Cohort profile: Hlabisa HIV treatment and care programme

Increasing HIV-1 Drug Resistance Between 2010 and 2012 in Adults Participating in Population-Based HIV Surveillance in Rural KwaZulu-Natal, South Africa

As more human immunodeficiency virus (HIV)–infected patients access combination antiretroviral therapy (cART), higher proportions of newly infected patients may be infected with drug-resistant viruses. Regular surveillance of transmitted drug resistance (TDR) is required in southern Africa where high rates of transmission persist despite rapid expansion of ART. Dried blood spot samples from cART-naive participants from two rounds of an annual population-based HIV surveillance program in rural KwaZulu-Natal were tested for HIV RNA, and samples with HIV RNA >10,000 copies/ml were genotyped for drug resistance. The 2009 surveillance of drug resistance mutation (SDRM) list was used for drug resistance interpretation. The data were added to previously published data from the same program, and the χ² test for trend was used to test for trend in estimated prevalence of any TDR. Seven hundred and one participants' data were analyzed: 67 (2010), 381 (2011), and 253 (2012). No TDR was detected in 2010. Years 2011 and 2012 had 18 participants with SDRMs 4.7% and 7.1%, respectively (p = .02, χ² test for trend). The nonnucleoside reverse transcriptase inhibitor mutation, K103N, was the most common mutation, occurring in 27 (3.8%) of the participants, while nucleoside reverse transcriptase inhibitor (NRTI) SDRMs were detected in 10 (1.4%) of the participants, of whom eight had only a single NRTI SDRM. The increase in levels of drug resistance observed in this population could be a signal of increasing transmission of drug-resistant HIV. Thus, continued surveillance is critical to inform public health policies around HIV treatment and prevention.

Uptake of Home-Based HIV Testing, Linkage to Care, and Community Attitudes about ART in Rural KwaZulu-Natal, South Africa: Descriptive Results from the First Phase of the ANRS 12249 TasP Cluster-Randomised Trial

BACKGROUND

The 2015 WHO recommendation of antiretroviral therapy (ART) for all immediately following HIV diagnosis is partially based on the anticipated impact on HIV incidence in the surrounding population. We investigated this approach in a cluster-randomised trial in a high HIV prevalence setting in rural KwaZulu-Natal. We present findings from the first phase of the trial and report on uptake of home-based HIV testing, linkage to care, uptake of ART, and community attitudes about ART.

METHODS AND FINDINGS

Between 9 March 2012 and 22 May 2014, five clusters in the intervention arm (immediate ART offered to all HIV-positive adults) and five clusters in the control arm (ART offered according to national guidelines, i.e., CD4 count ≤ 350 cells/μl) contributed to the first phase of the trial. Households were visited every 6 mo. Following informed consent and administration of a study questionnaire, each resident adult (≥16 y) was asked for a finger-prick blood sample, which was used to estimate HIV prevalence, and offered a rapid HIV test using a serial HIV testing algorithm. All HIV-positive adults were referred to the trial clinic in their cluster. Those not linked to care 3 mo after identification were contacted by a linkage-to-care team. Study procedures were not blinded. In all, 12,894 adults were registered as eligible for participation (5,790 in intervention arm; 7,104 in control arm), of whom 9,927 (77.0%) were contacted at least once during household visits. HIV status was ever ascertained for a total of 8,233/9,927 (82.9%), including 2,569 ascertained as HIV-positive (942 tested HIV-positive and 1,627 reported a known HIV-positive status). Of the 1,177 HIV-positive individuals not previously in care and followed for at least 6 mo in the trial, 559 (47.5%) visited their cluster trial clinic within 6 mo. In the intervention arm, 89% (194/218) initiated ART within 3 mo of their first clinic visit. In the control arm, 42.3% (83/196) had a CD4 count ≤ 350 cells/μl at first visit, of whom 92.8% initiated ART within 3 mo. Regarding attitudes about ART, 93% (8,802/9,460) of participants agreed with the statement that they would want to start ART as soon as possible if HIV-positive. Estimated baseline HIV prevalence was 30.5% (2,028/6,656) (95% CI 25.0%, 37.0%). HIV prevalence, uptake of home-based HIV testing, linkage to care within 6 mo, and initiation of ART within 3 mo in those with CD4 count ≤ 350 cells/μl did not differ significantly between the intervention and control clusters. Selection bias related to noncontact could not be entirely excluded.

CONCLUSIONS

Home-based HIV testing was well received in this rural population, although men were less easily contactable at home; immediate ART was acceptable, with good viral suppression and retention. However, only about half of HIV-positive people accessed care within 6 mo of being identified, with nearly two-thirds accessing care by 12 mo. The observed delay in linkage to care would limit the individual and public health ART benefits of universal testing and treatment in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01509508.

Brief Report: Virologic Monitoring Can Be a Cost-Effective Strategy to Diagnose Treatment Failure on First-Line ART

Supplemental Digital Content is Available in the Text.

CD4 count testing is perceived to be an affordable strategy to diagnose treatment failure on first-line antiretroviral therapy. We hypothesize that the superior accuracy of viral load (VL) testing will result in less patients being incorrectly switched to more expensive and toxic second-line regimens. Using data from a drug resistance cohort, we show that CD4 testing is approximately double the cost to make 1 correct regimen switch under certain diagnostic thresholds (CD4 = US $499 vs. VL = US $186 or CD4 = US $3031 vs. VL = US $1828). In line with World Health Organization guidelines, our findings show that VL testing can be both an accurate and cost-effective treatment monitoring strategy.

The Effect of Antiretroviral Treatment on Health Care Utilization in Rural South Africa: A Population-Based Cohort Study

BACKGROUND

The effect of the rapid scale-up of vertical antiretroviral treatment (ART) programs for HIV in sub-Saharan Africa on the overall health system is under intense debate. Some have argued that these programs have reduced access for people suffering from diseases unrelated to HIV because ART programs have drained human and physical resources from other parts of the health system; others have claimed that the investments through ART programs have strengthened the general health system and the population health impacts of ART have freed up health care capacity for the treatment of diseases that are not related to HIV. To establish the population-level impact of ART programs on health care utilization in the public-sector health system, we compared trends in health care utilization among HIV-infected people receiving and not receiving ART with HIV-uninfected people during a period of rapid ART scale-up.

METHODS AND FINDINGS

We used data from the Wellcome Trust Africa Centre for Population Health, which annually elicited information on health care utilization from all surveillance participants over the period 2009-2012 (N = 32,319). We determined trends in hospitalization, and public-sector and private-sector primary health care (PHC) clinic visits for HIV-infected and -uninfected people over a time period of rapid ART scale-up (2009-2012) in this community. We regressed health care utilization on HIV status and ART status in different calendar years, controlling for sex, age, and area of residence. The proportion of people who reported to have visited a public-sector primary health care (PHC) clinic in the last 6 months increased significantly over the period 2009-2012, for both HIV-infected people (from 59% to 67%; p<0.001), and HIV-uninfected people (from 41% to 47%; p<0.001). In contrast, the proportion of HIV-infected people visiting a private-sector PHC clinic declined from 22% to 12% (p<0.001) and hospitalization rates declined from 128 to 82 per 1000 PY (p<0.001). For HIV-uninfected people, the proportion visiting a private-sector PHC clinic declined from 16% to 9%, and hospitalization rates declined from 78 to 44 per 1000 PY (p<0.001). After controlling for potential confounding factors, all trends remained of similar magnitude and significance.

CONCLUSIONS

Our results indicate that the ART scale-up in this high HIV prevalence community has shifted health care utilization from hospitals and private-sector primary care to public-sector primary care. Remarkably, this shift is observed for both HIV-infected and -uninfected populations, supporting and extending hypotheses of 'therapeutic citizenship' whereby HIV-infected patients receiving ART facilitate primary care access for family and community members. One explanation of our findings is that ART has improved the capacity or quality of primary care in this community and, as a consequence, increasingly met overall health care needs at the primary care level rather than at the secondary level. Future research needs to confirm this causal interpretation of our findings using qualitative work to understand causal mechanisms or quasi-experimental quantitative studies to increase the strength of causal inference.

HIV drug resistance levels in adults failing first-line antiretroviral therapy in an urban and a rural setting in South Africa

OBJECTIVES

Urban and rural HIV treatment programmes face different challenges in the long-term management of patients. There are few studies comparing drug resistance profiles in patients accessing treatment through these programmes. The aim of this study was to perform such a comparison.

METHODS

HIV drug resistance data and associated treatment and monitoring information for adult patients failing first-line therapy in an urban and a rural programme were collected. Data were curated and managed in SATuRN RegaDB before statistical analysis using Microsoft Excel 2013 and stata Ver14, in which clinical parameters, resistance profiles and predicted treatment responses were compared.

RESULTS

Data for 595 patients were analysed: 492 patients from a rural setting and 103 patients from an urban setting. The urban group had lower CD4 counts at treatment initiation than the rural group (98 vs. 126 cells/μL, respectively; P = 0.05), had more viral load measurements performed per year (median 3 vs. 1.4, respectively; P < 0.01) and were more likely to have no drug resistance mutations detected (35.9% vs. 11.2%, respectively; P < 0.01). Patients in the rural group were more likely to have been on first-line treatment for a longer period, to have failed for longer, and to have thymidine analogue mutations. Notwithstanding these differences, the two groups had comparable predicted responses to the standard second-line regimen, based on the genotypic susceptibility score. Mutations accumulated in a sigmoidal fashion over failure duration.

CONCLUSIONS

The frequency and patterns of drug resistance, as well the intensity of virological monitoring, in adults with first-line therapy failure differed between the urban and rural sites. Despite these differences, based on the genotypic susceptibility scores, the majority of patients across the two sites would be expected to respond well to the standard second-line regimen.

Obligation to family during times of transition: care, support and the response to HIV and AIDS in rural South Africa

In rural South Africa, high HIV prevalence has the potential to affect the care and support that kin are able to provide to those living with HIV. Despite this, families seem to be largely resilient and a key source of care and support to family affected by HIV. In this article, we explore the motivations for the provision of care and support by kin. We use the results of a small-scale in-depth qualitative study conducted in 10 households over 6 months in rural KwaZulu-Natal, South Africa, to show that family obligation and conditional reciprocity operate in varying degrees and build social capital. We highlight the complexity of kin relations where obligation is not guaranteed or is limited, requiring the consideration of policy measures that provide means of social support that are not reliant on the family.

Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa

Introduction

We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa.

