Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment

A Risk Prediction Model to Identify People Living with HIV Who are High-risk for Disengagement from Care after HIV Diagnosis in South Africa

The provision of ART in South Africa has transformed the HIV epidemic, resulting in an increase in life expectancy by over 10 years. Despite this, nearly 2 million people living with HIV are not on treatment. The objective of this study was to develop and externally validate a practical risk assessment tool to identify people with HIV (PWH) at highest risk for attrition from care after testing. A machine learning model incorporating clinical and psychosocial factors was developed in a primary cohort of 498 PWH. LASSO regression analysis was used to optimize variable selection. Multivariable logistic regression analysis was applied to build a model using 80% of the primary cohort as a training dataset and validated using the remaining 20% of the primary cohort and data from an independent cohort of 96 participants. The risk score was developed using the Sullivan and D'Agostino point based method. Of 498 participants with mean age 35.7 years, 192 (38%) did not initiate ART after diagnosis. Controlling for site, factors associated with non-engagement in care included being < 35 years, feeling abandoned by God, maladaptive coping strategies using alcohol or other drugs, no difficulty concentrating, and having high levels of confidence in one's ability to handle personal challenges. An effective risk score can enable clinicians and implementers to focus on tailoring care for those most in need of ongoing support. Further research should focus on potential strategies to enhance the generalizability and evaluate the implementation of the proposed risk prediction model in HIV treatment programs.

Social support receipt as a predictor of mortality: A cohort study in rural South Africa

The mechanisms connecting various types of social support to mortality have been well-studied in high-income countries. However, less is known about how these relationships function in different socioeconomic contexts. We examined how four domains of social support-emotional, physical, financial, and informational-impact mortality within a sample of older adults living in a rural and resource-constrained setting. Using baseline survey and longitudinal mortality data from HAALSI, we assessed how social support affects mortality in a cohort of 5059 individuals aged 40 years or older in rural Mpumalanga, South Africa. Social support was captured as the self-reported frequency with which close social contacts offered emotional, physical, financial, and informational support to respondents, standardized across the sample to increase interpretability. We used Cox proportional hazard models to evaluate how each support type affected mortality controlling for potential confounders, and assessed potential effect-modification by age and sex. Each of the four support domains had small positive associations with mortality, ranging from a hazard ratio per standard deviation of support of 1.04 [95% CI: 0.95,1.13] for financial support to 1.09 [95% CI: 0.99,1.18] for informational support. Associations were often stronger for females and younger individuals. We find baseline social support to be positively associated with mortality in rural South Africa. Possible explanations include that insufficient social support is not a strong driver of mortality risk in this setting, or that social support does not reach some necessary threshold to buffer against mortality. Additionally, it is possible that the social support measure did not capture more relevant aspects of support, or that our social support measures captured prior morbidity that attracted support before the study began. We highlight approaches to evaluate some of these hypotheses in future research.

Improvement in the 95-95-95 Targets Is Accompanied by a Reduction in Both the Human Immunodeficiency Virus Transmission Rate and Incidence in China

BACKGROUND

In 2016, China has implemented the World Health Organization's "treat all" policy. We aimed to assess the impact of significant improvements in the 95-95-95 targets on population-level human immunodeficiency virus (HIV) transmission dynamics and incidence.

METHODS

We focused on 3 steps of the HIV care continuum: diagnosed, on antiretroviral therapy, and achieving viral suppression. The molecular transmission clusters were inferred using HIV-TRACE. New HIV infections were estimated using the incidence method in the European Centre for Disease Prevention and Control HIV Modelling Tool.

RESULTS

Between 2004 and 2023, the national HIV epidemiology database recorded 2.99 billion person-times of HIV tests and identified 1 976 878 new diagnoses. We noted a roughly "inverted-V" curve in the clustering frequency, with the peak recorded in 2014 (67.1% [95% confidence interval, 63.7%-70.5%]), concurrent with a significant improvement in the 95-95-95 targets from 10-13-<71 in 2005 to 84-93-97 in 2022. Furthermore, we observed a parabolic curve for a new infection with the vertex occurring in 2010.

CONCLUSIONS

In general, it was suggested that the improvements in the 95-95-95 targets were accompanied by a reduction in both the population-level HIV transmission rate and incidence. Thus, China should allocate more effort to the first "95" target to achieve a balanced 95-95-95 target.

Mortality risk information and health-seeking behavior during an epidemic

In a context where pessimistic survival perceptions have been widespread as a result of the HIV/AIDS epidemic (Fig. 1 A), we study vaccine uptake and other health behaviors during the recent COVID-19 pandemic. Leveraging a longitudinal cohort study in rural Malawi that has been followed for up to 25 y, we document that a 2017 mortality risk information intervention designed to reduce pessimistic mortality perceptions (Fig. 1 B) resulted in improved health behavior, including COVID-19 vaccine uptake (Fig. 1 C). We also report indirect effects for siblings and household members. This was likely the result of a reinforcing process where the intervention triggered engagement with the healthcare system and stronger beliefs in the efficacy of modern biomedical treatments, which led to the adoption of health risk reduction behavior, including vaccine uptake. Our findings suggest that health information interventions focused on survival perceptions can be useful in promoting health behavior and participation in the formal healthcare system, even during health crises-such as the COVID-19 pandemic-that are unanticipated at the time of the intervention. We also note the importance of the intervention design, where establishing rapport, tailoring the content to the local context, and spending time with respondents to convey the information contributed to the salience of the message.

Life expectancy in relation to societal development level: significant discordant factors

OBJECTIVES

The aim of this study is to determine the interdependence between life expectancy and numerous social indicators, i.e., to determine the factors that encourage an increase or decrease in life expectancy.

METHODS

Pearson coefficients as well as linear and logarithmic trends and correlations between the dependent variable of life expectancy and numerous independent variables were calculated and analysed. The calculations were carried out for all countries in the world for which data is available. Based on the strength of the correlations between life expectancy and numerous indicators, we have tried to determine the reasons for the different values of life expectancy in the various countries.

RESULTS

Important factors for achieving high life expectancy values are economic development and healthcare spending but the spread of "diseases of the modern era", such as obesity or diabetes, have a significant negative impact on life expectancy. Other important limiting factors for life expectancy are large income inequalities, a higher share of private healthcare expenditure in total healthcare expenditure and lower total healthcare expenditure. Less developed societies can significantly increase their life expectancy by providing clean water and safe sanitation and by combating various infectious diseases (especially HIV).

CONCLUSIONS

Life expectancy is a meaningful indicator of the state of social development and accurately reflects the general state of a particular society. It has been shown that GDP per capita (PPP) is a key determinant of life expectancy, while other important factors play the role of a further modifier.

"I am adhering to HIV treatment so that I can live to support her": A qualitative study of upward intergenerational support in South Africa

Background

Intergenerational family care, which was upended by the HIV epidemic in sub-Saharan Africa (SSA), may return to a pre-HIV era arrangement as access to antiretroviral therapy (ART) expands and treated adults can once again provide support for older household members. Empirical research has demonstrated positive 'spillover effects' of ART uptake from treated adults to younger generations, yet much less is known about the nature and breadth of such effects to older generations. This study explores the role and lived experiences among adults who take up ART and those of an older generation with whom they live.

Methods

We conducted a qualitative study consisting of semi-structured interviews (n = 46) embedded in the Agincourt Health and Demographic Surveillance System (HDSS) in rural South Africa, between July and September 2022. We purposefully sampled two respondent categories: (i) young or middle-aged adults on ART (aged 18-59 years old); and (ii) older adults (aged ≥60 years old) who were affiliated with a young or middle-aged adult on ART. We used thematic content analysis to extract, code, and categorise relevant text by types of upward spillover effects from ART in younger adults to older adults. Quantitative data was extracted from the existing Agincourt HDSS database and matched to qualitative interview data based on Clinic link unique identifiers of study participants.

Results

Mean age was 41 years among young or middle-aged adults (n = 29) and 72 years among older adults (n = 17). Among younger adults, time on ART ranged from five months to more than 21 years. Both young or middle-aged adults on ART and older adults reported positive spillover effects for older adults across five main tiers: caregiving, financial support, physical and mental health, living arrangements and household relationships, and stigma and reputation. Spillover challenges included financial costs and caregiving responsibilities following ART initiation of young or middle-aged adults, although these additional caregiving responsibilities were generally not perceived as particularly burdensome.

Conclusions

ART is likely to benefit older adults in South Africa whose families are affected by HIV. This study identified a wide range of perceived spillover effects from ART in younger adults to older adults, including improvements to upward intergenerational support. These qualitative findings offer a guide to researchers, policymakers, and donors to capitalise on the broader societal effects of a large-scale health intervention to further support family structures and meet the needs of a growing older population.

