Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa

Results of the Sukuma Ndoda ("Stand up, Man") HIV Self-Screening and Assisted Linkage to Care Project in Johannesburg: A Quasi-Experimental Pre-Post Evaluation

BACKGROUND

HIV testing rates among South African men lag behind rates for women and national targets. Community-based HIV self-screening (HIVSS) distribution and follow-up by community health workers (CHWs) is a scalable option to increase testing coverage, diagnosis, and treatment initiation. We provided HIVSS and assisted linkage to care to men not recently tested (within the past 12 months) residing in high-HIV-burden areas of Johannesburg.

METHODS

CHWs distributed HIVSS in 6 clinic catchment areas. Follow-up to encourage confirmatory testing and antiretroviral therapy initiation was conducted through personal support (PS) or an automated short message service (SMS) follow-up and linkage system in 3 clinic areas each. Using a quasi-experimental pre-post design, we compared differences in the proportion of men testing in the clinic catchment areas during the HIVSS campaign (June-August 2019) to the 3 months prior (March-May 2019) and compared treatment initiations by assisted linkage strategy.

RESULTS

Among 4793 participants accepting HIVSS, 62% had never tested. Among 3993 participants with follow-up data, 90.6% reported using their HIVSS kit. Testing coverage among men increased by 156%, from under 4% when only clinic-based HIV testing services were available to 9.5% when HIVSS and HIV testing services were available (z = -11.6; P < 0.01). Reported test use was higher for men followed through PS (99% vs. 68% in SMS); however, significantly more men reported reactive self-test results in the SMS group compared with PS (6.4% vs. 2.0%), resulting in more antiretroviral therapy initiations in the SMS group compared with PS (23 vs. 9; P < 0.01).

CONCLUSIONS

CHW HIVSS distribution significantly increases testing among men. While PS enabled personalized follow-up, reporting differences indicate SMS is more acceptable and better aligned with expectations of privacy associated with HIVSS.

Cost Analysis of Short Messaging Service and Peer Navigator Interventions for Linking and Retaining Adults Recently Diagnosed With HIV in Care in South Africa

INTRODUCTION

Large proportions of people living with HIV (PLHIV) in sub-Saharan Africa are not linked to or retained in HIV care. There is a critical need for cost-effective interventions to improve engagement and retention in care and inform optimal allocation of resources.

METHODS

We estimated costs associated with a short message service (SMS) plus peer navigation (SMS+PN) intervention; an SMS-only intervention; and standard of care (SOC), within the I-Care cluster-randomized trial to improve HIV care engagement for recently diagnosed PLHIV. We employed a uniform cost data-collection protocol to quantify resources used and associated costs for each intervention.

RESULTS

Compared with SOC, the SMS+PN intervention cost $1284 ($828-$2859) more per additional patient linked to care within 30 days and $1904 ($1158-$5343) more per additional patient retained in care at 12 months, while improving linkage by 24% (95% CI: 11 to 36) and retention by 16% (95% CI: 6 to 26). By contrast, the SMS-only intervention cost $198 ($93-dominated) more per additional patient linked to care and $697 ($171-dominated) more per additional patient retained in care but was not significantly associated with improvements in linkage (12%; 95% CI: -1 to 25) or retention (3%; 95% CI: -7 to 14) compared with SOC. The efficiency of the SMS+PN intervention could be improved by 46%, to $690 more per additional patient linked and $1023 more per additional patient retained in care, if implemented within the Department of Health using more efficient distribution of staff resources.

DISCUSSION

Findings suggest that scale-up of the SMS+PN intervention could benefit patients, improving care and health outcomes while being cost-effective.

Process evaluation of the 'Lafiyan Yara' project on enhancing access to HIV testing services using existing community structures in Nigeria

BACKGROUND

The Lafiyan Yara Project aimed to increase demand for HIV counselling, testing, treatment, and prevention services among pregnant women and children in Taraba State, Nigeria. Implemented from 2019 to 2021, the project utilized existing community structures, including traditional birth attendants, village health workers, and patent and proprietary medicine vendors, for mobilization. This study assessed the project's activities, contributors, relevance, effectiveness, and efficiency.