Methods

Individuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.

Results

Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24–0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49–0.96) or at least some secondary school (aOR=0.59; CI 0.41–0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44–0.78) or 2–5 km from the nearest TasP clinic (aOR=0.57; CI 0.41–0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58–0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12–1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13–4.10) versus not.

Conclusions

Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.

Factors associated with pre-ART loss-to-follow up in adults in rural KwaZulu-Natal, South Africa: a prospective cohort study

BACKGROUND

Timely initiation of antiretroviral treatment (ART) requires sustained engagement in HIV care before treatment eligibility. We assessed loss to follow-up (LTFU) correlates in HIV-positive adults accessing HIV treatment and care, not yet ART-eligible (CD4 >500 cells/mm(3)).

METHODS

This was a sub-study of a prospective cohort study (focusing on sexual behaviour) in an area of high HIV prevalence and widespread ART availability in rural KwaZulu-Natal, South Africa. Psychosocial, clinical and demographic data were collected at recruitment from individuals with CD4 >500 cells/mm(3). LTFU was defined as not attending clinic within 13 months of last visit or before death. Individuals starting ART were censored at ART initiation. Data were collected between January 2009 and January 2013. Analysis used Competing Risks regression.

RESULTS

Two hundred forty-seven individuals (212 females) were recruited (median follow-up 2.13 years, total follow-up 520.15 person-years). 86 remained in pre-ART care (34.8 %), 94 were LTFU (38.1 %), 58 initiated ART (23.5 %), 7 died (2.8 %), 2 transferred out (0.8 %). The LTFU rate was 18.07 per 100 person-years (95 % CI 14.76-21.12). LTFU before a competing event was 13.5 % at one and 34.4 % at three years. Lower LTFU rates were significantly associated with age (>37 versus ≤37 years: adjusted sub-Hazard ratio (aSHR) 0.51, 95 % CI 0.30-0.87), openness with family/friends (a little versus not at all, aSHR 0.81, 95 % CI 0.45-1.43; a lot versus not at all, aSHR 1.57, 95 % CI 0.94-2.62), children (0 versus 4+, aSHR 0.68, 95 % CI 0.24-1.87; 1 versus 4+, aSHR 2.05 95 % CI 1.14-3.69, 2 versus 4+; aSHR 1.71, 95 % CI 0.94-3.09; 3 versus 4a, aSHR 1.14, 95 % CI 0.57-2.30), previous CD4 counts (1 versus 0, aSHR 0.81, 95 % CI 0.45-1.43; 2+ versus 0, aSHR 0.43, 95 % CI 0.25-0.73), and most recent partner HIV status (not known versus HIV-positive, aSHR 0.77, 95 % CI 0.50-1.19; HIV-negative versus HIV-positive, aSHR 2.40, 95 % CI 1.18-4.88). The interaction between openness with family/friends and HIV partner disclosure was close to significance (p = 0.06). Those who had neither disclosed to partners nor were open with family/friends had lowest LTFU rates.

CONCLUSIONS

Strategies to retain younger people in pre-ART care are required. How openness with others, partner HIV status and disclosure, and children relate to LTFU needs further exploration.

Measuring the Impact of Antiretroviral Therapy Roll-Out on Population Level Fertility in Three African Countries

Background

UNAIDS official estimates of national HIV prevalence are based on trends observed in antenatal clinic surveillance, after adjustment for the reduced fertility of HIV positive women. Uptake of ART may impact on the fertility of HIV positive women, implying a need to re-estimate the adjustment factors used in these calculations. We analyse the effect of antiretroviral therapy (ART) provision on population-level fertility in Southern and East Africa, comparing trends in HIV infected women against the secular trends observed in uninfected women.

Methods

We used fertility data from four community-based demographic and HIV surveillance sites: Kisesa (Tanzania), Masaka and Rakai (Uganda) and uMkhanyakude (South Africa). All births to women aged 15–44 years old were included in the analysis, classified by mother’s age and HIV status at time of birth, and ART availability in the community. Calendar time period of data availability relative to ART Introduction varied across the sites, from 5 years prior to ART roll-out, to 9 years after. Calendar time was classified according to ART availability, grouped into pre ART, ART introduction (available in at least one health facility serving study site) and ART available (available in all designated health facilities serving study site). We used Poisson regression to calculate age adjusted fertility rate ratios over time by HIV status, and investigated the interaction between ART period and HIV status to ascertain whether trends over time were different for HIV positive and negative women.

Results

Age-adjusted fertility rates declined significantly over time for HIV negative women in all four studies. However HIV positives either had no change in fertility (Masaka, Rakai) or experienced a significant increase over the same period (Kisesa, uMkhanyakude). HIV positive fertility was significantly lower than negative in both the pre ART period (age adjusted fertility rate ratio (FRR) range 0.51 95%CI 0.42–0.61 to 0.73 95%CI 0.64–0.83) and when ART was widely available (FRR range 0.57 95%CI 0.52–0.62 to 0.83 95%CI 0.78–0.87), but the difference has narrowed. The interaction terms describing the difference in trends between HIV positives and negatives are generally significant.

Conclusions

Differences in fertility between HIV positive and HIV negative women are narrowing over time as ART becomes more widely available in these communities. Routine adjustment of ANC data for estimating national HIV prevalence will need to allow for the impact of treatment.

Understanding Specific Contexts of Antiretroviral Therapy Adherence in Rural South Africa: A Thematic Analysis of Digital Stories from a Community with High HIV Prevalence

Near-perfect adherence to antiretroviral therapy (ART) is required to achieve the best possible prevention and treatment outcomes. Yet, there have been particular concerns about the challenges of adherence among patients living in resource-limited settings in sub-Saharan Africa. The primary objective of this study was to explore adherence in a low-resourced, rural community of high HIV prevalence in South Africa and to identify specific individual and structural factors that can either challenge or support adherence in this context. We applied digital stories as a qualitative research tool to gain insights into personal contexts of HIV and ART adherence. Through an inductive thematic analysis of twenty story texts, soundtracks and drawings, we explored experiences, understandings, and contexts of the participants and identified potential barriers and facilitators for those on lifelong treatment. We found that many of the stories reflected a growing confidence in the effectiveness of ART, which should be viewed as a key facilitator to successful adherence since this attitude can promote disclosure and boost access to social support. Nevertheless, stories also highlighted the complexity of the issues that individuals and households face as they deal with HIV and ART in this setting and it is clear that an overburdened local healthcare system has often struggled to meet the demands of a rapidly expanding epidemic and to provide the necessary medical and emotional support. Our analysis suggests several opportunities for further research and the design of novel health interventions to support optimal adherence. Firstly, future health promotion campaigns should encourage individuals to test together, or at least accompany each other for testing, to encourage social support from the outset. Additionally, home-based testing and ART club interventions might be recommended to make it easier for individuals to adhere to their treatment regimens and to provide a sense of support and solidarity.

Implementation and Operational Research: Risk Charts to Guide Targeted HIV-1 Viral Load Monitoring of ART: Development and Validation in Patients From Resource-Limited Settings

BACKGROUND

HIV-1 RNA viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not available in many resource-limited settings. We developed and validated CD4-based risk charts to guide targeted VL testing.

METHODS

We modeled the probability of virologic failure up to 5 years of ART based on current and baseline CD4 counts, developed decision rules for targeted VL testing of 10%, 20%, or 40% of patients in 7 cohorts of patients starting ART in South Africa, and plotted cutoffs for VL testing on colour-coded risk charts. We assessed the accuracy of risk chart-guided VL testing to detect virologic failure in validation cohorts from South Africa, Zambia, and the Asia-Pacific.

RESULTS

In total, 31,450 adult patients were included in the derivation and 25,294 patients in the validation cohorts. Positive predictive values increased with the percentage of patients tested: from 79% (10% tested) to 98% (40% tested) in the South African cohort, from 64% to 93% in the Zambian cohort, and from 73% to 96% in the Asia-Pacific cohort. Corresponding increases in sensitivity were from 35% to 68% in South Africa, from 55% to 82% in Zambia, and from 37% to 71% in Asia-Pacific. The area under the receiver operating curve increased from 0.75 to 0.91 in South Africa, from 0.76 to 0.91 in Zambia, and from 0.77 to 0.92 in Asia-Pacific.

CONCLUSIONS

CD4-based risk charts with optimal cutoffs for targeted VL testing maybe useful to monitor ART in settings where VL capacity is limited.

Time and Money: The True Costs of Health Care Utilization for Patients Receiving "Free" HIV/Tuberculosis Care and Treatment in Rural KwaZulu-Natal

BACKGROUND

HIV and tuberculosis (TB) services are provided free of charge in many sub-Saharan African countries, but patients still incur costs.

METHODS

Patient-exit interviews were conducted in primary health care clinics in rural South Africa with representative samples of 200 HIV-infected patients enrolled in a pre-antiretroviral treatment (pre-ART) program, 300 patients receiving antiretroviral treatment (ART), and 300 patients receiving TB treatment. For each group, we calculated health expenditures across different spending categories, time spent traveling to and using services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models.

RESULTS

Total monthly health expenditures [1 USD = 7.3 South African Rand (ZAR)] were ZAR 171 [95% confidence interval (CI): 134 to 207] for pre-ART, ZAR 164 (95% CI: 141 to 187) for ART, and ZAR 122 (95% CI: 105 to 140) for TB patients (P = 0.01). Total monthly time costs (in hours) were 3.4 (95% CI: 3.3 to 3.5) for pre-ART, 5.0 (95% CI: 4.7 to 5.3) for ART, and 3.2 (95% CI: 2.9 to 3.4) for TB patients (P < 0.01). Although overall patient costs were similar across groups, pre-ART patients spent on average ZAR 29.2 more on traditional healers and ZAR 25.9 more on chemists and private doctors than ART patients, whereas ART patients spent ZAR 34.0 more than pre-ART patients on transport to clinics (P < 0.05 for all results). Thirty-one percent of pre-ART, 39% of ART, and 41% of TB patients borrowed money or sold assets to finance health care.

CONCLUSIONS

Patients receiving nominally free care for HIV/TB face large private costs, commonly leading to financial distress. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving retention and adherence. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under HIV treatment-as-prevention policies, may not substantially increase patients' financial burden.