MORTALITY RISK INFORMATION, SURVIVAL EXPECTATIONS AND SEXUAL BEHAVIOURS

We investigate the impact of a randomised information intervention about population-level mortality on health investment and subjective health expectations. Our focus is on risky sex in a high-HIV-prevalence environment. Treated individuals are less likely to engage in risky sexual practices one year after the intervention, with, for example, an 8% increase in abstinence. We collected detailed data on individuals' subjective expectations about their own and population survival, as well as other important health outcomes. Our findings emphasise the significance of integrating subjective expectation data in field experiments to identify the pathways that lead to behavioural change.

Disparities in access to appointments for contraceptive services among Black, Hispanic, White, and recently incarcerated women in Alabama, Louisiana, and Mississippi

OBJECTIVE

To measure differences in access to contraceptive services based on history of incarceration and its intersections with race/ethnicity and insurance status.

DATA SOURCES AND STUDY SETTING

Primary data were collected from telephone calls to physician offices in Alabama, Louisiana, and Mississippi in 2021.

STUDY DESIGN

We deployed a field experiment. The outcome variables were appointment offers, wait days, and questions asked of the caller. The independent variables were callers' incarceration history, race/ethnicity, and insurance.

DATA COLLECTION METHODS

Using standardized scripts, Black, Hispanic, and White female research assistants called actively licensed primary care physicians and Obstetrician/Gynecologists asking for the next available appointment for a contraception prescription. Physicians were randomly selected and randomly assigned to callers. In half of calls, callers mentioned recent incarceration. We also varied insurance status.

PRINCIPAL FINDINGS

Appointment offer rates were five percentage points lower (95% CI: -0.10 to 0.01) for patients with a history of incarceration and 11 percentage points lower (95% CI: -0.15 to -0.06) for those with Medicaid. We did not find significant differences in appointment offer rates or wait days when incarceration status was interacted with race or insurance. Schedulers asked questions about insurance significantly more often to recently incarcerated Black patients and recently incarcerated patients who had Medicaid.

CONCLUSIONS

Women with a history of incarceration have less access to medical appointments; this access did not vary by race or insurance status among women with a history of incarceration.

The Association Between HIV-Related Stigma and the Uptake of HIV Testing and ART Among Older Adults in Rural South Africa: Findings from the HAALSI Cohort Study

HIV testing and antiretroviral therapy (ART) remain critical for curbing the spread of HIV/AIDS, but stigma can impede access to these services. Using data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we used a multivariable logistic regression to examine the correlation between HIV-related stigma, HIV testing and ART uptake in older adults. We used four questions to measure stigma, with three assessing social stigma (reflecting social distancing preferences) and one assessing anticipated stigma (disclosure concern). We combined the three social stigma questions to generate a social stigma score ranging from 0 to 3, with higher scores indicating higher stigma. Anticipated stigma was prevalent 85% (95% CI 0.84-0.86), and social stigma was also frequent 25% (95% CI 0.24-0.27). Higher social stigma scores correlated with decreased HIV testing for all participants with social stigma. Compared to those with a score of 0, odds of testing decreased with higher stigma scores (OR = 0.66, 95% CI 0.53-0.81, p = 0.000) for a score of 1 and (OR = 0.56, 95% CI 0.38-0.83, p = 0.004) for a score of 3. ART uptake also decreased with higher social stigma scores among people living with HIV (PLWH), although it was significant for those with a score of 2 (OR = 0.41, 95% CI 0.19-0.87, p = 0.020). These findings emphasize that HIV-related stigma hampers testing and ART uptake among older adults in rural South Africa. Addressing stigma is crucial for improving testing rates, early diagnosis, and treatment initiation among the older population and achieving UNAIDS 95-95-95 targets.

Population-Based Trends in Complexity of Hospital Inpatients

Importance

Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression.

Objective

To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period.

Design, Setting and Participants

This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023.

Exposure

The passage of time (15-year study interval).

Main Outcomes and Measures

Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval.

Results

The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively).

Conclusions and Relevance

By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.

Mapping evidence on barriers to and facilitators of diagnosing noncommunicable diseases (NCDs) among people living with human immunodeficiency virus (PLWH) in low- and middle-income countries (LMICs) in Africa: A scoping review protocol

BACKGROUND

Noncommunicable diseases (NCDs) represent a global public health challenge in all population groups, but the prevalence of major NCDs, such as depression, hypercholesterolemia, hypertension, obesity and diabetes, is increasing at a rapid rate among people living with human immunodeficiency virus (PLWH). Studies show that integrated NCDs and human immunodeficiency virus (HIV) services have improved the patient outcome of PLWH with comorbidities with NCDs. It requires a strengthened and sustainable way of diagnosing major NCDs early among PLWH. However, there is limited evidence regarding the barriers to and facilitators of early diagnosis of NCDs (depression, hypercholesterolemia, hypertension, obesity and diabetes) among PLWH in low- and middle-income countries (LMICs). This review will systematically map the literature and describe the barriers and facilitators of diagnosing NCDs (depression, hypercholesterolemia, hypertension, obesity and diabetes) among PLWH in LMICs in Africa.

METHODS

The methodology presented by Arksey and O'Malley and the recommendation set out by Levac and colleagues will be used. PubMed, MEDLINE with full text via the EBSCO host, Google Scholar, Science Direct and Scopus will be used for a comprehensive search for data extraction. The search will be conducted using keywords, Boolean terms, and Medical Subject Headings (MeSH). All studies with eligible titles will be exported to the EndNote citation manager for deduplication and imported to Rayyan software for screening. Two reviewers will independently screen abstracts, and the preferred reporting items for systematic review and meta-analysis extension to scoping review (PRISMA-Sc) guidelines will be used to guide the search in conducting the scoping review. We will perform descriptive data analysis for quantitative studies, NVivo software version 12 will be used for qualitative studies, and thematic content analysis will be carried out. This scoping review will include studies that included PLWH with those diagnosed with major NCDs (depression, hypercholesterolemia, hypertension, obesity, and diabetes) in LMICs in Africa.

DISCUSSION

This scoping review will highlight evidence mapping on barriers and facilitators of diagnosing NCDs (depression, hypercholesterolemia, hypertension, obesity, and diabetes) among PLWH LMICs in Africa. Scoping Review Registration: registered on Open Science Framework (https://osf.io/xvtwd/).

Barriers and facilitators for interventions to improve ART adherence in Sub-Saharan African countries: A systematic review and meta-analysis

BACKGROUND

The HIV/AIDS pandemic remains a significant public health issue, with sub-Saharan Africa (SSA) at its epicentre. Although antiretroviral therapy (ART) has been introduced to decrease new infections and deaths, SSA reports the highest incidence of HIV/AIDS, constituting two-thirds of the global new infections. This review aimed to elucidate the predominant barriers and facilitators influencing ART adherence and to identify effective strategies to enhance ART adherence across SSA.

METHODS

A comprehensive review was conducted on studies examining barriers to ART adherence and interventions to boost adherence among HIV-positive adults aged 15 and above in SSA, published from January 2010 onwards. The research utilized databases like Medline Ovid, CINAHL, Embase, and Scopus. Included were experimental and quasi-experimental studies, randomized and non-randomized controlled trials, comparative before and after studies, and observational studies such as cross-sectional, cohort, prospective and retrospective studies. Two independent reviewers screened the articles, extracted pertinent data, and evaluated the studies' methodological integrity using Joanna Briggs Institute's standardized appraisal tools. The compiled data underwent both meta-analysis and narrative synthesis.

RESULTS

From an initial pool of 12,538 papers, 45 were selected (30 for narrative synthesis and 15 for meta-analysis). The identified barriers and facilitators to ART adherence were categorized into seven principal factors: patient-related, health system-related, medication-related, stigma, poor mental health, socioeconomic and socio-cultural-related factors. Noteworthy interventions enhancing ART adherence encompassed counselling, incentives, mobile phone short message service (SMS), peer delivered behavioural intervention, community ART delivery intervention, electronic adherence service monitoring device, lay health worker lead group intervention and food assistance. The meta-analysis revealed a statistically significant difference in ART adherence between the intervention and control groups (pooled OR = 1.56, 95%CI:1.35-1.80, p = <0.01), with evidence of low none statistically significant heterogeneity between studies (I2 = 0%, p = 0.49).

CONCLUSION

ART adherence in SSA is influenced by seven key factors. Multiple interventions, either standalone or combined, have shown effectiveness in enhancing ART adherence. To optimize ART's impact and mitigate HIV's prevalence in SSA, stakeholders must consider these barriers, facilitators, and interventions when formulating policies or treatment modalities. For sustained positive ART outcomes, future research should target specific underrepresented groups like HIV-infected children, adolescents, and pregnant women in SSA to further delve into the barriers, facilitators and interventions promoting ART adherence.