METHODS

The process evaluation was conducted using focus group discussions and key informant interviews with beneficiaries, community leaders, project staff, health facility personnel, and government officials. Data analysis employed framework analysis.

RESULTS

The Lafiyan Yara project was reported to have achieved notable successes, including increased HIV testing rates among children and pregnant women, improved linkage to care services, reduced mother-to-child transmission of HIV, increased HIV/AIDS awareness and knowledge, and enhanced community engagement and support. Challenges identified included insufficient funding for community mobilizers, training needs for health workers, and inadequate availability of test kits at health facilities. Confidentiality and stigma issues arose during community mobilizations. A key lesson learned was the importance of a comprehensive HIV care approach, emphasizing testing and ensuring support for individuals testing positive.

CONCLUSIONS

The project's approach of leveraging community structures to create demand for HIV services among women and children proved effective, provided proper linkage to care for those testing positive. Addressing stigma and involving husbands/fathers in the community approach are crucial for improving outcomes.

TRIAL REGISTRATION

IPHOAU/12/1384.

Statistical methods applied for the assessment of the HIV cascade and continuum of care: a systematic scoping review

OBJECTIVES

This scoping review aims to identify and synthesise existing statistical methods used to assess the progress of HIV treatment programmes in terms of the HIV cascade and continuum of care among people living with HIV (PLHIV).

DESIGN

Systematic scoping review.

DATA SOURCES

Published articles were retrieved from PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Excerpta Medica dataBASE (EMBASE) databases between April and July 2022. We also strategically search using the Google Scholar search engine and reference lists of published articles.

ELIGIBILITY CRITERIA

This scoping review included original English articles that estimated and described the HIV cascade and continuum of care progress in PLHIV. The review considered quantitative articles that evaluated either HIV care cascade progress in terms of the Joint United Nations Programme on HIV and AIDS targets or the dynamics of engagement in HIV care.

DATA EXTRACTION AND SYNTHESIS

The first author and the librarian developed database search queries and screened the retrieved titles and abstracts. Two independent reviewers and the first author extracted data using a standardised data extraction tool. The data analysis was descriptive and the findings are presented in tables and visuals.

RESULTS

This review included 300 articles. Cross-sectional study design methods were the most commonly used to assess the HIV care cascade (n=279, 93%). In cross-sectional and longitudinal studies, the majority used proportions to describe individuals at each cascade stage (276/279 (99%) and 20/21 (95%), respectively). In longitudinal studies, the time spent in cascade stages, transition probabilities and cumulative incidence functions was estimated. The logistic regression model was common in both cross-sectional (101/279, 36%) and longitudinal studies (7/21, 33%). Of the 21 articles that used a longitudinal design, six articles used multistate models, which included non-parametric, parametric, continuous-time, time-homogeneous and discrete-time multistate Markov models.

CONCLUSIONS

Most literature on the HIV cascade and continuum of care arises from cross-sectional studies. The use of longitudinal study design methods in the HIV cascade is growing because such methods can provide additional information about transition dynamics along the cascade. Therefore, a methodological guide for applying different types of longitudinal design methods to the HIV continuum of care assessments is warranted.

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa

OBJECTIVE

We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART).

DESIGN

I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation.

METHODS

Eighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status.

RESULTS

Overall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC.

CONCLUSION

Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs.

TRIAL REGISTRATION

NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

Interventions to improve antiretroviral adherence in HIV-infected pregnant women: A systematic review and meta-analysis

Background

Medication adherence in HIV-infected pregnant women remains suboptimal. This systematic review and meta-analysis aimed to evaluate the effectiveness of interventions on improving antiretroviral adherence targeting among HIV-infected pregnant women.

Methods

Five databases were screened to identify quasi-experimental studies and randomized controlled trials. The risk ratios (RR) and confidential intervals (CI) were extracted to estimate the improvement in antiretroviral adherence after interventions compared with control conditions. This study was registered with PROSPERO, number CRD42021256317.