Change of treatment guidelines and evolution of ART initiation in rural South Africa: data of a large HIV care and treatment programme

Background

While WHO recommendations are to treat people earlier and earlier, it will considerably increase the number of HIV infected people eligible for antiretroviral therapy (ART). In South Africa, a country which carries one of the highest HIV burden worldwide, very few studies are available on the impact of the ART guidelines on time to ART initiation in both individuals with low CD4 count and those newly eligible for ART. We thus aimed to describe ART initiation percentages in a large HIV programme in rural KwaZulu-Natal, South Africa, according to the temporal changes of national ART eligibility guidelines from 2007 to 2012.

Methods

Adults who accessed the decentralized Hlabisa HIV treatment programme in 2007–2012 were included. Three periods following the temporal change of ART eligibility guidelines were defined (Period 1: until April 2010; Period 2: April 2010 - July 2011; Period 3: from August 2011). Percentages of ART initiation within three months of programme entry were estimated in men, in women of childbearing age (<40 years old) and in older women, and stratifying by CD4 count. Trend tests and logistic regression models were used to study the effects of change of guidelines on ART initiation percentages.

Results

In individuals with CD4 count ≤200 cells/μL (N = 5709 men, N = 6743 women <40 years old and N = 2017 older women), percentages of ART initiation did not differ over time (p trend = 0.25; 0.28; and 0.14, respectively). In individuals with CD4 count = 201–350 cells/μL (N = 2680 men, N = 6086 women <40 years old and N = 1415 older women), percentages of ART initiation significantly increased over time (p trend <0.01 for the three groups): from 6 % in Period 1 to 20 % in Period 2 to 40 % in Period 3 in women of childbearing age, and from 7 % to 8-10 % to 42 % in men and in older women.

Conclusions

As temporal changes of guidelines, percentages of ART initiation significantly increased in newly ART eligible people and did not decrease in individuals with very low CD4 counts. It will be crucial to continue verifying the evolution of these percentages of ART initiation with future recommendations reaching near-to-universal access to ART, to ensure that individuals most in need of ART receive it.

The effect of maternal and child early life factors on grade repetition among HIV exposed and unexposed children in rural KwaZulu-Natal, South Africa

Receiving an education is essential for children living in poverty to fulfil their potential. Success in the early years of schooling is important as children who repeat grade one are particularly at risk for future dropout. We examined early life factors associated with grade repetition through logistic regression and explored reasons for repeating a grade through parent report. In 2012-2014 we re-enrolled children aged 7-11 years in rural KwaZulu-Natal who had been part of an early life intervention. Of the 894 children included, 43.1% had repeated a grade, of which 62.9% were boys. Higher maternal education (aOR 0.44; 95% CI 0.2-0.9) and being further along in the birth order (aOR 0.46; 95% CI 0.3-0.9) reduced the odds of grade repetition. In addition, maternal HIV status had the strongest effect on grade repetition for girls (aOR 2.17; 95% CI 1.3-3.8), whereas for boys, it was a fridge in the household (aOR 0.59; 95% CI 0.4-1.0). Issues with school readiness was the most common reason for repeating a grade according to parental report (126/385, 32.7%), while school disruptions was an important reason among HIV-exposed boys. Further research is needed to elucidate the pathways through which HIV affects girls' educational outcomes and potentially impacts on disrupted schooling for boys. Our results also highlight the importance of preparation for schooling in the early years of life; future research could focus on gaining a better understanding of mechanisms by which to improve early school success, including increased quality of reception year and investigating the protective effect of older siblings.

Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study

BACKGROUND

Studies of HIV-serodiscordant couples in stable sexual relationships have provided convincing evidence that antiretroviral therapy can prevent the transmission of HIV. We aimed to quantify the preventive effect of a public-sector HIV treatment and care programme based in a community with poor knowledge and disclosure of HIV status, frequent migration, late marriage, and multiple partnerships. Specifically, we assessed whether an individual's hazard of HIV acquisition was associated with antiretroviral therapy coverage among household members of the opposite sex.

METHODS

In this prospective cohort study, we linked patients' records from a public-sector HIV treatment programme in rural KwaZulu-Natal, South Africa, with population-based HIV surveillance data collected between 2004 and 2012. We used information about coresidence to construct estimates of HIV prevalence and antiretroviral therapy coverage for each household. We then regressed the time to HIV seroconversion for 14,505 individuals, who were HIV-uninfected at baseline and individually followed up over time regarding their HIV status, on opposite-sex household antiretroviral therapy coverage, controlling for household HIV prevalence and a range of other potential confounders.

FINDINGS

2037 individual HIV seroconversions were recorded during 54,845 person-years of follow-up. For each increase of ten percentage points in opposite-sex household antiretroviral therapy coverage, the HIV acquisition hazard was reduced by 6% (95% CI 2–9), after controlling for other factors. This effect size translates into large reductions in HIV acquisition hazards when household antiretroviral therapy coverage is substantially increased. For example, an increase of 50 percentage points in household antiretroviral therapy coverage (eg, from 20% to 70%) reduced the hazard of HIV acquisition by 26% (95% CI 9–39).

INTERPRETATION

Our findings provide further evidence that antiretroviral therapy significantly reduces the risk of onward transmission of HIV in a real-world setting in sub-Saharan Africa. Awareness that antiretroviral therapy can prevent transmission to coresident sexual partners could be a powerful motivator for HIV testing and antiretroviral treatment uptake, retention, and adherence.

FUNDING

Wellcome Trust and National Institute of Child Health and Human Development (US National Institutes of Health).

Time to eligibility for antiretroviral therapy in adults with CD4 cell count > 500 cells/μL in rural KwaZulu-Natal, South Africa

OBJECTIVES

Understanding of progression to antiretroviral therapy (ART) eligibility and associated factors remains limited. The objectives of this analysis were to determine the time to ART eligibility and to explore factors associated with disease progression in adults with early HIV infection.

METHODS

HIV-infected adults (≥ 18 years old) with CD4 cell count > 500 cells/μl were enrolled in the study at three primary health care clinics, and a sociodemographic, behavioural and partnership-level questionnaire was administered. Participants were followed 6-monthly and ART eligibility was determined using a CD4 cell count threshold of 350 cells/μl. Kaplan - Meier and Cox proportional hazard regression modelling were used in the analysis.

RESULTS

A total of 206 adults contributed 381 years of follow-up; 79 (38%) reached the ART eligibility threshold. Median time to ART eligibility was shorter for male patients (12.0 months) than for female patients (33.9 months). Male sex [adjusted hazard ratio (aHR) 3.13; 95% confidence interval (CI) 1.82-5.39], residing in a household with food shortage in the previous year (aHR 1.58; 95% CI 0.99-2.54), and taking nutritional supplements in the first 6 months after enrolment (aHR 2.06; 95% CI 1.11-3.83) were associated with shorter time to ART eligibility. Compared with reference CD4 cell count ≤  559 cells/μl, higher CD4 cell count was associated with longer time to ART eligibility [aHR 0.46 (95% CI 0.25-0.83) for CD4 cell count 560-632 cells/μl; aHR 0.30 (95% CI 0.16-0.57) for CD4 cell count 633-768 cells/μl; and aHR 0.17 (95% CI 0.08-0.38) for CD4 cell count > 768 cells/μl].

CONCLUSIONS

Over one in three adults with CD4 cell count > 500 cells/μl became eligible for ART at a CD4 cell count threshold of 350 cells/μl over a median of 2 years. The shorter time to ART eligibility in male patients suggests a possible need for sex-specific pre-ART care and monitoring strategies.

A longitudinal population-based analysis of relationship status and mortality in KwaZulu-Natal, South Africa 2001-2011

Background

Mortality risk is lower in married than in unmarried men and women. However, little is known about the association between mortality and relationship status in South Africa where marriage rates are low, migration is common, many couples are not co-resident and HIV prevalence is high.

Method

Using demographic surveillance data collected from 2001 to 2011, relationship status was categorised as conjugal (partners belong to the same household), non-conjugal (partners do not belong to the same household) or not partnered. Rates of relationship formation and dissolution were calculated by age and sex. Controlling for antiretroviral treatment (ART) introduction in 2005 as well as education, sex-specific and age-specific Cox proportional hazards models were used to investigate the association between relationship status and (1) all-cause mortality and (2) non-AIDS mortality.

Results

Before 2005, individuals in conjugal relationships had a lower hazard of all-cause mortality in all age groups than not partnered men and women. Non-conjugal relationships lowered the risk of dying compared with not partnered men and women in fewer age groups. After ART introduction, the protective association of conjugal relationships was weaker but remained generally significant for men and women but not in non-conjugal relationships. In the later period, the association is reversed in young men (20–29 years) with mortality higher in conjugal and non-conjugal relationships compared with men not partnered. The analysis of non-AIDS deaths provided similar results.

Conclusions

The higher degree of social connections within a shared household environment that characterises conjugal relationships affords men and women greater protection against mortality.

Maternal and child psychological outcomes of HIV disclosure to young children in rural South Africa: the Amagugu intervention

OBJECTIVES

Increasingly, HIV-infected parents are surviving to nurture their children. Parental HIV disclosure is beneficial, but disclosure rates to younger children remain low. Previously, we demonstrated that the 'Amagugu' intervention increased disclosure to young children; however, effects on psychological outcomes have not been examined in detail. This study investigates the impact of the intervention on the maternal and child psychological outcomes.

METHOD

This pre-post evaluation design enrolled 281 HIV-infected women and their HIV-uninfected children (6-10 years) at the Africa Centre for Health and Population Studies, in rural South Africa. The intervention included six home-based counselling sessions delivered by lay-counsellors. Psychological outcomes included maternal psychological functioning (General Health Questionnaire, GHQ12 using 0,1,2,3 scoring); parenting stress (Parenting Stress Index, PSI36); and child emotional and behavioural functioning (Child Behaviour Checklist, CBCL).

RESULTS

The proportions of mothers with psychological distress reduced after intervention: GHQ threshold at least 12 (from 41.3 to 24.9%, P < 0.001) and GHQ threshold at least 20 (from 17.8 to 11.7%, P = 0.040). Parenting stress scores also reduced (Pre M = 79.8; Post M = 76.2, P < 0.001): two subscales, parental distress and parent-child relationship, showed significant improvement, while mothers' perception of 'child as difficult' was not significantly improved. Reductions in scores were not moderated by disclosure level (full/partial). There was a significant reduction in child emotional and behavioural problems (CBCL Pre M = 56.1; Post M = 48.9, P < 0.001).

CONCLUSION

Amagugu led to improvements in mothers' and children's mental health and parenting stress, irrespective of disclosure level, suggesting general nonspecific positive effects on family relationships. Findings require validation in a randomized control trial.