Home-based HIV testing strategies for middle-aged and older adults in rural South Africa

OBJECTIVE

More than one in four adults over 40 years with HIV in South Africa are unaware of their status and not receiving antiretroviral therapy (ART). HIV self-testing may offer a powerful approach to closing this gap for aging adults. Here, we report the results of a randomized comparative effectiveness trial of three different home-based HIV testing strategies for middle-aged and older adults in rural South Africa.

DESIGN

Two thousand nine hundred and sixty-three individuals in the 'Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI)' cohort study were randomized 1 : 1 : 1 to one of three types of home-based and home-delivered HIV testing modalities: rapid testing with counseling; self-testing, and both rapid testing with counselling and self-testing.

METHOD

In OLS regression analyses, we estimated the treatment effects on HIV testing and HIV testing frequency at about 1 year after delivery. Finally, we assessed the potential adverse effects of these strategies on the secondary outcomes of depressive symptom as assessed by the CESD-20, linkage to care, and risky sexual behavior.

RESULTS

There were no significant differences in HIV testing uptake or testing frequency across groups. However, respondents in the self-testing treatment arms were more likely to shift from testing at home and a facility [self-testing (HIVST), -8 percentage points (pp); 95% confidence interval (CI) -14 to -2 pp; self-testing plus rapid testing and counselling (ST+RT+C); -9 pp, 95% CI -15 to -3 pp] to testing only at home (HIVST 5 pp; 95% CI 2 to 9 pp; ST+RT+C: 5 pp, 95% CI 1 to 9 pp) - suggesting a revealed preference for self-testing in this population. We also found no adverse effects of this strategy on linkage to care for HIV and common comorbidities, recent sexual partners, or condom use. Finally, those in the self-testing only arm had significantly decreased depressive symptom scores by 0.58 points (95% CI -1.16 to -0.01).

CONCLUSION

We find HIV self-testing to be a well tolerated and seemingly preferred home-based testing option for middle-aged and older adults in rural South Africa. This approach should be expanded to achieve the UNAIDS 95-95-95 targets.

Barriers and facilitators to ART adherence among ART non-adherence people living with HIV in Cameroon: A qualitative phenomenological study

BACKGROUND

Antiretroviral therapy (ART) needs to be taken for life with near perfect levels of adherence for it to be effective. Nonetheless, ART non-adherence is still observed in sub-Saharan African (SSA) countries such as Cameroon. The objective of this study was to assess the factors influencing non-adherence and or adherence among people living with HIV (PLWH) who have experienced non-adherence to ART in Cameroon.

METHODS

A descriptive qualitative study of PLWH who have experienced non-adherence with ART in Cameroon was conducted. Data were collected using in-depth interviews. Collected data were analyzed using the NVIVO 12 software.

RESULTS

In total, 43 participants participated in this study. The Southwest and Littoral regions each contributed 15 (34.88%) of participants, participants' mean age was 37.1 years (SD: 9.81) and majority 34 (82.93%) were females. ART adherence barriers include those related to patient (forgetfulness, business with other things, unwillingness to swallow drugs daily), medication (side effects), health service (arrogance of caregivers, occasional drug shortages at treatment centre, poor counseling of patient), stigma (fear of status disclosure), use of alternative treatment (traditional medicine, prayers and deliverance), resource limitation (limited food, limited finances), environmental/social (limited or no home support), and political instability (disruption of free circulation by ghost towns, roadblocks and gunshots in some regions). ART adherence facilitators include social support (family and peer support), aligning treatment with patient's daily routines (align ART with schedule of family members), use of reminders (phone alarm, sound of church bell), health sector/caregiver support (messages to patient, financial support, proper counseling), and patient's awareness of HIV status/ART knowledge (awareness of HIV positive status, Knowledge of ART benefits).

CONCLUSION

ART adherence barriers in Cameroon include those related to patient, medication, health service, stigma, use of alternative treatment, resource limitation, environmental/social, and political instability. ART adherence facilitators include social support, aligning treatment with patient's daily routines, use of reminders, health sector/caregiver support, and patient's awareness of HIV status/ART knowledge. Given these barriers and facilitators, continuous information provision and consistent support both from patients' families and caregivers are needed to improve adherence among patients. Further studies including many regions and larger samples using both in-depth and focused group discussions as well as quantitative approaches are required to uncover the burden related to ART non-adherence.

The effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019: a data note

OBJECTIVES

South Africa is experiencing both HIV and hypertension epidemics. Data were compiled for a study to identify effects of HIV and high systolic blood pressure on mortality risk among people aged 40-plus in a rural South African area experiencing high prevalence of both conditions. We aim to release the replication data set for this study.

DATA DESCRIPTION

The research data comes from the 2010-11 Ha Nakekela (We Care) population-based survey nested in the Agincourt Health and socio-Demographic Surveillance System (AHDSS) located in the northeast region of South Africa. An age-sex-stratified probability sample was drawn from the AHDSS. The public data set includes information on individual socioeconomic characteristics and measures of HIV status and blood pressure for participants aged 40-plus by 2019. The AHDSS, through its annual surveillance, provided mortality data for nine years subsequent to the survey. These data were converted to person-year observations and linked to the individual-level survey data using participants' AHDSS census identifier. The data can be used to replicate Houle et al. (2022) - which used discrete-time event history models stratified by sex to assess differential mortality risks according to Ha Nakekela measures of HIV-infection, HIV-1 RNA viral load, and systolic blood pressure.

HIV infection

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

Current oral hygiene and recreational behavioral trends in HIV disease

OBJECTIVE

HIV disease is evolving with more HIV+ persons experiencing a high quality of life with well-controlled viremia. We recently enrolled a large cohort of HIV+ and clinically relevant HIV- persons for oral microbiome analyses that included a questionnaire related to oral hygiene and recreational behaviors. Here, the questionnaire responses were analyzed for behavioral trends within the cohort, together with trends over time by comparison to a previous geographically centered HIV+ cohort.

METHODS

Data were collected by questionnaire at baseline visits as cross-sectional assessments. Multivariable analyses were conducted for associations of HIV status as well as age, race, and sex, on oral hygiene/recreational behaviors.

RESULTS

HIV+ subjects had reduced brushing frequency, but increased incidence of past cleanings and frequency of dry mouth, compared to the HIV- subjects. Within the entire cohort, positive associations were identified between age and several oral hygiene practices, and between age, race, and sex for several recreational behaviors. In comparison to the historical cohort, the contemporary HIV+ cohort participated in fewer high-risk behaviors, but with similar trends for smoking and oral hygiene practices.

CONCLUSION

HIV status had little association with oral hygiene and recreational behaviors despite several differences in age, race, and sex. Behavioral trends over time support a higher quality of life in people currently living with HIV.

Spatiotemporal evolution and characteristics of worldwide life expectancy

Exploring global differences in life expectancy can facilitate the development of strategies to narrow regional disparities. However, few researchers have systematically examined patterns in the evolution of worldwide life expectancy over a long time period. Spatial differences among 181 countries in 4 types of worldwide life expectancy patterns from 1990 to 2019 were investigated via geographic information system (GIS) analysis. The aggregation characteristics of the spatiotemporal evolution of life expectancy were revealed by local indicators of spatial association. The analysis employed spatiotemporal sequence-based kernel density estimation and explored the differences in life expectancy among regions with the Theil index. We found that the global life expectancy progress rate shows upward then downward patterns over the last 30 years. Female have higher rates of spatiotemporal progression in life expectancy than male, with less internal variation and a wider spatial aggregation. The global spatial and temporal autocorrelation of life expectancy shows a weakening trend. The difference in life expectancy between male and female is reflected in both intrinsic causes of biological differences and extrinsic causes such as environment and lifestyle habits. Investment in education pulls apart differences in life expectancy over long time series. These results provide scientific guidelines for obtaining the highest possible level of health in countries around the world.

Disparities in the Prevalence of Osteoporosis and Osteopenia in Men and Women Living in Sub-Saharan Africa, the UK, and the USA

PURPOSE

To review the rising prevalence of osteopenia and osteoporosis in sub-Saharan Africa and the challenges this poses to governments and healthcare services. Using existing studies, we compare the prevalence of osteopenia and osteoporosis in men and women from sub-Saharan Africa to US and UK cohorts. Context-specific disparities in healthcare are discussed particularly the challenges in diagnosis and treatment of osteoporosis.

RECENT FINDINGS

There are few epidemiological data describing the burden of osteoporosis in sub-Saharan Africa. In the studies and cohorts presented here, osteoporosis prevalence varies by sex, country and area of residence, but is generally higher in African populations, than has previously been appreciated. Risk factors contributing to poorer bone health include HIV, malnutrition and "inflammaging." Reprioritization towards care of ageing populations is urgently required. Equitable access to implementable preventative strategies, diagnostic services, treatments and pathways of care for bone health (for example embedded within HIV services) need now to be recognized and addressed by policy makers.