Results

Nine studies were included in the review, totaling 2,900 participants. Three interventions had significance: enhanced standard of care (eSOC, RR 1.14, 95%CI 1.07-1.22, Z = 3.79, P < 0.01), eSOC with supporter (RR 1.12, 95%CI 1.04-1.20, Z = 2.97, P < 0.01) and device reminder (RR 1.33, 95%CI 1.04-1.72, Z = 2.23, P = 0.03).

Discussion

The study supported the eSOC and the device reminder as effective intervention strategies for improving HIV medication adherence. Based on the current findings, the study called for more efforts to improve antiretroviral care for pregnant women through involving multicenter, large-sample, and high-quality research and combining the device reminder with other intervention methods.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256317, identifier CRD42021256317.

Individual and healthcare supply-related HIV transmission factors in HIV-positive patients enrolled in the antiretroviral treatment access program in the Centre and Littoral regions in Cameroon (ANRS-12288 EVOLCam survey)

Background

Despite great progress in antiretroviral treatment (ART) access in recent decades, HIV incidence remains high in sub-Saharan Africa. We investigated the role of individual and healthcare supply-related factors in HIV transmission risk in HIV-positive adults enrolled in 19 HIV services in the Centre and Littoral regions of Cameroon.

Methods

Factors associated with HIV transmission risk (defined as both unstable aviremia and inconsistent condom use with HIV-negative or unknown status partners) were identified using a multi-level logistic regression model. Besides socio-demographic and behavioral individual variables, the following four HIV-service profiles, identified using cluster analysis, were used in regression analyses as healthcare supply-related variables: 1) district services with large numbers of patients, almost all practicing task-shifting and not experiencing antiretroviral drugs (ARV) stock-outs (n = 4); 2) experienced and well-equipped national reference services, most practicing task-shifting and not experiencing ARV stock-outs (n = 5); 3) small district services with limited resources and activities, almost all experiencing ARV stock-outs (n = 6); 4) small district services with a wide range of activities and half not experiencing ARV stock-outs (n = 4).

Results

Of the 1372 patients (women 67%, median age [Interquartile]: 39 [33–44] years) reporting sexual activity in the previous 12 months, 39% [min-max across HIV services: 25%-63%] were at risk of transmitting HIV. The final model showed that being a woman (adjusted Odd Ratio [95% Confidence Interval], p-value: 2.13 [1.60–2.82], p<0.001), not having an economic activity (1.34 [1.05–1.72], p = 0.019), having at least two sexual partners (2.45 [1.83–3.29], p<0.001), reporting disease symptoms at HIV diagnosis (1.38 [1.08–1.75], p = 0.011), delayed ART initiation (1.32 [1.02–1.71], p = 0.034) and not being ART treated (2.28 [1.48–3.49], p<0.001) were all associated with HIV transmission risk. Conversely, longer time since HIV diagnosis was associated with a lower risk of transmitting HIV (0.96 [0.92–0.99] per one-year increase, p = 0.024). Patients followed in the third profile had a higher risk of transmitting HIV (1.71 [1.05–2.79], p = 0.031) than those in the first profile.

Conclusions

Healthcare supply constraints, including limited resources and ARV supply chain deficiency may impact HIV transmission risk. To reduce HIV incidence, HIV services need adequate resources to relieve healthcare supply-related barriers and provide suitable support activities throughout the continuum of care.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis

INTRODUCTION

Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement.

METHODS

We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis.

RESULTS AND DISCUSSION

We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty.

CONCLUSIONS

Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

Gender, Mental Health, and Entry Into Care with Advanced HIV Among People Living with HIV in Cameroon Under a National 'Treat All' Policy

