial arms consisting of “e-HIS” (HIS-UK delivered digitally), “ProHIS” (HIS-UK delivered face-to-face), and control condition (usual National Health Service [NHS] care) will be compared against the following 3 primary outcomes: the extent to which correct and consistent condom use is increased; improvement of condom use experiences (pleasure as well as fit and feel); and decrease in chlamydia test positivity. Eligibility criteria include men aged 16-25 years at risk of STIs through reporting of condom use errors (ie, breakage or slippage) or condomless penile-vaginal or penile-anal intercourse with casual or new sexual partners during the previous 3 months. Prospective participants will be recruited through targeted advertisements and an opportunistic direct approach at selected sexual health and genitourinary medicine services and university-associated health centers and general practitioner practices. Community and educational establishments will be used to further advertise the study and signpost men to recruitment sites. Participants will be randomly allocated to 1 of 3 trial arms. A repeated measures design will assess the parallel arms with baseline and 12 monthly follow-up questionnaires after intervention and 3 chlamydia screening points (baseline, 6, and 12 months).

Results

Recruitment commenced in March 2020. Due to the COVID-19 pandemic, the study was halted and has since reopened for recruitment in Summer 2021. A 30-month recruitment period is planned.

Conclusions

If effective and cost-effective, HIS-UK can be scaled up into routine NHS usual care to reduce both STI transmission in young people and pressure on NHS resources. This intervention may further encourage sexual health services to adopt digital technologies, allowing for them to become more widely available to young people while decreasing health inequalities and fear of stigmatization.

Trial Registration

ISRCTN Registry ISRCTN11400820; https://www.isrctn.com/ISRCTN11400820

Optimising a couples-focused intervention to increase couples' HIV testing and counselling using the person-based approach: a qualitative study in Kwa-Zulu Natal, South Africa

OBJECTIVES

This qualitative study explored how to optimise a couples-focused intervention to promote couples HIV testing and counselling (CHTC).

SETTING

Community setting in Kwa-Zulu Natal, South Africa.

PARTICIPANTS

Qualitative interviews were conducted with 20 couples who had participated in a couples-focused intervention and five staff members delivering the intervention. Partners were interviewed individually by researchers of the same gender.

INTERVENTION

A couples-focused intervention comprised of two group sessions and four couples counselling sessions was previously shown to significantly increase uptake to CHTC in Kwa-Zulu Natal, South Africa. However, more than half of couples participating in the intervention still chose not to test together during follow-up.

ANALYSIS

The transcripts were analysed using the table of changes from the person-based approach. Proposed optimisations were discussed with a community group to ensure the intervention was as persuasive and acceptable as possible.

RESULTS

Many couples found it challenging to discuss CHTC with their partner due to an implied lack of trust. Optimisations to the intervention were identified to increase readiness to discuss CHTC, including education about serodiscordance, discussions about CHTC by peer mentors and open discussion of personal barriers to CHTC during couples' counselling sessions. Additional training for staff in open questioning techniques could help them feel more comfortable to explore couples' perceived barriers to CHTC, rather than advising couples to test. A logic model was developed to show anticipated mechanisms through which the optimised intervention would increase uptake to CHTC, including increasing knowledge, increasing positive outcome beliefs and managing negative emotions.

CONCLUSIONS

In-depth qualitative research informed optimisations to a couples-focused intervention for further evaluation in South Africa to encourage uptake to CHTC. Suggestions are made for optimal methods to gain open feedback on intervention experiences where participants may be reluctant to share negative views.

Determining the prevalence and incidence of SARS-CoV-2 infection in prisons in England: a repeated panel survey & enhanced outbreak investigation

Background

There are over 80,000 people imprisoned in England and Wales in 117 prisons. The management of the COVID-19 pandemic presents particular challenges in this setting where confined, crowded, and poorly ventilated conditions facilitate the rapid spread of infectious diseases.

Objective

The COVID-19 in Prison Study aims to examine the epidemiology of SARS-CoV-2 in prisons in England in order to inform public health policy and practice during the pandemic and recovery. The primary objective is to estimate the proportion of positive tests of SARS-CoV-2 infection among residents and staff within selected prisons. The secondary objectives include estimating the incidence rate of SARS-CoV-2 infection and examining how the proportion of positive tests and the incidence rate vary among individual, institutional, and system level factors.