High prevalence of self-reported sexually transmitted infections among older adults in Tanzania: results from a list experiment in a population-representative survey

PURPOSE

Self-report of sensitive or stigmatized health states is often subject to social desirability and interviewer biases. To reduce such biases, we estimated the rate of sexually transmitted infections (STIs) using a list experiment.

METHODS

This population-representative study was nested within the Dar es Salaam Urban Cohort Study, a Health and Demographic Surveillance System (HDSS) in the Ukonga ward of Dar es Salaam, Tanzania. Men and women aged ≥40years were randomly assigned to receive a list of either four control items (i.e., the control group) or four control items plus an additional item on having had a disease through sexual contacts in the past 12months (i.e., the treatment group). We calculated the mean difference in the total number of items to which respondents answered "yes" in the treatment versus control group and compared this prevalence estimate to the one measured by the direct question.

RESULTS

A total of 2310 adults aged ≥40years were enrolled in the study: 32% were male and 48% were aged 40-49years. The estimated prevalence of having STIs in the past 12months was 17.8% (95% confidence interval [CI] 12.3-23.3) in the list experiment, almost 10 times higher than the estimated prevalence of 1.8% (95%CI 1.3-2.4) based on the direct question (P < .001). STI prevalence remained high after adjusting for age, the number of lifetime sex partners, alcohol consumption and smoking in multivariate linear regression (15.6%; 95% CI 7.3-23.9).

CONCLUSIONS

We found a substantially higher prevalence of STIs among older adults in urban Tanzania when we based our estimation on a list experiment rather than a direct question in a population-representative survey. List experiments should be considered to elimnate social desirability and interviewer biases in surveys of sensitive or stigmatized health states. The very high prevalence of STIs highlights the need for improved access to STI screening, prevention and treatment for older adults in urban Africa.

Correlates of physical activity among people living with and without HIV in rural Uganda

Background

Antiretroviral therapy (ART) has led to diminishing AIDS-related mortality but a concomitant increase in non-communicable diseases (NCDs) for people with HIV (PWH). Whereas physical activity (PA) has been shown to help prevent NCDs and NCD outcomes in other settings, there are few data on PA and its correlates among PWH in high-endemic settings. We aimed to compare PA by HIV serostatus in rural Uganda.

Methods

We analysed data from the UGANDAC study, an observational cohort including PWH in ambulatory HIV care in Mbarara, Uganda, and age- and gender-matched people without HIV (PWOH). Our primary outcome of interest was PA, which we assessed using the International Physical Activity Questionnaire and considered as a continuous measure of metabolic equivalents in minutes/week (MET-min/week). Our primary exposure of interest was HIV serostatus. We fit univariable and multivariable linear regression models to estimate the relationship between HIV and PA levels, with and without addition of sociodemographic and clinical correlates of PA (MET-min/week). In secondary analyses, we explored relationships restricted to rural residents, and interactions between gender and serostatus.

Results

We enrolled 309 participants, evenly divided by serostatus and gender. The mean age of PWH was 52 [standard deviation (SD) 7.2] and 52.6 (SD 7.3) for PWOH. In general, participants engaged in high levels of PA regardless of serostatus, with 81.2% (251/309) meeting criteria for high PA. However, PWOH reported higher mean levels of PA met-minutes/week than PWH (9,128 vs 7,152, p ≤ 0.001), and a greater proportion of PWOH (88.3%; 136/154) met the criteria for high PA compared to PWH (74.2%; 115/155). In adjusted models, lower levels of PA persisted among PWH (β = -1,734, 95% CI: -2,645, -824, p ≤ 0.001). Results were similar in a sensitivity analysis limited to people living in rural areas.

Conclusion

In a rural Ugandan cohort, PWOH had higher levels of PA than PWH. Interventions that encourage PA among PWH may have a role in improving NCD risk profiles among PWH in the region.

Population-level viremia predicts HIV incidence at the community level across the Universal Testing and Treatment Trials in eastern and southern Africa

Universal HIV testing and treatment (UTT) strategies aim to optimize population-level benefits of antiretroviral treatment. Between 2012 and 2018, four large community randomized trials were conducted in eastern and southern Africa. While their results were broadly consistent showing decreased population-level viremia reduces HIV incidence, it remains unclear how much HIV incidence can be reduced by increasing suppression among people living with HIV (PLHIV). We conducted a pooled analysis across the four UTT trials. Leveraging data from 105 communities in five countries, we evaluated the linear relationship between i) population-level viremia (prevalence of non-suppression-defined as plasma HIV RNA >500 or >400 copies/mL-among all adults, irrespective of HIV status) and HIV incidence; and ii) prevalence of non-suppression among PLHIV and HIV incidence, using parametric g-computation. HIV prevalence, measured in 257 929 persons, varied from 2 to 41% across the communities; prevalence of non-suppression among PLHIV, measured in 31 377 persons, from 3 to 70%; population-level viremia, derived from HIV prevalence and non-suppression, from < 1% to 25%; and HIV incidence, measured over 345 844 person-years (PY), from 0.03/100PY to 3.46/100PY. Decreases in population-level viremia were strongly associated with decreased HIV incidence in all trials (between 0.45/100PY and 1.88/100PY decline in HIV incidence per 10 percentage points decline in viremia). Decreases in non-suppression among PLHIV were also associated with decreased HIV incidence in all trials (between 0.06/100PY and 0.17/100PY decline in HIV incidence per 10 percentage points decline in non-suppression). Our results support both the utility of population-level viremia as a predictor of incidence, and thus a tool for targeting prevention interventions, and the ability of UTT approaches to reduce HIV incidence by increasing viral suppression. Implementation of universal HIV testing approaches, coupled with interventions to leverage linkage to treatment, adapted to local contexts, can reduce HIV acquisition at population level.

Broadly neutralizing antibodies and long-acting antiretroviral drugs as treatments for HIV

PURPOSE OF REVIEW

To discuss progress and challenges in the development of antiretroviral regimens that combine broadly neutralizing antibodies (bNAbs) and long-acting (LA) small-molecule antiretroviral drugs (ARVs).

RECENT FINDINGS

Data are extremely limited, with results from only a single phase 1a clinical trial reported to date. That study, a combination of lenacapavir plus the bNAbs teropavimab and zinlirvimab, maintained viral suppression over 26 weeks in 18 of 20 participants. A second pilot study, ACTG A5357, which tests the safety and virologic efficacy of the combination of LA injectable cabotegravir with the bNAb VRC07-523LS is fully enrolled; results are expected in the second half of 2023.

SUMMARY

The development of regimens that combine bNAbs and LA ARVs has been challenging. Both agents need similar half-lives in order to harmonize dosing schedules. In addition, the need to perform bNAb susceptibility testing to assure activity of the bNAb in order to protect against the risk of developing resistance to the LA ARV has slowed enrollment into trials and poses substantial logistical challenges to widespread adoption of these combinations should they prove safe and effective. Improvements in manufacture that reduce the cost of goods and advances in delivery systems are needed to ensure equitable access to these regimens.

Estimating the welfare gains from anti-retroviral therapy in Sub-Saharan Africa

Since the start of the century, many countries in Sub-Saharan Africa have experienced large gains in life expectancy and average consumption levels. Around the same time, an unprecedented international effort has taken place to combat HIV/AIDS mortality with the expansion of anti-retroviral therapy (ART) across many of the hardest hit countries. In this paper, I estimate the impact of ART on average welfare over time in 42 countries using the equivalent consumption approach. I decompose the change in welfare to isolate the relative contribution of ART-driven improvements in life expectancy and consumption. The results indicate that ART has accounted for around 12% of total welfare growth in SSA between 2000 and 2017. In those countries most affected by HIV/AIDS, this figure rises to around 40%. Moreover, the estimates suggest that welfare in some of the worst-hit countries would have declined over time without the ART expansion.

Record linkage without patient identifiers: proof of concept using data from South Africa's national HIV program

Background

Linkage between health databases typically requires identifiers such as patient names and personal identification numbers. We developed and validated a record linkage strategy to combine administrative health databases without the use of patient identifiers, with application to South Africa's public sector HIV treatment program.

Methods

We linked CD4 counts and HIV viral loads from South Africa's HIV clinical monitoring database (TIER.Net) and the National Health Laboratory Service (NHLS) for patients receiving care between 2015-2019 in Ekurhuleni District (Gauteng Province). We used a combination of variables related to lab results contained in both databases (result value; specimen collection date; facility of collection; patient year and month of birth; and sex). Exact matching linked on exact linking variable values while caliper matching applied exact matching with linkage on approximate test dates (± 5 days). We then developed a sequential linkage approach utilising specimen barcode matching, then exact matching, and lastly caliper matching. Performance measures were sensitivity and positive predictive value (PPV); share of patients linked across databases; and percent increase in data points for each linkage approach.