Participation dynamics in population-based longitudinal HIV surveillance in rural South Africa

Population-based HIV surveillance is crucial to inform understanding of the HIV pandemic and evaluate HIV interventions, but little is known about longitudinal participation patterns in such settings. We investigated the dynamics of longitudinal participation patterns in a high HIV prevalence surveillance setting in rural South Africa between 2003 and 2012, taking into account demographic dynamics. At any given survey round, 22,708 to 30,495 persons were eligible. Although the yearly participation rates were relatively modest (26% to 46%), cumulative rates increased substantially with multiple recruitment opportunities: 68% of eligible persons participated at least once, 48% at least twice and 31% at least three times after five survey rounds. We identified two types of study fatigue: at the individual level, contact and consent rates decreased with multiple recruitment opportunities and, at the population level, these rates also decreased over calendar time, independently of multiple recruitment opportunities. Using sequence analysis and hierarchical clustering, we identified three broad individual participation profiles: consenters (20%), switchers (43%) and refusers (37%). Men were over represented among refusers, women among consenters, and temporary non-residents among switchers. The specific subgroup of persons who were systemically not contacted or refusers constitutes a challenge for population-based surveillance and interventions.

Barriers to antiretroviral treatment initiation in rural KwaZulu-Natal, South Africa

OBJECTIVES

Although antiretroviral therapy (ART) has been freely available since 2004 in South Africa, not all those who are eligible initiate ART. We aimed to investigate individual and household characteristics as barriers to ART initiation in men and women in rural KwaZulu-Natal.

METHODS

Adults ≥ 16 years old living within a sociodemographic surveillance area (DSA) who accessed the local HIV programme between 2007 and 2011 were included in the study. Individual and household factors associated with ART initiation within 3 months of becoming eligible for ART were investigated using multivariable logistic regression stratified by sex and after exclusion of individuals who died before initiating ART.

RESULTS

Of the 797 men and 1598 women initially included, 8% and 5.5%, respectively, died before ART initiation and were excluded from further analysis. Of the remaining 733 men and 1510 women, 68.2% and 60.2%, respectively, initiated ART ≤ 3 months after becoming eligible (P = 0.34 after adjustment for CD4 cell count). In men, factors associated with a higher ART initiation rate were being a member of a household located < 2 km from the nearest HIV clinic and being resident in the DSA at the time of ART eligibility. In women, ART initiation was more likely in those who were not pregnant, in members of a household where at least one person was on ART and in those with a high wealth index.

CONCLUSIONS

In this rural South African setting, barriers to ART initiation differed for men and women. Supportive individual- and household-level interventions should be developed to guarantee rapid ART initiation taking account gender specificities.

The impact of gender norms on condom use among HIV-positive adults in KwaZulu-Natal, South Africa

Critical to preventing the spread of HIV is promoting condom use among HIV-positive individuals. Previous studies suggest that gender norms (social and cultural constructions of the ways that women and men are expected to behave) may be an important determinant of condom use. However, the relationship has not been evaluated among HIV-positive women and men in South Africa. We examined gender norms and condom use at last sex among 550 partnerships reported by 530 sexually-active HIV-positive women (372) and men (158) who had sought care, but not yet initiated antiretroviral therapy in a high HIV-prevalence rural setting in KwaZulu-Natal, South Africa between January 2009 and March 2011. Participants enrolled in the cohort study completed a baseline questionnaire that detailed their socio-demographic characteristics, socio-economic circumstances, religion, HIV testing history and disclosure of HIV status, stigma, social capital, gender norms and self-efficacy. Gender norms did not statistically differ between women and men (p = 0.18). Overall, condoms were used at last sex in 58% of partnerships. Although participants disclosed their HIV status in 66% of the partnerships, 60% did not have knowledge of their partner's HIV status. In multivariable logistic regression, run separately for each sex, women younger than 26 years with more equitable gender norms were significantly more likely to have used a condom at last sex than those of the same age group with inequitable gender norms (OR = 8.88, 95% CI 2.95-26.75); the association between condom use and gender norms among women aged 26+ years and men of all ages was not statistically significant. Strategies to address gender inequity should be integrated into positive prevention interventions, particularly for younger women, and supported by efforts at a societal level to decrease gender inequality.

Who cares? Implications of care-giving and -receiving by HIV-infected or -affected older people on functional disability and emotional wellbeing

This paper examines how care-giving to adults and/or children and care-receiving is associated with the health and wellbeing of older people aged 50+ in rural South Africa. Data used are from a cross-sectional survey adapted from World Health Organization's Study on Global Ageing and Adult Health (SAGE) conducted in 2009/10 in rural South Africa. Bivariate statistics and multivariate logistical regression were used to assess the relationship between care-giving and/or care-receiving with functional disability, quality of life or emotional wellbeing, and self-rated health status, adjusted for socio-demographic factors. Sixty-three per cent of 422 older people were care-givers to at least one young adult or child; 27 per cent of older people were care-givers due to HIV-related reasons in young adults; 84 per cent of participants were care-recipients mainly from adult children, grandchildren and spouse. In logistic regressions adjusting for sex, age, marital status, education, receipt of grants, household headship, household wealth and HIV status, care-giving was statistically significantly associated with good functional ability as measured by ability to perform activities of daily living. This relationship was stronger for older people providing care-giving to adults than to children. In contrast, care-givers were less likely to report good emotional wellbeing; again the relationship was stronger for care-givers to adults than children. Simultaneous care-giving and -receiving was likewise associated with good functional ability, but about a 47 per cent lower chance of good emotional wellbeing. Participants who were HIV-infected were more likely to be in better health but less likely to be receiving care than those who were HIV-affected. Our findings suggest a strong relationship between care-giving and poor emotional wellbeing via an economic or psychological stressor pathway. Interventions that improve older people's socio-economic circumstances and reduce financial hardship as well as those that provide social support would go some way towards mitigating this relationship.

Preventing unintended pregnancy and HIV transmission: effects of the HIV treatment cascade on contraceptive use and choice in rural KwaZulu-Natal

BACKGROUND

For women living with HIV, contraception using condoms is recommended because it prevents not only unintended pregnancy but also acquisition of other sexually transmitted infections and onward transmission of HIV. Dual-method dual-protection contraception (condoms with other contraceptive methods) is preferable over single-method dual-protection contraception (condoms alone) because of its higher contraceptive effectiveness. We estimate the effect of progression through the HIV treatment cascade on contraceptive use and choice among HIV-infected women in rural South Africa.

METHODS

We linked population-based surveillance data on contraception collected by the Wellcome Trust Africa Centre for Health and Population Studies to data from the local antiretroviral treatment (ART) program in Hlabisa subdistrict, KwaZulu-Natal. In bivariate probit regression, we estimated the effects of progressing through the cascade on contraceptive choice among HIV-infected sexually active women aged 15-49 years (N = 3169), controlling for a wide range of potential confounders.

FINDINGS

Contraception use increased across the cascade from <40% among HIV-infected women who did not know their status to >70% among women who have been on ART for 4-7 years. Holding other factors equal (1) awareness of HIV status, (2) ART initiation, and (3) being on ART for 4-7 years increased the likelihood of single-method/dual-method dual protection by the following percentage points (pp), compared with women who were unaware of their HIV status: (1) 4.6 pp (P = 0.030)/3.5 pp (P = 0.001), (2) 10.3 pp (P = 0.003)/5.2 pp (P = 0.007), and (3) 21.6 pp (P < 0.001)/11.2 pp (P < 0.001).

CONCLUSIONS

Progression through the HIV treatment cascade significantly increased the likelihood of contraception in general and contraception with condoms in particular. ART programs are likely to contribute to HIV prevention through the behavioral pathway of changing contraception use and choice.

The Economic Consequences of AIDS mortality in South Africa

We quantify the impact of adult deaths on household economic wellbeing, using a large longitudinal dataset spanning more than a decade. Verbal autopsies allow us to distinguish AIDS mortality from that due to other causes. The timing of the lower socioeconomic status observed for households with AIDS deaths suggests that the socioeconomic gradient in AIDS mortality is being driven primarily by poor households being at higher risk for AIDS, rather than AIDS impoverishing the households. Following a death, households that experienced an AIDS death are observed being poorer still. However, the additional socioeconomic loss following an AIDS death is very similar to the loss observed from sudden death. Funeral expenses can explain some of the impoverishing effects of death in the household. In contrast, the loss of an employed member cannot. To date, antiretroviral therapy has not changed the socioeconomic status gradient observed in AIDS deaths.

Barriers and facilitators to paediatric adherence to antiretroviral therapy in rural South Africa: a multi-stakeholder perspective

Poor adherence to antiretroviral therapy (ART) contributes to the development of drug resistance. HIV-infected children, especially those 5 years and under, are dependent on a caregiver to adhere to ART. However, characteristics of the caregiver, child, regimen, clinic and social context affect clinic attendance and medication-taking, both of which constitute adherent behaviour. We conducted nine interviews and three focus groups to determine how doctors, nurses, counsellors, traditional healers and caregivers understood the barriers and facilitators to ART adherence among children residing in rural South Africa. The data were transcribed, translated into English from isiZulu where necessary, and coded using Atlas.ti version 7. Results were interpreted through the lens of Bronfenbrenner's Ecological Systems Theory. We found that at the micro-level, palatability of medication and large volumes of medication were problematic for young children. Characteristics of the caregiver including absent mothers, grandmothers as caregivers and denial of HIV amongst fathers were themes related to the micro-system. Language barriers and inconsistent attendance of caregivers to monthly clinic visits were factors affecting adherence in the meso-system. Adherence counselling and training were the most problematic features in the exo-system. In the macro-system, the effects of food insecurity and the controversy surrounding the use of traditional medicines were most salient. Increased supervision and regular training amongst lay adherence counsellors are needed, as well as regular monitoring of the persons attending the clinic on the child's behalf.

Regression discontinuity designs in epidemiology: causal inference without randomized trials

When patients receive an intervention based on whether they score below or above some threshold value on a continuously measured random variable, the intervention will be randomly assigned for patients close to the threshold. The regression discontinuity design exploits this fact to estimate causal treatment effects. In spite of its recent proliferation in economics, the regression discontinuity design has not been widely adopted in epidemiology. We describe regression discontinuity, its implementation, and the assumptions required for causal inference. We show that regression discontinuity is generalizable to the survival and nonlinear models that are mainstays of epidemiologic analysis. We then present an application of regression discontinuity to the much-debated epidemiologic question of when to start HIV patients on antiretroviral therapy. Using data from a large South African cohort (2007-2011), we estimate the causal effect of early versus deferred treatment eligibility on mortality. Patients whose first CD4 count was just below the 200 cells/μL CD4 count threshold had a 35% lower hazard of death (hazard ratio = 0.65 [95% confidence interval = 0.45-0.94]) than patients presenting with CD4 counts just above the threshold. We close by discussing the strengths and limitations of regression discontinuity designs for epidemiology.