Methods

Phase 1 comprises a repeated panel survey of prison residents and staff in a representative sample of 28 prisons across England. All residents and staff in the study prisons are eligible for inclusion. Participants will be tested for SARS-CoV-2 using a nasopharyngeal swab twice (6 weeks apart). Staff will also be tested for antibodies to SARS-CoV-2. Phase 2 focuses on SARS-CoV-2 infection in prisons with recognized COVID-19 outbreaks. Any prison in England will be eligible to participate if an outbreak is declared. In 3 outbreak prisons, all participating staff and residents will be tested for SARS-CoV-2 antigens at the following 3 timepoints: as soon as possible after the outbreak is declared (day 0), 7 days later (day 7), and at day 28. They will be swabbed twice (a nasal swab for lateral flow device testing and a nasopharyngeal swab for polymerase chain reaction testing). Testing will be done by external contractors. Data will also be collected on individual, prison level, and community factors. Data will be stored and handled at the University of Southampton and Public Health England. Summary statistics will summarize the prison and participant characteristics. For the primary objective, simple proportions of individuals testing positive for SARS-CoV-2 and incidence rates will be calculated. Linear regression will examine the individual, institutional, system, and community factors associated with SARS-CoV-2 infection within prisons.

Results

The UK Government’s Department for Health and Social Care funds the study. Data collection started on July 20, 2020, and will end on May 31, 2021. As of May 2021, we had enrolled 4192 staff members and 6496 imprisoned people in the study. Data analysis has started, and we expect to publish the initial findings in summer/autumn 2021. The main ethical consideration is the inclusion of prisoners, who are vulnerable participants.

Conclusions

This study will provide unique data to inform the public health management of SARS-CoV-2 in prisons. Its findings will be of relevance to health policy makers and practitioners working in prisons.

International Registered Report Identifier (IRRID)

DERR1-10.2196/30749

Thetha Nami: participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and youth in rural South Africa

BACKGROUND

Despite effective biomedical tools, HIV remains the largest cause of morbidity/mortality in South Africa - especially among adolescents and young people. We used community-based participatory research (CBPR), informed by principles of social justice, to develop a peer-led biosocial intervention for HIV prevention in KwaZulu-Natal (KZN).

METHODS

Between March 2018 and September 2019 we used CBPR to iteratively co-create and contextually adapt a biosocial peer-led intervention to support HIV prevention. Men and women aged 18-30 years were selected by community leaders of 21 intervention implementation areas (izigodi) and underwent 20 weeks of training as peer-navigators. We synthesised quantitative and qualitative data collected during a 2016-2018 study into 17 vignettes illustrating the local drivers of HIV. During three participatory intervention development workshops and community mapping sessions, the peer-navigators critically engaged with vignettes, brainstormed solutions and mapped the components to their own izigodi. The intervention components were plotted to a Theory of Change which, following a six-month pilot and process evaluation, the peer-navigators refined. The intervention will be evaluated in a randomised controlled trial ( NCT04532307 ).

RESULTS

Following written and oral assessments, 57 of the 108 initially selected participated in two workshops to discuss the vignettes and co-create the Thetha Nami (`talk to me'). The intervention included peer-led health promotion to improve self-efficacy and demand for HIV prevention, referrals to social and educational resources, and aaccessible youth-friendly clinical services to improve uptake of HIV prevention. During the pilot the peer-navigators approached 6871 young people, of whom 6141 (89%) accepted health promotion and 438 were linked to care. During semi-structured interviews peer-navigators described the appeal of providing sexual health information to peers of a similar age and background but wanted to provide more than just "onward referral". In the third participatory workshop 54 peer-navigators refined the Thetha Nami intervention to add three components: structured assessment tool to tailor health promotion and referrals, safe spaces and community advocacy to create an enabling environment, and peer-mentorship and navigation of resources to improve retention in HIV prevention.

CONCLUSION

Local youth were able to use evidence to develop a contextually adapted peer-led intervention to deliver biosocial HIV prevention.

Effect of peer-distributed HIV self-test kits on demand for biomedical HIV prevention in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social networks versus direct delivery

STUDY OBJECTIVE

We investigated two peer distribution models of HIV self-testing (HIVST) in HIV prevention demand creation compared with trained young community members (peer navigators).

METHODS

We used restricted randomisation to allocate 24 peer navigator pairs (clusters) in KwaZulu-Natal 1:1:1: (1) standard of care (SOC): peer navigators distributed clinic referrals, pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) information to 18-30 year olds. (2) peer navigator direct distribution (PND): Peer navigators distributed HIVST packs (SOC plus two OraQuick HIVST kits) (3) incentivised peer networks (IPN): peer navigators recruited young community members (seeds) to distribute up to five HIVST packs to 18-30 year olds within their social networks. Seeds received 20 Rand (US$1.5) for each recipient who distributed further packs. The primary outcome was PrEP/ART linkage, defined as screening for PrEP/ART eligibility within 90 days of pack distribution per peer navigator month (pnm) of outreach, in women aged 18-24 (a priority for HIV prevention). Investigators and statisticians were blinded to allocation. Analysis was intention to treat. Total and unit costs were collected prospectively.