Results

We attempted to link 2,017,290 lab results from TIER.Net (representing 523,558 unique patients) and 2,414,059 lab results from the NHLS database. Linkage performance was evaluated using specimen barcodes (available for a minority of records in TIER.net) as a "gold standard". Exact matching achieved a sensitivity of 69.0% and PPV of 95.1%. Caliper-matching achieved a sensitivity of 75.7% and PPV of 94.5%. In sequential linkage, we matched 41.9% of TIER.Net labs by specimen barcodes, 51.3% by exact matching, and 6.8% by caliper matching, for a total of 71.9% of labs matched, with PPV=96.8% and Sensitivity = 85.9%. The sequential approach linked 86.0% of TIER.Net patients with at least one lab result to the NHLS database (N=1,450,087). Linkage to the NHLS Cohort increased the number of laboratory results associated with TIER.Net patients by 62.6%.

Conclusions

Linkage of TIER.Net and NHLS without patient identifiers attained high accuracy and yield without compromising patient privacy. The integrated cohort provides a more complete view of patients' lab history and could yield more accurate estimates of HIV program indicators.

Context counts: Investigating pain management interventions in HIV-positive men living in a rural area

BACKGROUND

Pain remains a prevalent and burdensome complaint for people living with human immunodeficiency virus and/or aquired immunodeficiency syndrome (LWHA). Positive Living (PL), a multimodal pain intervention, reduced pain in female South Africans LWHA. We investigated the efficacy of the PL programme in South African males living with human immunodeficiency virus and/or acquired immunodeficiency syndrome (MLWA) in a rural community.

AIM

To determine the effects of a multimodal pain intervention in MLWHA.

SETTING

Various primary care clinics in Manguzi, Kwa-Zulu Natal, South Africa.

METHODOLOGY

Therapeutic relationship (TR) intervention alone or in combination with the PL programme were allocated to HIV-positive men between the ages of 18-40. Pain intensity and interference were the primary outcome measures. Secondary outcome measures included physical function, health-related quality of life, depressive symptoms and self-efficacy.

RESULTS

Forty-seven men (mean age 35 ± 3 years) were recruited with baseline mean pain severity of 5.02 (± 3.01) and pain interference of 4.6 (± 3.18). Nineteen men were allocated to the TR intervention alone, 28 were allocated to the TR intervention and PL programme. Attendance at the intervention sessions varied from 10% to 36%. No changes in any outcomes were recorded.

CONCLUSION

Poor attendance at the intervention and follow-up sessions make these results an unreliable reflection of the intervention. Contextual factors including internal migration and issues around employment were identified. These may influence healthcare utilisation for MLWHA living in rural settings.Contribution: Unmet healthcare needs of MLWHA in a rural community have been identified. If we are to 'leave no one behind', healthcare interventions should account for context and be 'rural-proofed'.

The Impact of Human Immunodeficiency Virus and Menopause on Bone Mineral Density: A Longitudinal Study of Urban-Dwelling South African Women

An estimated 25% of South African women live with human immunodeficiency virus (HIV). Antiretroviral therapy roll-out has improved life expectancy, so many more women now reach menopause. We aimed to quantify changes in bone mineral density (BMD) during the menopausal transition in urban-dwelling South African women with and without HIV and determine whether HIV infection modified the effect of menopause on BMD changes. A 5-year population-based longitudinal study recruited women aged 40-60 years residing in Soweto and collected demographic and clinical data, including HIV status, anthropometry, and BMD, at baseline and at 5-year follow-up. All women were staged as pre-, peri-, or postmenopausal at both time points. Multivariable linear regression assessed relationships and interactions between HIV infection, menopause, and change in BMD. At baseline, 450 women had mean age 49.5 (SD 5.7) years, 65 (14.4%) had HIV, and 140 (31.1%), 119 (26.4%), and 191 (42.4%) were pre-, peri-, and postmenopausal, respectively; 34/205 (13.6%) women ≥50 years had a total hip (TH) or lumbar spine (LS) T-score ≤ -2.5. At follow-up 38 (8.4%), 84 (18.7%), and 328 (72.9%) were pre-, peri-, and postmenopausal. Those with HIV at baseline lost more total body (TB) BMD (mean difference -0.013 [95% confidence interval -0.026, -0.001] g/cm2 , p = 0.040) and gained more weight 1.96 [0.32, 3.60] kg; p = 0.019 than HIV-uninfected women. After adjusting for age, baseline weight, weight change, and follow-up time, the transition from pre- to postmenopause was associated with greater TB BMD losses in women with HIV (-0.092 [-0.042, -0.142] g/cm2 ; p = 0.001) than without HIV (-0.038 [-0.016, -0.060] g/cm2 , p = 0.001; interaction p = 0.034). Similarly, in women who were postmenopausal at both time points, those with HIV lost more TB BMD (-0.070 [-0.031, -0.108], p = 0.001) than women without HIV (-0.036 [-0.015, -0.057], p = 0.001, interaction p = 0.049). Findings were consistent but weaker at the LS and TH. Menopause-related bone loss is greater in women with HIV, suggesting women with HIV may be at greater risk of osteoporotic fractures. HIV services should consider routine bone health assessment in midlife women as part of long-term HIV care delivery. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research

BACKGROUND

Antiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research.

METHODS

We conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children ('downward' spillover effects) and older adults ('upward' spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies.

FINDINGS

We identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART.

CONCLUSIONS

ART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.

Healthcare provider perceptions on the implementation of the universal test-and-treat policy in South Africa: a qualitative inquiry

BACKGROUND

South Africa had an estimated 7.5 million people living with HIV (PLHIV), accounting for approximately 20% of the 38.4 million PLHIV globally in 2021. In 2015, the World Health Organization recommended the universal test and treat (UTT) intervention which was implemented in South Africa in September 2016. Evidence shows that UTT implementation faces challenges in terms of human resources capacity or infrastructure. We aim to explore healthcare providers (HCPs)' perspectives on the implementation of the UTT strategy in uThukela District Municipality in KwaZulu-Natal province.

METHODS

A qualitative study was conducted with one hundred and sixty-one (161) healthcare providers (HCPs) within 18 healthcare facilities in three subdistricts, comprising of Managers, Nurses, and Lay workers. HCPs were interviewed using an open ended-survey questions to explore their perceptions providing HIV care under the UTT strategy. All interviews were thematically analysed using both inductive and deductive approaches.

RESULTS

Of the 161 participants (142 female and 19 male), 158 (98%) worked at the facility level, of which 82 (51%) were nurses, and 20 (12.5%) were managers (facility managers and PHC manager/supervisors). Despite a general acceptance of the UTT policy implementation, HCPs expressed challenges such as increased patient defaulter rates, increased work overload, caused by the increased number of service users, and physiological and psychological impacts. The surge in the workload under conditions of inadequate systems' capacity and human resources, gave rise to a greater burden on HCPs in this study. However, increased life expectancy, good quality of life, and immediate treatment initiation were identified as perceived positive outcomes of UTT on service users. Perceived influence of UTT on the health system included, increased number of patients initiated, decreased burden on the system, meeting the 90-90-90 targets, and financial aspects.

CONCLUSION

Health system strengthening such as providing more systems' capacity for expected increase in workload, proper training and retraining of HCPs with new policies in the management of patient readiness for lifelong ART journey, and ensuring availability of medicines, may reduce strain on HCPs, thus improving the delivery of the comprehensive UTT services to PLHIV.

"I'm Getting Life from the Treatment": Perceptions of Life and Death Among Middle-Aged and Older Medication-Adherent Persons Living with HIV in Rural South Africa

The widespread availability of health information and treatment for HIV in Southern Africa does not reach all populations. Few programs and materials are developed with middle-aged and older rural individuals living with HIV as the target audience, despite this being a growing population. This vacuum inevitably exacerbates the disjuncture between clinical and experiential knowledge. This study uses in-depth interviews from 2018 with middle-aged and older rural South Africans who self-report medication adherence to ART in order to explore experiences of living with HIV and beliefs about anti-retroviral treatment (ART). Participants revealed a general sense of vulnerability as a major motivation for HIV medication adherence. A majority of the participants believed that death was imminent if they defaulted on ART at any point in time. Although the availability of ART brought hope to many, HIV was still perceived as a death sentence, particularly if ART adherence was imperfect. The study findings suggest a need to examine the psychosocial component of community programs for middle-aged and older people living with HIV. For this growing population that experienced the full course of the epidemic, more research is needed on the burden of psychological and mental health issues emerging from the need for long-term HIV medication adherence.