Are social support and HIV coping strategies associated with lower depression in adults on antiretroviral treatment? Evidence from rural KwaZulu-Natal, South Africa

We assess depression rates and investigate whether depression among HIV-infected adults receiving antiretroviral treatment (ART) is associated with social support and HIV coping strategies in rural South Africa (SA). The study took place in a decentralised public-sector ART programme in a poor, rural area of KwaZulu-Natal, SA, with high-HIV prevalence and high-ART coverage. The 12-item General Health Questionnaire (GHQ12), validated in this setting, was used to assess depression in 272 adults recently initiated on ART. Estimates of depression prevalence ranged from 33% to 38%, depending on the method used to score the GHQ12. Instrumental social support (providing tangible factors for support, such as financial assistance, material goods or services), but not emotional social support (expressing feelings, such as empathy, love, trust or acceptance, to support a person), was significantly associated with lower likelihood of depression [adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) 0.52-0.81, P < 0.001], when controlling for sex, age, marital status, education, household wealth and CD4 cell count. In addition, using "avoidance of people" as a strategy to cope with HIV was associated with an almost three times higher odds of depression (aOR = 2.79, CI: 1.34-5.82, P = 0.006), whereas none of the other five coping strategies we assessed was significantly associated with depression. In addition to antidepressant drug treatment, interventions enhancing instrumental social support and behavioural therapy replacing withdrawal behaviours with active HIV coping strategies may be effective in reducing the burden of depression among patients on ART.

Maternal HIV disclosure to young HIV-uninfected children: an evaluation of a family-centred intervention in South Africa

OBJECTIVES

Sub-Saharan Africa has large populations of HIV-infected parents who need support to raise their HIV-uninfected children. This research evaluates the 'Amagugu Intervention' aimed at supporting mothers to disclose their own HIV diagnosis to their HIV-uninfected children.

DESIGN

Uncontrolled pre and post-intervention evaluation.

SETTING

Africa Centre for Health and Population Studies, South Africa.

PARTICIPANTS

Two hundred and eighty-one HIV-infected women and their HIV-uninfected children aged 6-10 years.

INTERVENTION

This lay counsellor-led intervention included six sessions conducted with mothers at home, providing printed materials and child-friendly activities to support disclosure of their diagnosis.

MAIN OUTCOME MEASURE

The primary outcome was disclosure to the child (full, partial, none). The secondary outcomes included maternal mental health (General Health Questionnaire) and child mental health (Child Behaviour Checklist).

RESULTS

One hundred and seventy-one (60%) women 'fully' disclosed and 110 (40%) women 'partially' disclosed their HIV status to their child. Women who perceived their health to be excellent were less likely to 'fully' disclose compared to those considering their health to be poorer [adjusted odds ratio 0.50 (0.26-0.98), P = 0.042]. [corrected]. Compared to those not in a current partnership, those with a current partner were almost three times more likely to 'fully' disclose [adjusted odds ratio 2.92 (1.33-6.40), P = 0.008]. Mothers reported that most children reacted calmly to 'full' (79%) or 'partial' disclosure (83%). Compared to 'partial' disclosure, 'full' disclosure was associated with more children asking questions about maternal death (18 versus 8%).

CONCLUSIONS

This intervention is acceptable in resource-limited settings and shows promise. Further research using a controlled design is needed to test this intervention.

Review: [corrected] The changing face of the HIV epidemic in sub-Saharan Africa

The widespread roll-out of antiretroviral therapy (ART) has substantially changed the face of human immunodeficiency virus (HIV). Timely initiation of ART in HIV-infected individuals dramatically reduces mortality and improves employment rates to levels prior to HIV infection. Recent findings from several studies have shown that ART reduces HIV transmission risk even with modest ART coverage of the HIV-infected population and imperfect ART adherence. While condoms are highly effective in the prevention of HIV acquisition, they are compromised by low and inconsistent usage; male medical circumcision substantially reduces HIV transmission but uptake remains relatively low; ART during pregnancy, delivery and breastfeeding can virtually eliminate mother-to-child transmission but implementation is challenging, especially in resource-limited settings. The current HIV prevention recommendations focus on a combination of preventions approach, including ART as treatment or pre- or post-exposure prophylaxis together with condoms, circumcision and sexual behaviour modification. Improved survival in HIV-infected individuals and reduced HIV transmission risk is beginning to result in limited HIV incidence decline at population level and substantial increases in HIV prevalence. However, achievements in HIV treatment and prevention are threatened by the challenges of lifelong adherence to preventive and therapeutic methods and by the ageing of the HIV-infected cohorts potentially complicating HIV management. Although current thinking suggests prevention of HIV transmission through early detection of infection immediately followed by ART could eventually result in elimination of the HIV epidemic, controversies remain as to whether we can treat our way out of the HIV epidemic.

An affordable HIV-1 drug resistance monitoring method for resource limited settings

HIV-1 drug resistance has the potential to seriously compromise the effectiveness and impact of antiretroviral therapy (ART). As ART programs in sub-Saharan Africa continue to expand, individuals on ART should be closely monitored for the emergence of drug resistance. Surveillance of transmitted drug resistance to track transmission of viral strains already resistant to ART is also critical. Unfortunately, drug resistance testing is still not readily accessible in resource limited settings, because genotyping is expensive and requires sophisticated laboratory and data management infrastructure. An open access genotypic drug resistance monitoring method to manage individuals and assess transmitted drug resistance is described. The method uses free open source software for the interpretation of drug resistance patterns and the generation of individual patient reports. The genotyping protocol has an amplification rate of greater than 95% for plasma samples with a viral load >1,000 HIV-1 RNA copies/ml. The sensitivity decreases significantly for viral loads <1,000 HIV-1 RNA copies/ml. The method described here was validated against a method of HIV-1 drug resistance testing approved by the United States Food and Drug Administration (FDA), the Viroseq genotyping method. Limitations of the method described here include the fact that it is not automated and that it also failed to amplify the circulating recombinant form CRF02_AG from a validation panel of samples, although it amplified subtypes A and B from the same panel.

Implementing antiretroviral resistance testing in a primary health care HIV treatment programme in rural KwaZulu-Natal, South Africa: early experiences, achievements and challenges

BACKGROUND

Antiretroviral drug resistance is becoming increasingly common with the expansion of human immunodeficiency virus (HIV) treatment programmes in high prevalence settings. Genotypic resistance testing could have benefit in guiding individual-level treatment decisions but successful models for delivering resistance testing in low- and middle-income countries have not been reported.

METHODS

An HIV Treatment Failure Clinic model was implemented within a large primary health care HIV treatment programme in northern KwaZulu-Natal, South Africa. Genotypic resistance testing was offered to adults (≥16 years) with virological failure on first-line antiretroviral therapy (one viral load >1000 copies/ml after at least 12 months on a standard first-line regimen). A genotypic resistance test report was generated with treatment recommendations from a specialist HIV clinician and sent to medical officers at the clinics who were responsible for patient management. A quantitative process evaluation was conducted to determine how the model was implemented and to provide feedback regarding barriers and challenges to delivery.

RESULTS

A total of 508 specimens were submitted for genotyping between 8 April 2011 and 31 January 2013; in 438 cases (86.2%) a complete genotype report with recommendations from the specialist clinician was sent to the medical officer. The median turnaround time from specimen collection to receipt of final report was 18 days (interquartile range (IQR) 13-29). In 114 (26.0%) cases the recommended treatment differed from what would be given in the absence of drug resistance testing. In the majority of cases (n = 315, 71.9%), the subsequent treatment prescribed was in line with the recommendations of the report.

CONCLUSIONS

Genotypic resistance testing was successfully implemented in this large primary health care HIV programme and the system functioned well enough for the results to influence clinical management decisions in real time. Further research will explore the impact and cost-effectiveness of different implementation models in different settings.

The association between self-reported stigma and loss-to-follow up in treatment eligible HIV positive adults in rural Kwazulu-Natal, South Africa

BACKGROUND

The relationship between loss-to-follow-up (LTFU) in HIV treatment and care programmes and psychosocial factors, including self-reported stigma, is important to understand. This prospective cohort study explored stigma and LTFU in treatment eligible adults who had yet not started antiretroviral therapy (ART).

METHODS

Psychosocial, clinical and demographic data were collected at a baseline interview. Self-reported stigma was measured with a multi-item scale. LTFU was defined as not attending clinic in the 90 days since last appointment or before death. Data was collected between January 2009 and January 2013 and analysed using Cox Regression.

RESULTS

380 individuals were recruited (median time in study 3.35 years, total time at risk 1065.81 person-years). 203 were retained (53.4%), 109 were LTFU (28.7%), 48 had died and were not LTFU at death (12.6%) and 20 had transferred out (5.3%). The LTFU rate was 10.65 per 100 person-years (95% CI: 8.48-12.34). 362 individuals (95.3%) started ART. Stigma total score (categorised in quartiles) was not significantly associated with LTFU in either univariable or multivariable analysis (adjusting for other variables in the final model): second quartile aHR 0.77 (95%CI: 0.41-1.46), third quartile aHR 1.20(95%CI: 0.721-2.04), fourth quartile aHR 0.62 (95%CI: 0.35-1.11). In the final multivariable model, higher LTFU rates were associated with male gender, increased openness with friends/family and believing that community problems would be solved at higher levels. Lower LTFU rates were independently associated with increased year of age, greater reliance on family/friends, and having children.

CONCLUSIONS

Demographic and other psychosocial factors were more closely related to LTFU than self-reported stigma. This may be consistent with high levels of social exposure to HIV and ART and with stigma affecting LTFU less than other stages of care. Research and clinical implications are discussed.

Patient satisfaction with HIV and TB treatment in a public programme in rural KwaZulu-Natal: evidence from patient-exit interviews

BACKGROUND

Patient satisfaction is a determinant of treatment uptake, adherence and retention, and an important health systems outcome. Queues, health worker-patient contact time, staff attitudes, and facility cleanliness may affect patient satisfaction. We quantified dimensions of patient satisfaction among HIV and TB patients in a rural sub-district of KwaZulu-Natal, South Africa, and identified underlying satisfaction factors that explained the data.