RESULTS

Between March and December 2019, 4163 packs (1098 SOC, 1480 PND, 1585 IPN) were distributed across 24 clusters. During 144 pnm, 272 18-30 year olds linked to PrEP/ART (1.9/pnm). Linkage rates for 18-24-year-old women were lower for IPN (n=26, 0.54/pnm) than PND (n=45, 0.80/pnm; SOC n=49, 0.85/pnm). Rate ratios were 0.68 (95% CI 0.28 to 1.66) for IPN versus PND, 0.64 (95% CI 0.26 to 1.62) for IPN versus SOC and 0.95 (95% CI 0.38 to 2.36) for PND versus SOC. In 18-30 year olds, PND had significantly more linkages than IPN (2.11 vs 0.88/pnm, RR 0.42, 95% CI 0.18 to 0.98). Cost per pack distributed was cheapest for IPN (US$36) c.f. SOC (US$64). Cost per person linked to PrEP/ART was cheaper in both peer navigator arms compared with IPN.

DISCUSSION

HIVST did not increase demand for PrEP/ART. Incentivised social network distribution reached large numbers with HIVST but resulted in fewer linkages compared with PrEP/ART promotion by peer navigators.

TRIAL REGISTRATION NUMBER

NCT03751826.

Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial)

We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm³ at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.

Common mental disorders and HIV status in the context of DREAMS among adolescent girls and young women in rural KwaZulu-Natal, South Africa

BACKGROUND

HIV affects many adolescent girls and young women (AGYW) in South Africa. Given the bi-directional HIV and mental health relationship, mental health services may help prevent and treat HIV in this population. We therefore examined the association between common mental disorders (CMD) and HIV-related behaviours and service utilisation, in the context of implementation of the combination DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) HIV prevention programme in rural uMkhanyakude district, KwaZulu-Natal. DREAMS involved delivering a package of multiple interventions in a single area to address multiple sources of HIV risk for AGYW.

METHODS

We analysed baseline data from an age-stratified, representative cohort of 13-22 year-old AGYW. We measured DREAMS uptake as a count of the number of individual-level or community-based interventions each participant received in the last 12 months. CMD was measured using the validated Shona Symptom Questionnaire, with a cut off score ≥ 9 indicating probable CMD. HIV status was ascertained through home-based serotesting. We used logistic regression to estimate the association between CMD and HIV status adjusting for socio-demographics and behaviours.

RESULTS

Probable CMD prevalence among the 2184 respondents was 22.2%, increasing steadily from 10.1% among 13 year-old girls to 33.1% among 22 year-old women. AGYW were more likely to report probable CMD if they tested positive for HIV (odds ratio vs. test negative: 1.88, 95% confidence interval: 1.40-2.53). After adjusting for socio-demographics and behaviours, there was evidence that probable CMD was more prevalent among respondents who reported using multiple healthcare-related DREAMS interventions.

CONCLUSION

We found high prevalence of probable CMD among AGYW in rural South Africa, but it was only associated with HIV serostatus when not controlling for HIV acquisition risk factors. Our findings highlight that improving mental health service access for AGYW at high risk for HIV acquisition might protect them. Interventions already reaching AGYW with CMD, such as DREAMS, can be used to deliver mental health services to reduce both CMD and HIV risks. There is a need to integrate mental health education into existing HIV prevention programmes in school and communities.

Home-Based Intervention to Test and Start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa

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.

Modelling the health and economic impacts of different testing and tracing strategies for COVID-19 in the UK

Background: Coronavirus disease 2019 (COVID-19) is resurgent in the UK and health and economic costs of the epidemic continue to rise. There is a need to understand the health and economic costs of different courses of action. Methods: We combine modelling, economic analysis and a user-friendly interface to contrast the impact and costs of different testing strategies: two levels of testing within the current test-trace-isolate (TTI) strategy (testing symptomatic people, tracing and isolating everyone) and a strategy where TTI is combined with universal testing (UT; i.e. additional population testing to identify asymptomatic cases). We also model effective coverage of face masks. Results: Increased testing is necessary to suppress the virus after lockdown. Partial reopening accompanied by scaled-up TTI (at 50% test and trace levels), full isolation and moderately effective coverage of masks (30% reduction in overall transmission) can reduce the current resurgence of the virus and protect the economy in the UK. Additional UT from December 2020 reduces the epidemic dramatically by Jan 2021 when combined with enhanced TTI (70% test-trace levels) and full isolation. UT could then be stopped; continued TTI would prevent rapid recurrence. This TTI+UT combination can suppress the virus further to save ~20,000 more lives and avoid ~£90bn economic losses, though costs ~£8bn more to deliver. We assume that all traced and lab-confirmed cases are isolated. The flexible interface we have developed allows exploration of additional scenarios, including different levels of reopening of society after the second lockdown in England as well as different levels of effective mask coverage. Conclusions: Our findings suggest that increased TTI is necessary to suppress the virus and protect the economy after the second lockdown in England. Additional UT from December 2020 reduces the epidemic dramatically by Jan 2021 and could then be stopped, as continued TTI would prevent rapid recurrence.

Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014

BACKGROUND

In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014.

METHODS

Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age.

RESULTS

The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively.

CONCLUSIONS

The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.

Acceptability of a tablet-based application to support early HIV testing among men in rural KwaZulu-Natal, South Africa: a mixed method study

Uptake of HIV testing remains low among men in South Africa. As part of a trial, we assessed the acceptability of a theoretically derived and adapted tablet-based-application (EPIC-HIV1) in rural South Africa. We conducted 20 in-depth interviews with men aged ≥18 years and offered a tablet-based survey to all men aged ≥15 years who received EPIC-HIV1 (Sep-Dec 2018). We conducted a descriptive analysis of the survey and used Self-Determination Theory (SDT) to guide our thematic analysis. A total of 232/307 (75%) completed the survey, 55% of whom were aged 15-24 years. 96%[ CI: 92.8-98.2%; n = 223] found EPIC-HIV1 acceptable and 77% [95% CI: 71.8-82.6%; n = 179] found it user-friendly. 222 [96%] reported that EPIC-HIV1 motivated them to test; 83% (192/232) tested for HIV, of which 33% (64/192) were first time testers. Those who did not consent (n = 40) were more likely to have had an HIV-positive test result. Participants reported that the app boosted their confidence to test. However, they were unsure that the app would help them overcome barriers to test in local clinics. Given reach and usability, an adapted SDT male-tailored app was found to be acceptable and could encourage positive health-seeking behavioural change among men.

92 Relocation in Care Homes (RICH) Study: The Experience of Different Stakeholders

Introduction

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Methods

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Results

Seven themes were identified and organised under three stages: pre-move (communication and involvement; preparation for the move; and attitudes towards the move), day-of-the-move (organisation of the move), and post-move (environmental change and impact; staff organisation and management; and settling in). Family and staff members reported that the pre-move information provided was inconsistent and staff did not feel involved in the planning and design process. Pre-move visits and staff and family support were beneficial for residents’ preparation for the move. All participants expressed sadness about the closure, and reported apprehension about moving. The moving day felt disorganised and stressful to staff who had to spread between the two homes. Post-move, the new care home was perceived by many participants as a ‘hotel’ rather than a home. Its larger size and confusing layout impacted negatively on residents and staff. New staff and changes in management structure were perceived by the different stakeholders to cause increased staff workload. Residents adjusted variably to the new home, with family support and staff continuity of care proving to be facilitators.

Conclusions

Despite extensive planning, relocation and adjustment was challenging. Recommendations for future relocations include: increasing involvement of staff in the planning and design of the home; ensuring consistent communication and organising staff rotas to maintain continuity of care.

Power relations and negotiations in contraceptive decision-making when husbands oppose family planning: analysis of ethnographic vignette couple data in Southwest Nigeria

Contraceptive use in Nigeria has remained low at less than 15% for over two decades. Although husbands' opposition is acknowledged as one of the factors impeding women's contraceptive use, little is known about how wives negotiate when their husbands oppose family planning. We addressed this research gap by conducting thematic analyses of qualitative data from 30 interviews of married couples. We employed thematic analysis to identify relevant themes from the transcribed data. The findings clearly demonstrate attitudes highlighting an imbalance in power relations and contraceptive decision-making within marital relationships. By initially complying with the husband's wish as a 'sign of honour', and then making further attempts at convincing him about family planning use, a woman can achieve her contraceptive target, or through the involvement of a third party. Wives are less empowered to overtly use contraceptives when their husbands oppose family planning. However, there are accepted justifications for covert use. The findings underscore the need to strengthen family planning interventions to enable behavioural change among Nigerian men, promote gender and reproductive health rights, and empower women with better negotiation skills.

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

INTRODUCTION

The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa.

METHODS

The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level.

RESULTS

8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited.

CONCLUSIONS

PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).

Are socioeconomic inequalities in the incidence of small-for-gestational-age birth narrowing? Findings from a population-based cohort in the South of England

OBJECTIVES

To investigate socioeconomic inequalities, using maternal educational attainment, maternal and partner employment status, and lone motherhood indicators, in the risk of small-for-gestational-age (SGA) births, their time trend, potential mediation by maternal smoking and body mass index, and effect modification by parity.

DESIGN

Population-based birth cohort using routine antenatal healthcare data.

SETTING

Babies born at University Hospital Southampton, UK, between 2004 and 2016.

PARTICIPANTS

65 909 singleton live births born to mothers aged ≥18 years between 24-week and 42-week gestation.