Validity of Self-Report for Ascertaining HIV Status Among Circular Migrants and Permanent Residents in South Africa: A Cross-Sectional, Population-Based Analysis

While expanded HIV testing is needed in South Africa, increasing accurate self-report of HIV status is an essential parallel goal in this highly mobile population. If self-report can ascertain true HIV-positive status, persons with HIV (PWH) could be linked to life-saving care without the existing delays required by producing medical records or undergoing confirmatory testing, which are especially burdensome for the country's high prevalence of circular migrants. We used Wave 1 data from The Migration and Health Follow-Up Study, a representative adult cohort, including circular migrants and permanent residents, randomly sampled from the Agincourt Health and Demographic Surveillance System in a rural area of Mpumalanga Province. Within the analytic sample (n = 1,918), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-report were calculated with dried blood spot (DBS) HIV test results as the standard. Among in-person participants (n = 2,468), 88.8% consented to DBS-HIV testing. HIV prevalence was 25.3%. Sensitivity of self-report was 43.9% (95% CI: 39.5-48.5), PPV was 93.4% (95% CI: 89.5-96.0); specificity was 99.0% (95% CI: 98.3-99.4) and NPV was 83.9% (95% CI: 82.8-84.9). Self-report of an HIV-positive status was predictive of true status for both migrants and permanent residents in this high-prevalence setting. Persons who self-reported as living with HIV were almost always truly positive, supporting a change to clinical protocol to immediately connect persons who say they are HIV-positive to ART and counselling. However, 56% of PWH did not report as HIV-positive, highlighting the imperative to address barriers to disclosure.

Global colorectal cancer research, 2007-2021: Outputs and funding

The purpose of this study was to provide an evidence base for colorectal cancer research activity that might influence policy, mainly at the national level. Improvements in healthcare delivery have lengthened life expectancy, but within a situation of increased cancer incidence. The disease burden of CRC has risen significantly, particularly in Africa, Asia and Latin America. Research is key to its control and reduction, but few studies have delineated the volume and funding of global research on CRC. We identified research papers in the Web of Science (WoS) from 2007 to 2021, and determined the contributions of the leading countries, the research domains studied, and their sources of funding. We identified 62 716 papers, representing 5.7% of all cancer papers. This percentage was somewhat disproportionate to the disease burden (7.7% in 2015), especially in Eastern Europe. International collaboration increased over the time period in almost all countries except in China. Genetics, surgery and prognosis were the leading research domains. However, research on palliative care and quality-of-life in CRC was lacking. In Western Europe, the main funding source was the charity sector, particularly in the UK, but in most other countries government played the leading role, especially in China and the USA. There was little support from industry. Several Asian countries provided minimal contestable funding, which may have reduced the impact of their CRC research. Certain countries must perform more CRC research overall, especially in domains such as screening, palliative care and quality-of-life. The private-non-profit sector should be an alternative source of support.

Prostate Cancer Disparities and Management in Southern Africa: Insights into Practices, Norms and Values

Prostate cancer (PCa) is a leading cause of mortality in men of African origin. While men of African descent in high-income countries (HICs) demonstrate poor prognosis compared to their European counterparts, African men on the African continent, particularly Southern Africa have shown even higher PCa mortality rates. Extrinsic factors such as the socioeconomic status, education level, income level, geographic location and race contribute to PCa patient outcome. These are further deepened by the African norms which are highly esteemed and may have detrimental effects on PCa patients' health. Insights into African cultures and social constructs have been identified as key elements towards improving men's health care seeking behaviour which will in turn improve PCa patients' outcome. Compared to Southern Africa, the Eastern, Western and Central African regions have lower PCa incidence rates but higher mortality rates. The availability of cancer medical equipment has also been reported to be disproportionate in Africa, with most cancer resources in Northern and Southern Africa. Even within Southern Africa, cancer management resources are unevenly available where one country must access PCa specialised care in the neighbouring countries. While PCa seems to be better managed in HICs, steps towards effective PCa management are urgently needed in Africa, as this continent represents a significant portion of low-middle-income countries (LMICs). Replacing African men in Africa with African American men may not optimally resolve PCa challenges in Africa. Adopting western PCa management practices can be optimised by integrating improved core-African norms. The aim of this review is to discuss PCa disparities in Africa, deliberate on the significance of integrating African norms around masculinity and discuss challenges and opportunities towards effective PCa care in Africa, particularly in Southern Africa.

Study Protocol for a Pilot Randomized Trial of a Virtual Occupational Therapy Fall Prevention Intervention for People With HIV and Alcohol Use

Background

People living with HIV (PLWH) are at risk for falls due to polypharmacy, unhealthy substance (risky alcohol and/or illicit drug) use, low physical activity, and frailty combined with typical age-related physical changes. Fall prevention is needed to reduce the morbidity related to falls and fractures, however, there is a paucity of data on the design of a fall prevention intervention and whether it can be delivered virtually. We describe the protocol of a pilot randomized trial of a virtual occupational therapy fall prevention intervention for people with HIV at high risk for falls and recent alcohol and/or drug use.

Method

PLWH will be recruited from the Boston ARCH 4F Cohort study, an observational study of PLWH to examine the impact of alcohol on falls. Trial participants will be randomized to either an occupational therapy-led fall prevention intervention or provided with written education about fall prevention and alcohol use (control). The 10-week fall prevention intervention was based upon results from qualitative interviews with PLWH about falls and will consist of weekly virtual group sessions, home exercises and phone-check-ins, delivered by occupational therapists. The primary outcome measures will be number of groups attended and a participant-completed satisfaction survey. Change in number of falls, alcohol and other drug use, and physical functioning will be examined.

Discussion

A virtual occupational therapy fall prevention intervention addresses the emerging concern of fall risk in PLWH and alcohol use. This pilot study will provide preliminary estimates of fall-related outcomes as well as feasibility of study procedures for a larger trial.

ClinicalTrialsgov Identifier

NCT04804579. Boston University Protocol Record H-41041.

Study protocol: A randomised trial of the effectiveness of the Common Elements Treatment Approach (CETA) for improving HIV treatment outcomes among women experiencing intimate partner violence in South Africa

INTRODUCTION

Intimate partner violence (IPV) is a barrier to consistent HIV treatment in South Africa. Previous trials have established that the Common Elements Treatment Approach (CETA), a cognitive-behavioural-based intervention, is effective in reducing mental and behavioural health problems but has not been trialled for effectiveness in improving HIV outcomes. This paper describes the protocol for a randomised trial that is testing the effectiveness of CETA in improving HIV treatment outcomes among women experiencing IPV in South Africa.

METHODS AND ANALYSIS

We are conducting a randomised trial among HIV-infected women on antiretroviral therapy, who have experienced sexual and/or physical IPV, to test the effect of CETA on increasing retention and viral suppression and reducing IPV. Women living with HIV who have an unsuppressed viral load or are at high risk for poor adherence and report experiencing recent IPV, defined as at least once within in the last 12 months, will be recruited from HIV clinics and randomised 1:1 to receive CETA or an active attention control (text message reminders). All participants will be followed for 24 months. Follow-up HIV data will be collected passively using routinely collected medical records. HIV outcomes will be assessed at 12 and 24 months post-baseline. Questionnaires on violence, substance use and mental health will be administered at baseline, post-CETA completion and at 12 months post-baseline. Our primary outcome is retention and viral suppression (<50 copies/mL) by 12 months post-baseline. We will include 400 women which will give us 80% power to detect an absolute 21% difference between arms. Our primary analysis will be an intention-to-treat comparison of intervention and control by risk differences with 95% CIs.

ETHICS AND DISSEMINATION

Ethics approval provided by University of the Witwatersrand Human Research Ethics Committee (Medical), Boston University Institutional Review Board and Johns Hopkins School Institutional Review Board. Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04242992.

Disability, a priority area for health research in South Africa: an analysis of the burden of disease study 2017

PURPOSE

Disabilities are increasing globally, which is attributed to the overall ageing of populations in affluent countries. This trend may differ in low and middle-income countries. This paper assesses the change over time in Years Lived with Disability (YLD) for South Africa and how this compares to regional and global trends.

MATERIALS AND METHODS

This secondary analysis of the Global Burden of Disease Study 2017 dataset describes the observed contribution of YLD to Disability-Adjusted Life Years (DALYs) per 100 000 people over the period 1990-2016, and forecast to 2030 using simple linear prediction. South African trends are compared to global and sub-Saharan African (SSA) trends to highlight the effect of HIV and policy implications.

RESULTS

Globally, the contribution of YLD to DALYs has increased from ±21.7% in 1990 to ±34% by 2016, with high socio-demographic index countries having a higher contribution (49%). HIV, mental health, musculoskeletal, neurological, and sense organ disorders are the five main contributors to YLD in South Africa (54%). Removing the effects of HIV/AIDS and sexually transmitted infections on YLD, South Africa's trend appears similar to the global trend, yet opposite to the SSA trend.