METHODS

We conducted patient-exit interviews with 300 HIV and 300 TB patients who were randomly selected using a two-stage cluster random sampling approach with primary sampling units (primary healthcare clinics) selected with probability-proportional-to-size sampling. We performed factor analysis to investigate underlying patient satisfaction factors. We compared the satisfaction with HIV and TB services and examined the relationships between patient satisfaction and patients' socio-demographic characteristics in multivariable regression.

RESULTS

Almost all patients (95% HIV, 97% TB) reported to be globally satisfied with the healthcare services received on the day of the interview. However, patient satisfaction with specific concrete aspects of the health services was substantially lower: 52% of HIV and 40% of TB patients agreed that some staff did not treat patients with sufficient respect (p = 0.02 for difference between the two patient groups); 65% of HIV and 40% of TB patients agreed that health worker queues were too long (p < 0.001). Based on factor analysis, we identified five factors underlying the HIV data and the TB data (availability, accommodation, acceptability and communication for HIV and TB patients; health worker preference for HIV patients only; and global satisfaction for TB patients only). The level of satisfaction did not vary significantly with patients' socio-demographic characteristics.

CONCLUSIONS

In this rural area, HIV and TB patients' evaluations of specific aspects of health services delivery revealed substantial dissatisfaction hidden in the global assessments of satisfaction. A wide range of patient satisfaction variables could be reduced to a few underlying factors that align broadly with concepts previously identified in the literature as affecting access to healthcare. Increases in health systems resources for HIV and TB, but also improvements in facility maintenance, staff attitudes and communication, are likely to substantially improve HIV and TB patients' satisfaction with the care they receive in public-sector treatment programmes in rural communities in South Africa.

Drug resistance in children at virological failure in a rural KwaZulu-Natal, South Africa, cohort

Background

Better understanding of drug resistance patterns in HIV-infected children on antiretroviral therapy (ART) is required to inform public health policies in high prevalence settings. The aim of this study was to characterise the acquired drug resistance in HIV-infected children failing first-line ART in a decentralised rural HIV programme.

Methods

Plasma samples were collected from 101 paediatric patients (≤15 yrs of age) identified as failing ART. RNA was extracted from the plasma, reverse transcribed and a 1.3 kb region of the pol gene was amplified and sequenced using Sanger sequencing protocols. Sequences were edited in Geneious and drug resistance mutations were identified using the RegaDB and the Stanford resistance algorithms. The prevalence and frequency of mutations were analysed together with selected clinical and demographic data in STATA v11.

Results

A total of 101 children were enrolled and 89 (88%) were successfully genotyped; 73 on a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen and 16 on a protease inhibitor (PI)-based regimen at the time of genotyping. The majority of patients on an NNRTI regimen (80%) had both nucleoside reverse-transcriptase inhibitor (NRTI) and NNRTI resistance mutations. M184V and K103N were the most common mutations amongst children on NNRTI-based and M184V among children on PI-based regimens. 30.1% had one or more thymidine analogue mutation (TAM) and 6% had ≥3 TAMs. Only one child on a PI-based regimen harboured a major PI resistance mutation.

Conclusions

Whilst the patterns of resistance were largely predictable, the few complex resistance patterns seen with NNRTI-based regimens and the absence of major PI mutations in children failing PI-based regimens suggest the need for wider access to genotypic resistance testing in this setting.

Reduction in early mortality on antiretroviral therapy for adults in rural South Africa since change in CD4+ cell count eligibility criteria

OBJECTIVE

To explore the impact of expanded eligibility criteria for antiretroviral therapy (ART) on median CD4⁺ cell count at ART initiation and early mortality on ART.

METHODS

Analyses included all adults (≥16 years) initiated on first-line ART between August 2004 and July 2012. CD4⁺ cell count threshold 350 cells per microliter for all adults was implemented in August 2011. Early mortality was defined as any death within 91 days of ART initiation. Trends in baseline CD4⁺ cell count and early mortality were examined by year (August to July) of ART initiation. Competing risks analysis was used to examine early mortality.

RESULTS

A total of 19,080 adults (67.6% female) initiated ART. Median CD4⁺ cell count at ART initiation was 110-120 cells per microliter over the first 6 years, increasing marginally to 145 cells per microliter in 2010-2011 and more significantly to 199 cells per microliter in 2011-2012. Overall, there were 875 deaths within 91 days of ART initiation; early mortality rate was 19.4 per 100 person-years [95% confidence interval (CI) 18.2 to 20.7]. After adjustment for sex, age, baseline CD4⁺ cell count, and concurrent tuberculosis (TB), there was a 46% decrease in early mortality for those who initiated ART in 2011-2012 compared with the reference period 2008-2009 (subhazard ratio, 0.54; 95% CI: 0.41 to 0.71).

CONCLUSIONS

Since the expansion of eligibility criteria, there is evidence of earlier access to ART and a significant reduction in early mortality rate in this primary health care programme. These findings provide strong support for national ART policies and highlight the importance of earlier ART initiation for achieving reductions in HIV-related mortality.

Decreased chronic morbidity but elevated HIV associated cytokine levels in HIV-infected older adults receiving HIV treatment: benefit of enhanced access to care?

BACKGROUND

The association of HIV with chronic morbidity and inflammatory markers (cytokines) in older adults (50+years) is potentially relevant for clinical care, but data from African populations is scarce.

OBJECTIVE

To examine levels of chronic morbidity by HIV and ART status in older adults (50+years) and subsequent associations with selected pro-inflammatory cytokines and body mass index.

METHODS

Ordinary, ordered and generalized ordered logistic regression techniques were employed to compare chronic morbidity (heart disease (angina), arthritis, stroke, hypertension, asthma and diabetes) and cytokines (Interleukins-1 and -6, C-Reactive Protein and Tumor Necrosis Factor-alpha) by HIV and ART status on a cross-sectional random sample of 422 older adults nested within a defined rural South African population based demographic surveillance.

RESULTS

Using a composite measure of all morbidities, controlling for age, gender, BMI, smoking and wealth quintile, HIV-infected individuals on ART had 51% decreased odds (95% CI:0.26-0.92) of current morbidity compared to HIV-uninfected. In adjusted regression, compared to HIV-uninfected, the proportional odds (aPOR) of having elevated inflammation markers of IL6 (>1.56 pg/mL) was nearly doubled in HIV-infected individuals on (aPOR 1.84; 95%CI: 1.05-3.21) and not on (aPOR 1.94; 95%CI: 1.11-3.41) ART. Compared to HIV-uninfected, HIV-infected individuals on ART had >twice partial proportional odds (apPOR=2.30;p=0.004) of having non-clinically significant raised hsCRP levels(>1 ug/mL); ART-naïve HIV-infected individuals had >double apPOR of having hsCRP levels indicative of increased heart disease risk(>3.9 ug/mL;p=0.008).

CONCLUSIONS

Although HIV status was associated with increased inflammatory markers, our results highlight reduced morbidity in those receiving ART and underscore the need of pro-actively extending these services to HIV-uninfected older adults, beyond mere provision at fixed clinics. Providing health services through regular community chronic disease screening would ensure health care reaches all older adults in need.

Prevalence and correlates of depression among HIV-infected and -affected older people in rural South Africa

BACKGROUND

Little is known about depression in older people in sub-Saharan Africa, the associated impact of HIV, and the influence on health perceptions.

OBJECTIVES

Examine the prevalence and correlates of depression; explore the relationship between depression and health perceptions in HIV-infected and -affected older people.

METHODS

In 2010, 422 HIV-infected and -affected participants aged 50+ were recruited into a cross-sectional study. Nurse professionals interviewed participants and a diagnosis of depressive episode was derived from the Composite International Diagnostic Interview (Depression module) using the International Classification of Diseases diagnostic criteria and categorised as major (MDE) or brief (BDE).

RESULTS

Overall, 42.4% (n=179) had a depressive episode (MDE: 22.7%, n=96; BDE: 19.7%, n=83). Prevalence of MDE was significantly higher in HIV-affected (30.1%, 95% CI 24.0-36.2%) than HIV-infected (14.8%, 95% CI 9.9-19.7%) participants; BDE was higher in HIV-infected (24.6%, 95% CI 18.7-30.6%) than in HIV-affected (15.1%, 95% CI 10.3-19.8%) participants. Being female (aOR 3.04, 95% CI 1.73-5.36), receiving a government grant (aOR 0.34, 95% CI 0.15-0.75), urban residency (aOR 1.86, 95% CI 1.16-2.96) and adult care-giving (aOR 2.37, 95% CI 1.37-4.12) were significantly associated with any depressive episode. Participants with a depressive episode were 2-3 times more likely to report poor health perceptions.

LIMITATIONS

Study limitations include the cross-sectional design, limited sample size and possible selection biases.

CONCLUSIONS

Prevalence of depressive episodes was high. Major depressive episodes were higher in HIV-affected than HIV-infected participants. Psycho-social support similar to that of HIV treatment programmes around HIV-affected older people may be useful in reducing their vulnerability to depression.

Elimination of HIV in South Africa through expanded access to antiretroviral therapy: a model comparison study

BACKGROUND

Expanded access to antiretroviral therapy (ART) using universal test and treat (UTT) has been suggested as a strategy to eliminate HIV in South Africa within 7 y based on an influential mathematical modeling study. However, the underlying deterministic model was criticized widely, and other modeling studies did not always confirm the study's finding. The objective of our study is to better understand the implications of different model structures and assumptions, so as to arrive at the best possible predictions of the long-term impact of UTT and the possibility of elimination of HIV.

METHODS AND FINDINGS

We developed nine structurally different mathematical models of the South African HIV epidemic in a stepwise approach of increasing complexity and realism. The simplest model resembles the initial deterministic model, while the most comprehensive model is the stochastic microsimulation model STDSIM, which includes sexual networks and HIV stages with different degrees of infectiousness. We defined UTT as annual screening and immediate ART for all HIV-infected adults, starting at 13% in January 2012 and scaled up to 90% coverage by January 2019. All models predict elimination, yet those that capture more processes underlying the HIV transmission dynamics predict elimination at a later point in time, after 20 to 25 y. Importantly, the most comprehensive model predicts that the current strategy of ART at CD4 count ≤350 cells/µl will also lead to elimination, albeit 10 y later compared to UTT. Still, UTT remains cost-effective, as many additional life-years would be saved. The study's major limitations are that elimination was defined as incidence below 1/1,000 person-years rather than 0% prevalence, and drug resistance was not modeled.