MAIN OUTCOME MEASURES

SGA (birth weight <10th percentile for others born at the same number of completed weeks compared with 2013/2014 within England and Wales).

RESULTS

Babies born to mothers educated up to secondary school level (adjusted OR (aOR) 1.32, 99% CI 1.19 to 1.47), who were unemployed (aOR 1.27, 99% CI 1.16 to 1.38) or with unemployed partners (aOR 1.27, 99% CI 1.13 to 1.43), were at greater risk of being SGA. There was no statistically significant change in the magnitude of this risk difference by these indicators over time between 2004 and 2016, as estimated by linear interactions with year of birth. Babies born to lone mothers were not at higher risk compared with partnered mothers after adjusting for maternal smoking (aOR 1.05, 99% CI 0.93 to 1.20). The inverse association between maternal educational attainment and SGA risk appeared greater in multiparous (aOR 1.40, 99% CI 1.10 to 1.77) compared with primiparous women (aOR 1.28, 99% CI 1.12 to 1.47), and the reverse was true for maternal and partner's unemployment where the association was stronger in primiparous women.

CONCLUSIONS

Socioeconomic inequalities in SGA risk by educational attainment and employment status are not narrowing over time, with differences in association strength by parity. The greater SGA risk in lone mothers was potentially explained by maternal smoking. Preventive interventions should target socially disadvantaged women, including preconception and postpartum smoking cessation to reduce SGA risk.

Home-based intervention to test and start (HITS) protocol: a cluster-randomized controlled trial to reduce HIV-related mortality in men and HIV incidence in women through increased coverage of HIV treatment

BACKGROUND

To realize the full benefits of treatment as prevention in many hyperendemic African contexts, there is an urgent need to increase uptake of HIV testing and HIV treatment among men to reduce the rate of HIV transmission to (particularly young) women. This trial aims to evaluate the effect of two interventions - micro-incentives and a tablet-based male-targeted HIV decision support application - on increasing home-based HIV testing and linkage to HIV care among men with the ultimate aim of reducing HIV-related mortality in men and HIV incidence in young women.

METHODS/DESIGN

This is a cluster randomized trial of 45 communities (clusters) in a rural area in the uMkhanyakude district of KwaZulu Natal, South Africa (2018-2021). The study is built upon the Africa Health Research Institute (AHRI)'s HIV testing platform, which offers annual home-based rapid HIV testing to individuals aged 15 years and above. In a 2 × 2 factorial design, individuals aged ≥15 years living in the 45 clusters are randomly assigned to one of four arms: i) a financial micro-incentive (food voucher) (n = 8); ii) male-targeted HIV specific decision support (EPIC-HIV) (n = 8); iii) both the micro incentives and male-targeted decision support (n = 8); and iv) standard of care (n = 21). The EPIC-HIV application is developed and delivered via a tablet to encourage HIV testing and linkage to care among men. A mixed method approach is adopted to supplement the randomized control trial and meet the study aims.

DISCUSSION

The findings of this trial will provide evidence on the feasibility and causal impact of two interventions - micro-incentives and a male-targeted HIV specific decision support - on uptake of home-based HIV testing, linkage to care, as well as population health outcomes including population viral load, HIV related mortality in men, and HIV incidence in young women (15-30 years of age).

TRIAL REGISTRATION

This trial was registered on 28 November 2018 on, identifier https://clinicaltrials.gov/ .

Female adherence self-efficacy before and after couple HIV testing and counseling within Malawi's Option B+ program

Adherence self-efficacy, belief in one's ability to adhere to daily medication, is strongly associated with antiretroviral therapy (ART) adherence and preventing mother-to-child HIV transmission. Couple-based interventions could enhance self-efficacy and adherence. We assessed the relationship between couple HIV testing and counseling (cHTC) and adherence self-efficacy using a 100-point culturally-adapted adherence self-efficacy scale (ASES). Secondarily, we explored the relationship between ASES and ART adherence. Ninety HIV-positive pregnant women at an antenatal clinic in Lilongwe, Malawi were enrolled in an observational cohort study. They were assessed with ASES immediately before and one month after receiving cHTC. Median ASES scores were 100 (IQR 95, 100) before and 100 (IQR 99, 100) after cHTC; there was a significant median difference (p = 0.02) for participants before and after cHTC. This change in ASES scores was associated with the odds of self-reported ART adherence in the full population (OR 1.1, p = 0.01), and there was a trend in the same direction for participants with imperfect baseline ASES scores (OR 1.1, p = 0.2). In our population, adherence self-efficacy and ART adherence were both quite high, and those who had room to improve in self-efficacy may have benefited from cHTC, which in turn could impact ART adherence and ultimately mother-to-child transmission.