CONCLUSION

Our analysis shows there is a growing burden of disability in South Africa. Differences in trends with the regional and global patterns can be attributed to the high burden of HIV and non-communicable diseases in South Africa. Therefore, strategies are urgently needed to increase integration of disability and rehabilitation services into chronic HIV and non-communicable disease management. This calls for disability screening to identify functional limitations in routine data collection and case management.IMPLICATIONS FOR REHABILITATIONSouth Africa has experienced an increase in disability prevalence over time.This requires strengthening of services such as mental health interventions, physiotherapy, optometry, and audiology, and linking major disease clusters, such as HIV and the NCDs, to rehabilitation services.The greatest contributors towards disability adjusted life years in South Africa are currently mental disorders (13.8%), HIV and sexually transmitted infections (11.8%), musculoskeletal disorders (10.4%), neurological disorders (8.2%), and sense organ diseases (7.5%).Routine data collection and case management needs to include disability screening to identify developing functional limitations.

HIV prevalence among men who have sex with men, transgender women and cisgender male sex workers in sub-Saharan Africa: a systematic review and meta-analysis

INTRODUCTION

Developing effective targets, policies and services for key populations requires estimations of population sizes and HIV prevalence across countries and regions. We estimated the relative and absolute HIV prevalence among men who have sex with men (MSM), transgender women and men, and male and transgender sex workers (MSW and TGSW) in sub-Saharan African countries using peer-reviewed literature.

METHODS

We performed a systematic review of peer-reviewed studies assessing HIV prevalence in MSM, transgender women and men, MSW and TGSW in sub-Saharan Africa between 2010 and 2021, following PRISMA guidelines. We searched Embase, Medline Epub, Africa Index Medicus, Africa Journal Online, Web of Science and Google Scholar. We calculated HIV prevalence ratios (PRs) between the study prevalence, and the geospatial-, sex, time and age-matched general population prevalence. We extrapolated results for MSM and transgender women to estimate HIV prevalence and the number living with HIV for each country in sub-Saharan Africa using pooled review results, and regression approximations for countries with no peer-reviewed data.

RESULTS AND DISCUSSION

We found 44 articles assessing HIV prevalence in MSM, 10 in transgender women, five in MSW and zero in transgender men and TGSW. Prevalence among MSM and transgender women was significantly higher compared to the general population: PRs of 11.3 [CI: 9.9-12.9] for MSM and 8.1 [CI: 6.9-9.6] for transgender women in Western and Central Africa, and, respectively, 1.9 [CI: 1.7-2.0] and 2.1 [CI: 1.9-2.4] in Eastern and Southern Africa. Prevalence among MSW was significantly higher in both Nigeria (PR: 12.4 [CI: 7.3-21.0]) and Kenya (PR: 8.6 [CI: 4.6-15.6]). Extrapolating our findings for MSM and transgender women resulted in an estimated HIV prevalence of 15% or higher for about 60% of all sub-Saharan African countries for MSM, and for all but two countries for transgender women.

CONCLUSIONS

HIV prevalence among MSM and transgender women throughout sub-Saharan Africa is alarmingly high. This high prevalence, coupled with the specific risks and vulnerabilities faced by these populations, highlights the urgent need for risk-group-tailored prevention and treatment interventions across the sub-continent. There is a clear gap in knowledge on HIV prevalence among transgender men, MSW and TGSW in sub-Saharan Africa.

Cohort profile: CareConekta: a pilot study of a smartphone application to improve engagement in postpartum HIV care in South Africa

PURPOSE

Pregnant and postpartum women living with HIV in South Africa are at high risk of dropping out of care, particularly after delivery. Population mobility may contribute to disruptions in HIV care, and postpartum women are known to be especially mobile. To improve engagement in HIV care during the peripartum period, we developed CareConekta, a smartphone application (app) that uses GPS coordinates to characterise mobility and allow for real-time intervention. We conducted a randomised controlled pilot study to assess feasibility, acceptability and initial efficacy of the app intervention to improve engagement in HIV care. This cohort profile describes participant enrolment and follow-up, describes the data collected and provides participant characteristics.

PARTICIPANTS

We enrolled 200 pregnant women living with HIV attending routine antenatal care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Eligible women must have owned smartphones that met the app's technical requirements. Seven participants were withdrawn near enrolment, leaving 193 in the cohort.

FINDINGS TO DATE

Data were collected from detailed participant questionnaires at enrolment and follow-up (6 months after delivery), as well as GPS data from the app, and medical records. Follow-up is complete; initial analyses have explored smartphone ownership, preferences and patterns of use among women screened for eligibility and those enrolled in the study.

FUTURE PLANS

Additional planned analyses will characterise mobility in the population using the phone GPS data and participant self-reported data. We will assess the impact of mobility on engagement in care for the mother and infant. We also will describe the acceptability and feasibility of the study, including operational lessons learnt. By linking this cohort to the National Health Laboratory Service National HIV Cohort in South Africa, we will continue to assess engagement in care and mobility outcomes for years to come. Collaborations are welcome.

TRIAL REGISTRATION NUMBER

NCT03836625.

Burden of hypertension and associated factors among HIV-positive adults in Busia County, Kenya

Introduction

the use of antiretroviral (ARVs) for the management of HIV (human immunodeficiency virus) infection has resulted in a prolonged lifespan among HIV-positive individuals. Both HIV infection and ARVs treatment put this population at a greater risk of developing hypertension. The study aimed at establishing the burden of hypertension and associated factors among HIV-positive population.

Methods

a cross-sectional design was employed where a total of 280 HIV-positive adults in Busia County were selected in a multi-stage sampling procedure between March and August 2020. Sociodemographic, economic and behavioral information was collected using a structured questionnaire. Anthropometric measurements were taken using standard methods while clinical data were extracted from patients´ medical records. Proportion was used to establish hypertension burden. Analyses were done using the T-test, Chi-square, and odds ratio.

Results

among the 280 study participants, 194 (69.3%) were females, and 239(85.4%) over 35 years of age. Hypertensive cases were 55 (19.6%). The hypertensive group had a significantly higher mean age (52.25±10.4 vs 44.9±11.3; p=0.002), waist-to-hip ratio (0.93±0.09 vs 0.89±0.07; p=0.016), HIV duration (8.64±4.63 vs 6.86±4.04; p=0.014) and cumulative ART treatment duration (8.31±4.61 vs 6.68±3.93; p=0.018). Factors found to be significantly associated with hypertension in the bivariate analysis included age (p=0.003); family history (p=0.024); duration of alcohol intake (p=0.034); HIV duration (p=0.033) and treatment duration (p=0.043). In the multivariate analysis, only age (p=0.045) and family history (p=0.018) contributed significantly in the logistic regression model.

Conclusion

the study revealed a slightly lower burden of hypertension among HIV -positive adults in Busia County. Age and family history were the factors independently associated with hypertension in this study.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

National Institutes of Health.

The Effect of Pretreatment Potential Resistance to NNRTIs on Antiviral Therapy in Patients With HIV/AIDS

BACKGROUND

With the increasing coverage of antiretroviral therapy, concerns for the emergence and transmission of HIV drug resistance (HIVDR) are arising. HIVDR was divided into 5 levels: sensitive, potentially resistant, low resistant, intermediate resistant, and high resistant. Most of the articles on HIVDR involved low-level, intermediate-level, and high-level drug resistance to antiretroviral drug, and few articles deal with potential drug resistance. Treatment failure associated with the level of low-level, intermediate-level, and high-level resistance to antiretroviral drug has been reported. However, whether virological failure (VF) is related to potential resistance remains unclear. In this study, we aimed to describe the situation of potential resistance to antiretroviral drug and whether it is related to VF.

METHODS

We analyzed the demographic, behavioral information, medical history, and drug resistance-associated mutation data from subjects. Drug resistance mutations at baseline and time of failure in patients suffering VF were detected by using the Vela automated next-generation sequencing platform. The χ2 test or Fisher exact test and logistic regression were used to assess the risk factors that contribute to VF in the potential drug-resistant people.

RESULTS

The prevalence of overall pretreatment drug resistance was 7.06% (233/3300), and the prevalence of pretreatment potential resistance was 8.79% (290/3300). All these patients with pretreatment potential first-line drugs resistance showed potential resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs), and some of them had potential drug resistance to NNRTIs and NRTIs or NNRTIs and PIs; among these patients, 94.71% (179/189) had V179 D/E mutations. The VF rate of first-line treatment for potentially resistant people is 17.99%. CD4+ T-cell count ≤200 cells/L at antiretroviral therapy initiation are risk factors for the failure of first-line treatment.

CONCLUSIONS

The prevalence of potential drug resistance among individuals with HIV and the VF rate of first-line treatment for potential drug-resistant people were high. To better optimize clinical management, prevention, and control of HIV, attention should be devoted to the potential resistance of nonnucleoside drugs.

Priorities for health and wellbeing for older people with and without HIV in Uganda: a qualitative methods study

Introduction

With improved HIV treatment availability in sub‐Saharan Africa, the population of older people with HIV (PWH) is growing. In this qualitative study, we intended to understand (1) the lived experiences of ageing people in rural Uganda, with and without HIV, (2) their fears and health priorities as they grow older.