CONCLUSIONS

Our results confirm previous predictions that the HIV epidemic in South Africa can be eliminated through universal testing and immediate treatment at 90% coverage. However, more realistic models show that elimination is likely to occur at a much later point in time than the initial model suggested. Also, UTT is a cost-effective intervention, but less cost-effective than previously predicted because the current South African ART treatment policy alone could already drive HIV into elimination. Please see later in the article for the Editors' Summary.

Sexual behaviour in a rural high HIV prevalence South African community: time trends in the antiretroviral treatment era

Objectives:

Data from generalized epidemic settings have consistently found that patients on antiretroviral therapy (ART) reduce sexual risk behaviours, but how sexual behaviour changes in the general population in response to ART availability, including amongst HIV-uninfected and undiagnosed adults, has not been characterized in these settings.

Design:

General population open cohort.

Methods:

We report trends in sexual behaviour indicators for men aged 17–54 years and women aged 17–49 years in rural KwaZulu-Natal province, based on annual sexual behaviour surveys during ART scale-up from 2005 to 2011. Estimates are adjusted for survey nonparticipation and nonresponse to individual survey items using inverse probability weighting and multiple imputation. Trends are presented by HIV status, knowledge of status, age and marital status.

Results:

Reports of condom use at last sex with a regular partner increased by 2.6% points per year [95% confidence interval (CI) 1.5%, 3.7%] for men and 4.1% per year (3.0%, 5.3%) for women. Condom use at last sex with a casual partner was high and did not change significantly over the period for both sexes. There were statistically significant declines in the percentage reporting multiple partnerships in the last year and the point prevalence of concurrency. Trends within subgroups were generally consistent with overall estimates.

Conclusion:

We find no evidence of increased sexual risk-taking following ART availability and protective changes in some behaviours, suggesting that general trends in sexual behaviour are not counter-acting preventive effects of HIV treatment. Continued monitoring of population-level sexual behaviour indicators will be essential to interpret the success of combination-prevention programmes.

Dramatic increase in HIV prevalence after scale-up of antiretroviral treatment

OBJECTIVES

To investigate HIV prevalence trends in a rural South African community after the scale-up of antiretroviral treatment (ART) in 2004.

METHODS

We estimated adult HIV prevalence (ages 15-49 years) using data from a large, longitudinal, population-based HIV surveillance in rural KwaZulu-Natal, South Africa, over the period from 2004 (the year when the public-sector ART scale-up started) to 2011. We control for selection effects due to surveillance nonparticipation using multiple imputation. We further linked the surveillance data to patient records from the local HIV treatment program to estimate ART coverage.

RESULTS

ART coverage of all HIV-infected people in this community increased from 0% in 2004 to 31% in 2011. Over the same observation period adult HIV prevalence increased steadily from 21 to 29%. The change in overall HIV prevalence is nearly completely explained by an increase of HIV-infected people receiving ART, and it is largely driven by increases in HIV prevalence in women and men older than 24 years.

CONCLUSION

The observed dramatic increase in adult HIV prevalence can most likely be explained by increased survival of HIV-infected people due to ART. Future studies should decompose HIV prevalence trends into HIV incidence and HIV-specific mortality changes to further improve the causal attribution of prevalence increases to treatment success rather than prevention failure.

High-levels of acquired drug resistance in adult patients failing first-line antiretroviral therapy in a rural HIV treatment programme in KwaZulu-Natal, South Africa

Objective

To determine the frequency and patterns of acquired antiretroviral drug resistance in a rural primary health care programme in South Africa.

Design

Cross-sectional study nested within HIV treatment programme.

Methods

Adult (≥18 years) HIV-infected individuals initially treated with a first-line stavudine- or zidovudine-based antiretroviral therapy (ART) regimen and with evidence of virological failure (one viral load >1000 copies/ml) were enrolled from 17 rural primary health care clinics. Genotypic resistance testing was performed using the in-house SATuRN/Life Technologies system. Sequences were analysed and genotypic susceptibility scores (GSS) for standard second-line regimens were calculated using the Stanford HIVDB 6.0.5 algorithms.

Results

A total of 222 adults were successfully genotyped for HIV drug resistance between December 2010 and March 2012. The most common regimens at time of genotype were stavudine, lamivudine and efavirenz (51%); and stavudine, lamivudine and nevirapine (24%). Median duration of ART was 42 months (interquartile range (IQR) 32–53) and median duration of antiretroviral failure was 27 months (IQR 17–40). One hundred and ninety one (86%) had at least one drug resistance mutation. For 34 individuals (15%), the GSS for the standard second-line regimen was <2, suggesting a significantly compromised regimen. In univariate analysis, individuals with a prior nucleoside reverse-transcriptase inhibitor (NRTI) substitution were more likely to have a GSS <2 than those on the same NRTIs throughout (odds ratio (OR) 5.70, 95% confidence interval (CI) 2.60–12.49).

Conclusions

There are high levels of drug resistance in adults with failure of first-line antiretroviral therapy in this rural primary health care programme. Standard second-line regimens could potentially have had reduced efficacy in about one in seven adults involved.

Sexual risk after HIV diagnosis: a comparison of pre-ART individuals with CD4>500 cells/µl and ART-eligible individuals in a HIV treatment and care programme in rural KwaZulu-Natal, South Africa

INTRODUCTION

Little is known about people diagnosed as HIV-positive who access HIV care early in their disease. In pre-ART studies published to date, only a minority of the participants have CD4>500 cells/µl.

METHODS

This cross-sectional study compared individuals presenting for HIV care with CD4>500 cells/µl, "pre-ART" (N=247), with individuals who had CD4<200 cells/µl or WHO Stage IV, "ART-eligible" (N=385). Baseline characteristics were contrasted between the two groups and logistic regression models used to explore group differences in: (a) being sexually active in the last month; (b) disclosure of HIV status to current partner; (c) knowing the HIV status of one's current partner; and (d) condom use at last sex.

RESULTS

Pre-ART and ART-eligible individuals were similar in terms of a wide range of socio-demographic characteristics. Controlling for gender, only current sexual behaviour and HIV-testing history were significantly different between ART groups. In multivariable models, participants in the pre-ART group were twice as likely to be sexually active in the last month, OR 2.06 95% CI (1.32, 3.21), and to know their partner's status, OR 1.95 (1.18, 3.22) compared to those in the ART-eligible group. Self-reported disclosure of HIV status to current sexual partner (71%), condom use at last sex (61%) and HIV concordancy within relationships were not significantly different between the two ART groups. Overall, 39% of the study participants reported knowing that they were in concordant HIV-positive relationships. Fifty-five percent of all participants reported not knowing their partner's HIV status, only half of whom reported using a condom at last sex. Pre-ART individuals were significantly less likely to have tested HIV-positive for the first time in the last year and to have tested for sickness-related reasons than the ART-eligible group.

CONCLUSIONS

Reported sexual risk behaviours by pre-ART individuals with CD4>500 cells/µl suggest a continued risk of onward HIV transmission. There is a need for positive prevention efforts to target this group given that current treatment guidelines do not provide them with ART. Strengthening support regarding disclosure, partner HIV testing and consistent condom use, and further promotion of HIV testing in the community to assist earlier diagnosis are urgently required.

Evaluation of the impact of immediate versus WHO recommendations-guided antiretroviral therapy initiation on HIV incidence: the ANRS 12249 TasP (Treatment as Prevention) trial in Hlabisa sub-district, KwaZulu-Natal, South Africa: study protocol for a cluster randomised controlled trial

BACKGROUND

Antiretroviral therapy (ART) suppresses HIV viral load in all body compartments and so limits the risk of HIV transmission. It has been suggested that ART not only contributes to preventing transmission at individual but potentially also at population level. This trial aims to evaluate the effect of ART initiated immediately after identification/diagnosis of HIV-infected individuals, regardless of CD4 count, on HIV incidence in the surrounding population. The primary outcome of the overall trial will be HIV incidence over two years. Secondary outcomes will include i) socio-behavioural outcomes (acceptability of repeat HIV counselling and testing, treatment acceptance and linkage to care, sexual partnerships and quality of life); ii) clinical outcomes (mortality and morbidity, retention into care, adherence to ART, virologic failure and acquired HIV drug resistance), iii) cost-effectiveness of the intervention. The first phase will specifically focus on the trial's secondary outcomes.

METHODS/DESIGN

A cluster-randomised trial in 34 (2 × 17) clusters within a rural area of northern KwaZulu-Natal (South Africa), covering a total population of 34,000 inhabitants aged 16 years and above, of whom an estimated 27,200 would be HIV-uninfected at start of the trial. The first phase of the trial will include ten (2 × 5) clusters. Consecutive rounds of home-based HIV testing will be carried out. HIV-infected participants will be followed in dedicated trial clinics: in intervention clusters, they will be offered immediate ART initiation regardless of CD4 count and clinical stage; in control clusters they will be offered ART according to national treatment eligibility guidelines (CD4 <350 cells/μL, World Health Organisation stage 3 or 4 disease or multidrug-resistant/extensively drug-resistant tuberculosis). Following proof of acceptability and feasibility from the first phase, the trial will be rolled out to further clusters.

DISCUSSION

We aim to provide proof-of-principle evidence regarding the effectiveness of Treatment-as-Prevention in reducing HIV incidence at the population level. Data collected from the participants at home and in the clinics will inform understanding of socio-behavioural, economic and clinical impacts of the intervention as well as feasibility and generalizability.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974.

Spatial clustering of all-cause and HIV-related mortality in a rural South African population (2000-2006)

BACKGROUND

Sub-Saharan Africa bears a disproportionate burden of HIV infection. Knowledge of the spatial distribution of HIV outcomes is vital so that appropriate public health interventions can be directed at locations most in need. In this regard, spatial clustering analysis of HIV-related mortality events has not been performed in a rural sub-Saharan African setting.