Recurrent child mortality risks and parity transition in Nigeria

BACKGROUND

Fertility rates remain persistently high in Nigeria, with little difference across socioeconomic groups. While the desire for large family size is culturally rooted, there is little understanding of how repeated child mortality experiences influence fertility behaviour and parity transition in Nigeria.

METHODS

Using birth history data from the 2013 Nigeria Demographic and Health Survey (NDHS), we applied life table techniques and proportional-hazard regression model to explore the effect of child survival experience on parity transitions. We hypothesize that a woman with one or more child death experience is at elevated risk of progressing towards higher parities.

RESULTS

Our findings show that child mortality is concentrated among mothers living in deprived conditions especially in rural areas of the northern part of Nigeria and among those with little or no education and, among those belonging to Hausa/Fulani ethnicity and Islam religion. Mothers with repeated experience of child deaths were significantly at a higher rate of progressing to higher parities than their counterparts (HR: 1.45; 95% CI: 1.31-1.61), when adjusted for relevant biological and socio-demographic characteristics.

CONCLUSION

Recurrent experience of child deaths exacerbates the risks to higher parity transition. Interventions aimed at reducing fertility in Nigeria should target promoting child survival and family planning concurrently.

The association between a detectable HIV viral load and non-communicable diseases comorbidity in HIV positive adults on antiretroviral therapy in Western Cape, South Africa

BACKGROUND

Past studies have found a relationship between detectable HIV viral load and non-communicable diseases (NCDs) in HIV-infected individuals on antiretroviral therapy in high-income settings, however there is little research in South Africa. Our objective was to investigate the association between detectable HIV viral load and prevalent NCDs in a primary health centre in peri-urban South Africa.

METHODS

HIV-infected adults (aged ≥25) who had been on antiretroviral therapy for ≥ six months and attended the HIV clinic within a primary health centre in Khayelitsha, Cape Town, were recruited. We recorded participants' demographics, HIV characteristics, the presence of NCDs via self-report, from clinic folders and from measurement of their blood pressure on the day of interview. We used logistic regression to estimate the association between a detectable HIV viral load and NCD comorbidity.

RESULTS

We recruited 330 adults. We found no association between a detectable HIV viral load and NCD comorbidity. Within our multivariable model, female gender (OR3·26; p = 0·02) age > 35 (OR 0·40; p = 0·02) low CD4 count (compared to CD4 < 300 (reference category): CD4:300-449 OR 0·28; CD4:450-599 OR 0·12, CD4:≥600 OR 0·12; p = < 0·001), and ever smoking (OR 3·95; p = < 0·001) were associated with a detectable HIV viral load. We found a lower prevalence of non-communicable disease in clinic folders than was self-reported. Furthermore the prevalence of hypertension measured on the day of interview was greater than that reported on self-report or in the clinic folders.

CONCLUSIONS

The lack of association between detectable viral load and NCDs in this setting is consistent with previous investigation in South Africa but differs from studies in high-income countries. Lower NCD prevalence in clinic records than self-report and a higher level of hypertension on the day than self-reported or recorded in clinic folders suggest under-diagnosis of NCDs in this population. This potential under-detection of NCDs may differ from a high-income setting and have contributed to our finding of a null association. Our findings also highlight the importance of the integration of HIV and primary care systems to facilitate routine monitoring for non-communicable diseases in HIV-infected patients.

The impact of HIV couple testing and counseling on social support among pregnant women and their partners in Lilongwe, Malawi: an observational study

Couples HIV testing and counseling (couple counseling) promotes safer sexual behaviors, increases communication between couples, and decreases HIV transmission. However, the impact of couple counseling on social support, critical for persons living with HIV, has not been examined. Ninety couples with a recently tested HIV-positive pregnant woman (female-positive couples) and 47 couples with a recently tested HIV-negative pregnant woman (female-negative couples) were enrolled in an observational study at an antenatal clinic in Malawi. Each couple member was assessed immediately before and one month after couple counseling for partner, family, and peer social support using the Multidimensional Scale of Perceived Social Support. Before couple counseling, social support was lower among women than men in both female-positive couples (β = -10.00, p < .01) and female-negative couples (β = -8.43, p  < .01). After couple counseling, social support increased for women in female-positive couples (β = 4.01, p < .01) and female-negative couples (β = 4.69, p < .01) but not for men in either type of couple. Couple counseling could be an effective strategy to increase social support for women, including those with recent HIV diagnoses.

Alcohol use and relationship quality among South African couples

OBJECTIVE

The HIV literature has largely ignored the importance of alcohol use in the quality of intimate relationships in sub-Saharan Africa (SSA), despite evidence of alcohol's role in relational behaviors that increase risk for HIV infection and other harms. The present study explored the association of alcohol use with relationship functioning among heterosexual couples from rural South Africa.