Methods

We conducted 36 semi‐structured interviews with individuals with and without HIV in Mbarara, Uganda from October 2019 to February 2020. Interview guide topics included priorities in older age, physical functioning in daily activities, social functioning, HIV‐related stigma and the impact of multimorbidity on health and independence. Interviews were conducted in Runyankole, transcribed, translated and inductively coded thematically by two researchers with tests for inter‐coder reliability.

Results

The respondents were purposively sampled to be evenly divided by sex and HIV serostatus. The median age of respondents was 57 (49–73). Two‐thirds were married or cohabitating, 94% had biological children and 75% cited farming as their primary livelihood. Overall, PWH considered themselves as healthy or healthier than people without HIV (PWOH). PWH rarely considered their HIV status a barrier to a healthy life, but some reported a constant sense of anxiety as it relates to their long‐term health. Irrespective of HIV status, nearly all respondents noted concerns about memory loss, physical pain, reductions in energy and the effect of these changes on their ability to complete physical tasks like small‐scale farming, and activities of daily living important to the quality of life, such as participating in community groups. Increasing reliance on others for social, physical and financial support was also a common theme. The most prevalent health concern among participants involved the threat of non‐communicable diseases and perceptions that physical functioning may diminish.

Conclusions

In rural Uganda, we found that PWH consider themselves to be healthy and do not anticipate a different ageing experience from PWOH. Common priorities shared by both groups included the desire for physical and financial independence, health maintenance and social support for daily functioning and social needs. Entities supporting geriatric care in Uganda would benefit from attention to concerns about functional limitations and reported needs as people age with and without HIV.

Applying machine learning and predictive modeling to retention and viral suppression in South African HIV treatment cohorts

HIV treatment programs face challenges in identifying patients at risk for loss-to-follow-up and uncontrolled viremia. We applied predictive machine learning algorithms to anonymised, patient-level HIV programmatic data from two districts in South Africa, 2016-2018. We developed patient risk scores for two outcomes: (1) visit attendance ≤ 28 days of the next scheduled clinic visit and (2) suppression of the next HIV viral load (VL). Demographic, clinical, behavioral and laboratory data were investigated in multiple models as predictor variables of attending the next scheduled visit and VL results at the next test. Three classification algorithms (logistical regression, random forest and AdaBoost) were evaluated for building predictive models. Data were randomly sampled on a 70/30 split into a training and test set. The training set included a balanced set of positive and negative examples from which the classification algorithm could learn. The predictor variable data from the unseen test set were given to the model, and each predicted outcome was scored against known outcomes. Finally, we estimated performance metrics for each model in terms of sensitivity, specificity, positive and negative predictive value and area under the curve (AUC). In total, 445,636 patients were included in the retention model and 363,977 in the VL model. The predictive metric (AUC) ranged from 0.69 for attendance at the next scheduled visit to 0.76 for VL suppression, suggesting that the model correctly classified whether a scheduled visit would be attended in 2 of 3 patients and whether the VL result at the next test would be suppressed in approximately 3 of 4 patients. Variables that were important predictors of both outcomes included prior late visits, number of prior VL tests, time since their last visit, number of visits on their current regimen, age, and treatment duration. For retention, the number of visits at the current facility and the details of the next appointment date were also predictors, while for VL suppression, other predictors included the range of the previous VL value. Machine learning can identify HIV patients at risk for disengagement and unsuppressed VL. Predictive modeling can improve the targeting of interventions through differentiated models of care before patients disengage from treatment programmes, increasing cost-effectiveness and improving patient outcomes.

Impact of HIV infection on survival among women with stage I-III breast cancer: Results from the South African breast cancer and HIV outcomes study

In some countries of sub-Saharan Africa, the prevalence of HIV exceeds 20%; in South Africa, 20.4% of people are living with HIV. We examined the impact of HIV infection on the overall survival (OS) of women with nonmetastatic breast cancer (BC) enrolled in the South African Breast Cancer and HIV Outcomes (SABCHO) study. We recruited women with newly diagnosed BC at six public hospitals from 1 July 2015 to 30 June 2019. Among women with stages I-III BC, we compared those with and without HIV infection on sociodemographic, clinical, and treatment factors. We analyzed the impact of HIV on OS using multivariable Cox proportional hazard models. Of 2367 women with stages I-III BC, 499 (21.1%) had HIV and 1868 (78.9%) did not. With a median follow-up of 29 months, 2-year OS was poorer among women living with HIV (WLWH) than among HIV-uninfected women (72.4% vs 80.1%, P < .001; adjusted hazard ratio (aHR) 1.49, 95% confidence interval (CI) = 1.22-1.83). This finding was consistent across age groups ≥45 years and <45 years, stage I-II BC and stage III BC, and ER/PR status (all P < .03). Both WLWH with <50 viral load copies/mL and WLWH with ≥50 viral load copies/mL had poorer survival than HIV-uninfected BC patients [aHR: 1.35 (1.09-1.66) and 1.54 (1.20-2.00), respectively], as did WLWH who had ≥200 CD4+ cells/mL at diagnosis [aHR: 1.39 (1.15-1.67)]. Because receipt of antiretroviral therapy has become widespread, WLWH is surviving long enough to develop BC; more research is needed on the causes of their poor survival.

Adherence barriers and interventions to improve ART adherence in Sub-Saharan African countries: A systematic review protocol

Background

The HIV/AIDS pandemic continues to be a major public health concern, particularly in Sub-Saharan Africa (SSA). Despite efforts to reduce new infections and deaths with the use of antiretroviral therapy (ART), SSA countries continue to bear the heaviest burden of HIV/AIDS globally, accounting for two-thirds of global new infections. The goal of this review is to identify common barriers to ART adherence as well as common effective interventions that can be implemented across SSA countries to improve ART adherence.

Methods

A systematic review of published studies on adult HIV-positive patients aged 15 or above, that have assessed the barriers to ART adherence and interventions improving patients’ adherence to ART in SSA countries shall be conducted. We will conduct electronic searches for articles that have been published starting from January 2010 onwards. The databases that shall be searched will include Medline Ovid, CINAHL, Embase, and Scopus. The review will include experimental and quasi-experimental studies such as randomized and non-randomized controlled trials as well as comparative before and after studies, and observational studies—cross-sectional studies, cohort studies, prospective and retrospective studies. Two independent reviewers will screen all identified studies, extract data and appraise the methodological quality of the studies using standard critical appraisal tools from the Joanna Briggs Institute. The extracted data will be subjected to a meta-analysis and narrative synthesis.

Discussion

This review will synthesize existing evidence on ART adherence barriers and strategies for improving patient adherence to ART in SSA countries. It will identify common barriers to adherence and common interventions proven to improve adherence across SSA. We anticipate that the findings of this review will provide information policy makers and stakeholders involved in the fight against HIV, will find useful in deriving better ways of not only retaining patients on treatment but having them adhere to their treatment.

Review registration

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42021262256.

Triazolyl Ru(II), Os(II), and Ir(III) complexes as potential HIV-1 inhibitors

Infection by the human immunodeficiency virus, which gives rise to acquired immunodeficiency syndrome, is still a major global health challenge, with millions of people being affected. The use of combination antiretroviral therapy has been a great success, leading to reduced mortality rates over the years. Although successful, these drugs are associated with various side effects, necessitating the development of new treatment strategies. This study investigated three metal-based complexes that were previously shown to possess some anticancer activity. The complexes were investigated against three pseudoviruses, which consisted of HIV-1 subtype C (CAP 210 and Du 156) and subtype A (Q 23). These complexes inhibited viral entry at low micromolar concentrations, with IC₅₀ values ranging from 5.34 to 7.41 µM for N-aryl-1H-1,2,3-triazole-based cyclometalated ruthenium-(II) (A), 2.35-8.09 µM for N-aryl-1H-1,2,3-triazole-based cyclometalated iridium-(III) (B) and 2.59-4.18 µM for N-aryl-1H-1,2,3-triazole-based cyclometalated osmium-(II) complex (C). This inhibition was significant, with no significant inhibition from the ligand alone at similar concentrations. Additionally, these concentrations were non-toxic to mammalian cells. The complexes were further analysed for their potential mechanism of action using in silico docking (Maestro 12.2), which indicated that the activity is potentially due to their interaction with the CCR5 co-receptor. The predicted interaction involved amino acids (Glu 283, Tyr 251 and Tyr 108) that are essential for the interaction of the chemokine receptor with viral gp120.

Predictors of migration in an HIV hyper-endemic rural South African community: evidence from a population-based cohort (2005-2017)

Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15-49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20-24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19-3.57), and 2.9-times higher among young men aged 20-24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69-3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 - 0.99) and men (aHR = 0.73, 95% CI 0.66 - 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.