METHODOLOGY AND RESULTS

Kulldorff's spatial scan statistic was used to identify HIV-related and all-cause mortality clusters (p<0.05) in a population-based demographic surveillance survey in rural KwaZulu Natal, South Africa (2000-2006). The analysis was split pre (2000-2003) and post (2004-2006) rollout of antiretroviral therapy, respectively. Between 2000-2006 a total of 86,175 resident individuals ≥15 years of age were under surveillance and 5,875 deaths were recorded (of which 2,938 were HIV-related) over 343,060 person-years of observation (crude all-cause mortality rate 17.1/1000). During both time periods a cluster of high HIV-related (RR = 1.46/1.51, p = 0.001) and high all-cause mortality (RR = 1.35/1.38, p = 0.001) was identified in peri-urban communities near the National Road. A consistent low-risk cluster was detected in the urban township in both time periods (RR = 0.60/0.39, p = 0.003/0.005) and in the first time period (2000-2003) a large cluster of low HIV-related and all-cause mortality in a remote rural area was identified.

CONCLUSIONS

HIV-related and all-cause mortality exhibit strong spatial clustering tendencies in this population. Highest HIV-related mortality and all-cause mortality occurred in the peri-urban communities along the National Road and was lowest in the urban township and remote rural communities. The geography of HIV-related mortality corresponded closely to the geography of HIV prevalence, with the notable exception of the urban township where high HIV-related mortality would have been expected on the basis of the high HIV prevalence. Our results suggest that HIV treatment and care programmes should be strengthened in easy-to-reach high density, peri-urban populations near National Roads where both HIV-related and all-cause mortality are highest.

Population-based CD4 counts in a rural area in South Africa with high HIV prevalence and high antiretroviral treatment coverage

Background

Little is known about the variability of CD4 counts in the general population of sub-Saharan Africa countries affected by the HIV epidemic. We investigated factors associated with CD4 counts in a rural area in South Africa with high HIV prevalence and high antiretroviral treatment (ART) coverage.

Methods

CD4 counts, health status, body mass index (BMI), demographic characteristics and HIV status were assessed in 4990 adult resident participants of a demographic surveillance in rural KwaZulu-Natal in South Africa; antiretroviral treatment duration was obtained from a linked clinical database. Multivariable regression analysis, overall and stratified by HIV status, was performed with CD4 count levels as outcome.

Results

Median CD4 counts were significantly higher in women than in men overall (714 vs. 630 cells/µl, p<0.0001), both in HIV-uninfected (833 vs. 683 cells/µl, p<0.0001) and HIV-infected adults (384.5 vs. 333 cells/µl, p<0.0001). In multivariable regression analysis, women had 19.4% (95% confidence interval (CI) 16.1–22.9) higher CD4 counts than men, controlling for age, HIV status, urban/rural residence, household wealth, education, BMI, self-reported tuberculosis, high blood pressure, other chronic illnesses and sample processing delay. At ART initiation, HIV-infected adults had 21.7% (95% CI 14.6–28.2) lower CD4 counts than treatment-naive individuals; CD4 counts were estimated to increase by 9.2% (95% CI 6.2–12.4) per year of treatment.

Conclusions

CD4 counts are primarily determined by sex in HIV-uninfected adults, and by sex, age and duration of antiretroviral treatment in HIV-infected adults. Lower CD4 counts at ART initiation in men could be a consequence of lower CD4 cell counts before HIV acquisition.

Disengagement from care in a decentralised primary health care antiretroviral treatment programme: cohort study in rural South Africa

ObjectiveTo determine rates of, and factors associated with, disengagement from care in a decentralised antiretroviral programme.

MethodsAdults (≥16 years) who initiated antiretroviral therapy (ART) in the Hlabisa HIV Treatment and Care Programme August 2004–March 2011 were included. Disengagement from care was defined as no clinic visit for 180 days, after adjustment for mortality. Cumulative incidence functions for disengagement from care, stratified by year of ART initiation, were obtained; competing-risks regression was used to explore factors associated with disengagement from care.

ResultsA total of 4,674 individuals (median age 34 years, 29% male) contributed 13 610 person-years of follow-up. After adjustment for mortality, incidence of disengagement from care was 3.4 per 100 person-years (95% confidence interval (CI) 3.1–3.8). Estimated retention at 5 years was 61%. The risk of disengagement from care increased with each calendar year of ART initiation (P for trend <0.001). There was a strong association between disengagement from care and higher baseline CD4+ cell count (subhazard ratio (SHR) 1.94 (P < 0.001) and 2.35 (P < 0.001) for CD4+ cell count 150–200 cells/μl and >200 cells/μl respectively, compared with CD4 count <50 cells/μl). Of those disengaged from care with known outcomes, the majority (206/303, 68.0%) remained resident within the local community.

ConclusionsIncreasing disengagement from care threatens to limit the population impact of expanded antiretroviral coverage. The influence of both individual and programmatic factors suggests that alternative service delivery strategies will be required to achieve high rates of long-term retention.

Initiation of antiretroviral therapy at rural primary health care clinics in KwaZulu Natal

South Africa bears the greatest burden of HIV infection globally with the most infected people living in KwaZulu-Natal (KZN). Decentralised medical care for HIV positive patients and antiretroviral therapy (ART) delivery to primary health care facilities were proposed nationally to achieve adequate ART coverage for patients in need of treatment. This study described the HIV positive patients who accessed medical care and were initiated on ART at two existing government Primary Health Care (PHC) clinics with no added donor support, in Ilembe, KZN. This was an observational descriptive study of ART initiation from 01 April 2008 to 30 April 2009. Data were collected from clinical records kept on site. HIV Testing and the pre-ART programmes which consisted of medical care prior to ART initiation are briefly described. Socio-economic, demographic and clinical characteristics of patients who were initiated on ART were sampled and described. A minority (2.95%) of the study population tested for HIV of which 36.0% tested positive. Majority (60.0%) of patients who joined the pre-ART programme care did not return. The ART sample consisted of 375 patients of whom 65.0% were women, 85.9% were unmarried, 61.6% were unemployed and 50.4% had a secondary level of education. Tuberculosis (TB) prevalence and incidence at ART initiation were 22.1% and 14.7% respectively. The prevalence of Syphilis and Hepatitis B co-infections were 13.1% and 8.6 % respectively. Two thirds of female patients (66.4%) received a Pap smear result of which the majority (62.3%) were abnormal. Uptake for HIV testing followed by relevant CD4 testing was poor. High TB, Hepatitis B and Syphilis co-infection was noted amongst patients initiated on ART. Cervical cancer screening must be intensified. Although ART initiation with no added external resources was successful, record keeping was suboptimal.Suid-Afrika dra die grootste las van MIV-infeksie ter wêreld met die meeste besmette mense in KwaZulu-Natal (KZN). Gedesentraliseerde mediese sorg vir MIV-positiewe pasiënte en dienslewering van antiretrovirale terapie (ART) aan primêre gesondheidsorg- fasiliteite is nasionaal voorgestel om optimale ART-behandeling aan behoeftige te verskaf. Hierdie studie beskryf MIV-positiewe pasiënte wat ART-behandeling ontvang by twee bestaande Primêre Gesondheidsorgklinieke (PGS) in Ilembe, KZN sonder enige bykomende skenkerondersteuning. Waarnemingstegnieke is in die studie gebruik om ART-bekendstelling van 01 April 2008 tot 30 April 2009 te bestudeer. Data van kliniese rekords wat op die perseel gehou is, is ingesamel. MIV-toetsing en mediese behandelingsprogramme voor die bekendstelling van ART word kortliks beskryf. Sosio-ekonomiese, demografiese en kliniese eienskappe van pasiënte wat aan ART bekendgestel is, is versamel en beskryf. Minimum (2.95%) respondente aan die studie is vir MIV getoets, waarvan 36.0% positief getoets het. Die Meerderheid (60.0%) van pasiënte wat by die voorafgaande ART-sorgprogram aangesluit het, het nie terugkeer nie. Die ART-steekproef het bestaan ​​uit 375 pasiënte waarvan 65.0% vroue was, 85.9% was ongetroud, 61.6% was werkloos en 50.4% het ’n sekondêre vlak van onderwys gehad. Die bestaan (reeds onder behandeling) en voorkoms (diagnose tydens bekendstelling van die ART-program) van Tuberkulose (TB) tydens ART-bekendstelling was 22.1% en 14.7% onderskeidelik. Die voorkoms van sifilis- en hepatitis B-infeksies was 13.1% en 8.6% onderskeidelik. Twee derdes van die vroulike pasiënte (66.4%) het ’n Papsmeer ondergaan, waarvan die meerderheid (62.3%) se uitslae abnormaal was. Die begrip vir MIV-toetsing gevolg deur toepaslike CD4-toetsing was swak. Hoë TB-, Hepatitis B- en sifilisinfeksies was by pasiënte aangeteken wat met ART-behandeling begin het. Ondersoeke vir servikale kanker moet verhoog word. Hoewel die ART-bekendstelling met geen toegevoegde eksterne hulpbronne suksesvol was, was rekordhouding nie optimaal nie.

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

The scale-up of antiretroviral therapy (ART) is expected to raise adult life expectancy in populations with high HIV prevalence. Using data from a population cohort of over 101,000 individuals in rural KwaZulu-Natal, South Africa, we measured changes in adult life expectancy for 2000-2011. In 2003, the year before ART became available in the public-sector health system, adult life expectancy was 49.2 years; by 2011, adult life expectancy had increased to 60.5 years--an 11.3-year gain. Based on standard monetary valuation of life, the survival benefits of ART far outweigh the costs of providing treatment in this community. These gains in adult life expectancy signify the social value of ART and have implications for the investment decisions of individuals, governments, and donors.

High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa

The landmark HIV Prevention Trials Network (HPTN) 052 trial in HIV-discordant couples demonstrated unequivocally that treatment with antiretroviral therapy (ART) substantially lowers the probability of HIV transmission to the HIV-uninfected partner. However, it has been vigorously debated whether substantial population-level reductions in the rate of new HIV infections could be achieved in "real-world" sub-Saharan African settings where stable, cohabiting couples are often not the norm and where considerable operational challenges exist to the successful and sustainable delivery of treatment and care to large numbers of patients. We used data from one of Africa's largest population-based prospective cohort studies (in rural KwaZulu-Natal, South Africa) to follow up a total of 16,667 individuals who were HIV-uninfected at baseline, observing individual HIV seroconversions over the period 2004 to 2011. Holding other key HIV risk factors constant, individual HIV acquisition risk declined significantly with increasing ART coverage in the surrounding local community. For example, an HIV-uninfected individual living in a community with high ART coverage (30 to 40% of all HIV-infected individuals on ART) was 38% less likely to acquire HIV than someone living in a community where ART coverage was low (<10% of all HIV-infected individuals on ART).