METHOD

Dyadic analyses were conducted with 443 sexually active, heterosexual, South African couples (886 individuals) to examine the association between male partners' alcohol use (abstinent, nonhazardous, and hazardous), and male and female partners' reports of relationship intimacy, trust, mutually constructive communication, demand/withdraw communication, and satisfaction. Five structural equation models were fit using male partner alcohol use as a predictor of male and female reports of relationship quality.

RESULTS

Women with a hazardous-drinking male partner (compared to an abstainer) reported significantly higher levels of intimacy (p <.05) and significantly more demand/withdraw communication (p <.001); men who were hazardous drinkers reported significantly less trust in their relationship compared to men who were abstainers (p < .01).

CONCLUSIONS

Hazardous alcohol use among South African couples is positively correlated with women's relationship intimacy and maladaptive communication patterns, yet negatively correlated with men's perceived trust.

High HIV incidence and low uptake of HIV prevention services: The context of risk for young male adults prior to DREAMS in rural KwaZulu-Natal, South Africa

BACKGROUND

Young men are less likely than young women to engage with HIV prevention and care, and their HIV-related mortality is higher. We describe HIV incidence and uptake of HIV services in men 20-29 years(y) in rural KwaZulu-Natal, South Africa, before the roll-out of DREAMS.

METHODS

We used data from a population-based demographic and HIV surveillance cohort. HIV incidence was estimated from anonymised testing in an annual serosurvey. Service uptake was assessed in 2011 and 2015, through two self-reported outcomes: 1) HIV testing in the past 12 months(m); 2) voluntary medical male circumcision(VMMC). Logistic regression was used to estimate odds ratios(OR) and 95% confidence intervals(CI) for factors associated with each outcome.

RESULTS

HIV incidence in 2011-2015 was 2.6/100 person-years (95%CI = 2.0-3.4) and 4.2 (95%CI = 3.1-5.6) among men 20-24y and 25-29y, respectively, with no significant change from 2006-2010. N = 1311 and N = 1221 young men participated in the 2011 and 2015 surveys, respectively. In both years, <50% reported testing for HIV in the past 12m. In 2011, only 5% reported VMMC, but coverage in 2015 increased to 40% and 20% in men 20-24y and 25-29y, respectively. HIV testing was positively associated with higher education and mobility. Testing uptake was higher in men reporting >1 partner in the past 12m, or condom use at last sex, but lower in those reporting a casual partner (adjusted (a)OR = 0.53, 95%CI = 0.37-0.75). VMMC uptake was associated with survey year and higher education. Men aged 25-29y and those who were employed (aOR = 0.66; 95%CI = 0.49-0.89) were less likely to report VMMC.

CONCLUSIONS

HIV incidence in men 20-29y was very high, and pre-exposure prophylaxis (PrEP) should be considered in this population. Uptake of services was low. VMMC coverage increased dramatically from 2011 to 2015, especially among younger men, suggesting a demand for this service. Interventions designed with and for young men are urgently needed.

Social support, disclosure and stigma and the association with non-adherence in the six months after antiretroviral therapy initiation among a cohort of HIV-positive adults in rural KwaZulu-Natal, South Africa

The World Health Organisation (WHO) recommends antiretroviral treatment (ART) initiation at human immunodeficiency virus (HIV) diagnosis. As ART programmes expand, addressing barriers to adherence is vital. Past mixed findings on the association between social support, stigma and non-disclosure with ART adherence highlights the need for further research. The primary aim of this study was to examine how these factors are associated with ART non-adherence in the six months after ART initiation. The secondary aim was to explore how other factors are associated with non-adherence. We conducted secondary analysis of prospective data from HIV-positive adults initiating ART. Social support, disclosure patterns, perceived stigma and other demographic factors were collected at ART initiation and six months follow-up. Logistic regression models were used to examine factors associated with self-reported ART non-adherence in the last six months and the last month before the six month follow-up (“recent”). Non-adherence in the last six months was twenty-five percent and recent non-adherence was nine percent. There was no association between non-adherence and social support, stigma or non-disclosure of HIV status. In the final model the odds of non-adherence in the last six months were significantly higher for those: with incomplete ART knowledge (aOR 2.10, 95%CI 1.21–3.66); who visited a healthcare provider for conditions other than HIV (aOR1.98, 95%CI 1.14–3.43); had higher CD4 counts at ART initiation (CD4 100–199:aOR 2.50, 95%CI 1.30–4.81; CD4 ≥ 200:aOR 2.85, 95%CI 1.10–7.40;referent CD4 < 100 cells/mm³); had tested HIV-positive in the last year (aOR 2.00, 95%CI 1.10–3.72; referent testing HIV-positive outside the last year); experienced a rash/itching secondary to ART (aOR 2.48, 95%CI 1.37–4.52); and significantly lower for those ≥48 years (aOR 0.65, 95%CI 0.46–0.90). Early non-adherence remains a concern. Incorporation of adherence monitoring and ART knowledge enhancement into appointments for ART collection may be beneficial.

Persistently high incidence of HIV and poor service uptake in adolescent girls and young women in rural KwaZulu-Natal, South Africa prior to DREAMS

BACKGROUND

Adolescent girls and young women (AGYW) bear the brunt of the HIV epidemic in South Africa. 'DREAMS' aims to reduce HIV incidence through multi-level combination prevention. We describe HIV incidence and uptake of HIV and sexual reproductive health (SRH) by AGYW in KwaZulu-Natal (KZN), prior to DREAMS.

METHODS

Longitudinal and cross-sectional analysis of women (15-24 year old) in a population-based HIV incidence cohort within a demographic surveillance site in KZN. Observation time for HIV incidence was person-years at risk while resident. "Current use of contraceptives" and "having an HIV test in the past 12 months" was compared between 2011 and 2015.

RESULTS

In 2015, HIV prevalence was 11.0% and 34.1% and HIV incidence (2011-2015) was 4.54% (95%CI:3.89-5.30) and 7.45% (95%CI:6.51-8.51) per year in 15-19 and 20-24 year olds respectively, with no significant decline compared to 2006-2010. In 2015, 90.7% of 20-24-year-olds were unemployed, 36.4% and 51.7% of 15-19 and 20-24 year olds reported recent migration; 20.9% and 72.6% of 15-19 and 20-24 year olds had ever been pregnant. In 2015, less than 50% reported condom-use at last sex, 15.0% of 15-19 year olds and 48.9% of 20-24 year olds were currently using contraception and 32.0% and 66.7% of 15-19 and 20-24 year olds had tested for HIV in the past 12 months. There had been no improvement compared to 2011. Factors associated with AGYW testing for HIV in the past 12 months were, survey year-2011 more likely than 2015 (aOR = 0.50), number of partners (aOR = 3.25), ever been pregnant (aOR = 2.47) and knowing where to find ART (aOR = 1.54). Factors associated with contraception use were being older (aOR = 4.83); ever been pregnant (aOR = 12.62); knowing where to get ART (aOR = 1.79) and having had an HIV test in past 12 months (aOR = 1.74).

CONCLUSION

Prior to DREAMS, HIV incidence in AGYW was high. HIV and SRH service uptake did not improve and was suboptimal. Findings highlight the need for combination HIV prevention programmes for AGYW in this economically vulnerable area.

A Breast Screening Shawl to Help Aboriginal Women Feel More Comfortable and Culturally Safe

Background: It is recommended that Australian women aged 50-74 have a breast screen every two years. Aboriginal women have lower breast screening participation than the general population, and face barriers at a system, service and individual level including: • Cultural: lack of cultural awareness/safety at screening services • Fear: historical apprehension about health services due to the after effects of colonization and intergenerational trauma • Shame: feeling embarrassment/shame at being undressed in front of a stranger • Past experience: having a past unpleasant breast screen, or hearing about someone else' • Knowledge: lack of knowledge about screening • Logistics: not knowing service provider locations or limited access to transport During a 2016 project between BreastScreen Victoria (BSV) and Women's Health West, Aboriginal women discussed the need for a shawl to cover them during screening. This idea is based on a successful New Zealand model. Based on this, the Victorian Aboriginal Health Service (VAHS), Victorian Aboriginal Community Controlled Health Organization (VACCHO) and BSV formed a partnership to trial a breast screening shawl with Aboriginal women. A key principle underpinning the project is that success will reflect the degree to which this is an Aboriginal-led initiative, driven by the needs of Aboriginal women, and steered by community-based Aboriginal health organizations. Project aims: • Assess whether a cultural, strength based screening process increases engagement of Aboriginal women • Determine whether a screening shawl enhances comfort and culturally safety • Encourage breast screening services to develop culturally safe screening practices • Develop a flexible model that can be easily adapted by other Aboriginal health services to reproduce the shawl, in recognition of the diversity of Aboriginal communities Methods: This project adopted the following strategies: • A project steering group was established • The shawl will be trialled via a group booking at one BSV clinic • Before the group booking, BSV clinic staff will attend culturally safety training • On the trial day, women will attend an information session at VAHS about breast screening and receive their shawl, travel to the BSV clinic together for screening, and return to VAHS to discuss their experiences Results: The trial will be fully evaluated in 2018 to determine whether project aims were achieved. Conclusion: Key learnings to date are: • Breast screening interventions for Aboriginal women must be community-led to ensure they are culturally appropriate, safe and acceptable • Aboriginal women face a number of barriers to breast screening at a system, service and individual level • Health services play a critical role in adopting culturally safe screening practices • Developing a flexible model that can be easily adapted by other Aboriginal health services is critical in ensuring the sustainability and acceptability of the shawl.