Delays in diagnosis and linkage to HIV care persist among people living with HIV (PLWH), even after expanded access to ART worldwide. Mental health may influence timely linkage to HIV care. Greater understanding of the relationship among gender, mental health, and delayed linkage to HIV care can inform strategies to improve the health of PLWH. We interviewed 426 PLWH initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) and the association between mental health and entry into care with advanced HIV. Separate multivariable log binomial regression models were used to estimate the association between mental health exposure and entry into HIV care with advanced HIV. Stratified analyses were used to assess effect modification by gender. Approximately 20, 15, and 12% of participants reported symptoms of depression, PTSD, and anxiety, respectively. The prevalence of mental health symptoms did not vary significantly by gender. Overall, 53% of participants enrolled in HIV care with advanced HIV: 51% of men and 54% of women. Screening positive for one of the mental health disorders assessed was associated with greater prevalence of enrollment with advanced HIV among men, but not among women. Future research should examine gender-specific pathways between mental health symptoms and entry into care with advanced HIV, particularly for men in Cameroon. The extent to which untreated mental health symptoms drive gender disparities throughout the HIV care continuum should be explored further.

Sexual and Physical Violence in Childhood Is Associated With Adult Intimate Partner Violence and Nonpartner Sexual Violence in a Representative Sample of Rural South African Men and Women

Intimate partner violence, nonpartner sexual violence, and physical and sexual violence against children are significant public health issues in South Africa. Theory suggests that experiencing violence in childhood plays a role in propensity to perpetrate violence or vulnerability to violence in adulthood. Most research to date on this topic has been conducted in high-resource countries or within urban or high-risk populations. We explore the relationship between violence in childhood and violence in adulthood in a community-based sample of 18- to 49-year-old adults in rural South Africa using data from a population-based survey (N = 1,044) in North West province in 2014. We measured childhood violence before age 15 years, experience of nonpartner sexual violence in adulthood, and IPV victimization and perpetration in the last 12 months. We conducted multivariate logistic regression; gender was tested as an effect modifier. All estimates are weighted to the subdistrict population. More women (2.7%) than men (0.8%) reported childhood forced sex, whereas fewer women (2.0%) than men (7.9%) reported childhood physical violence. Women and men reported similar rates of IPV victimization (6.8% vs. 5.4%), IPV perpetration (3.3% vs. 4.8%), and forced sex by a nonpartner (1.6% vs. 1.2%). We found that men and women who experienced childhood violence (combined physical and/or sexual) were significantly more likely to experience forced sex by a nonpartner (men: adjusted odds ratio [aOR] = 5.53, 95% confidence interval [CI] = [1.27, 24.0], p < .05; women: aOR = 51.1, 95% CI = [10.58, 246.3], p < .01) compared with those who did not experience childhood violence. They were also 2.5 times as likely to perpetrate recent IPV (aOR = 2.5, 95% CI = [0.97, 6.7], p = .06) or experience recent IPV (aOR = 2.5, 95% CI = [0.9, 6.9], p = .07), although this finding was marginally significant. These results align with the literature from other settings and population groups.

The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions

INTRODUCTION

The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade.

METHODS

We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero.

RESULTS AND DISCUSSION

Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care.

CONCLUSIONS

The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.

Health Care Providers' Challenges to High-Quality HIV Care and Antiretroviral Treatment Retention in Rural South Africa

Provision of high-quality HIV care is challenging, especially in rural primary care clinics in high HIV burden settings. We aimed to better understand the main challenges to quality HIV care provision and retention in antiretroviral treatment (ART) programs in rural South Africa from the health care providers' perspective. We conducted semi-structured qualitative interviews with 23 providers from nine rural clinics. Using thematic and framework analysis, we found that providers and patients face a set of complex and intertwined barriers at the structural, programmatic, and individual levels. More specifically, analyses revealed that their challenges are primarily structural (i.e., health system- and microeconomic context-specific) and programmatic (i.e., clinic- and provider-specific) in nature. We highlight the linkages that providers draw between the challenges they face, the motivation to do their job, the quality of the care they provide, and patients' dissatisfaction with the care they receive, all potentially resulting in poor retention in care.

Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study

Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010-2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indicators were associated with time to ART initiation. Of 459 diagnosed, 350 returned to the clinic for their CD4+ test results (linkage); 153 (33.3%) were ART-eligible according to treatment criteria at the time; 115 (75.2% of those eligible) initiated ART (median = 12.86 weeks [95% CI: 9.75, 15.97] after linkage). In adjusted Cox proportional hazard models, internalized stigma was associated with a 65% decrease in the rate of ART initiation (Adjusted hazard ratio [AHR] 0.35, 95% CI: 0.19-0.80) during the period less than four weeks after linkage to care, but not four or more weeks after linkage to care, suggesting that stigma-reduction interventions implemented shortly after diagnosis may accelerate ART uptake. As reported by others, older age was associated with more rapid ART initiation (AHR for 1-year age increase: 1.04, 95% CI: 1.01-1.07) and higher CD4+ cell count (≥300μL vs. <150μL) was associated with a lower rate of initiation (AHR 0.38, 95% CI: 0.19-0.80). Several other factors that were assessed prior to diagnosis, including stronger belief in traditional medicine, higher endorsement of stigma toward people living with HIV, food insecurity, and higher psychological distress, were found to be in the expected direction of association with ART initiation, but confidence intervals were wide and could not exclude a null finding.

Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men

BACKGROUND

HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique.

METHODS

This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI).

RESULTS

Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women.

CONCLUSION

The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.

Strategies for retention of heterosexual men in HIV care in sub-Saharan Africa: A systematic review

Expansion of Antiretroviral Therapy (ART) programs in sub-Saharan Africa (SSA) has increased the number of people accessing treatment. However, the number of males accessing and being retained along the human immunodeficiency virus (HIV) care cascade is significantly below the UNAIDS target. Male gender has been associated with poor retention in HIV care programs, and little is known about strategies that reduce attrition of men in ART programs. This review aimed to summarize any studies on strategies to improve retention of heterosexual males in HIV care in SSA. An electronic search was conducted through Ovid^® for three databases (MEDLINE^®, Embase and Global Health). Studies reporting interventions aimed at improving retention among heterosexual men along the HIV care cascade were reviewed. The inclusion criteria included randomized-controlled trials (RCTs), prospective or retrospective cohort studies that studied adult males (≥15years of age), conducted in SSA and published between January 2005 and April 2019 with an update from 2019 to 2020. The search returned 1958 articles, and 14 studies from eight countries met the inclusion criteria were presented using the PRISMA guidelines. A narrative synthesis was conducted. Six studies explored community-based adherence support groups while three compared use of facility versus community-based delivery models. Three studies measured the effect of national identity cards, disclosure of HIV status, six-monthly clinic visits and distance from the health center. Four studies measured risk of attrition from care using hazard ratios ranging from 1.2–1.8, four studies documented attrition proportions at an average of 40.0% and two studies an average rate of attrition of 43.4/1000PYs. Most (62%) included studies were retrospective cohorts, subject to risk of allocation and outcome assessment bias. A pooled analysis was not performed because of heterogeneity of studies and outcome definitions. No studies have explored heterosexual male- centered interventions in HIV care. However, in included studies that explored retention in both males and females, there were high rates of attrition in males. More male-centered interventions need to be studied preferably in RCTs. Registry number: PROSPERO2020 CRD42020142923 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020142923.

The role of drug resistance in poor viral suppression in rural South Africa: findings from a population-based study

BACKGROUND

Understanding factors driving virological failure, including the contribution of HIV drug resistance mutations (DRM), is critical to ensuring HIV treatment remains effective. We examine the contribution of drug resistance mutations for low viral suppression in HIV-positive participants in a population-based sero-prevalence survey in rural South Africa.

METHODS

We conducted HIV drug resistance genotyping and ART analyte testing on dried blood spots (DBS) from HIV-positive adults participating in a 2014 survey in North West Province. Among those with virologic failure (> 5000 copies/mL), we describe frequency of DRM to protease inhibitors (PI), nucleoside reverse transcriptase inhibitors (NRTI), and non-nucleoside reverse transcriptase inhibitors (NNRTI), report association of resistance with antiretroviral therapy (ART) status, and assess resistance to first and second line therapy. Analyses are weighted to account for sampling design.

RESULTS

Overall 170 DBS samples were assayed for viral load and ART analytes; 78.4% of men and 50.0% of women had evidence of virologic failure and were assessed for drug resistance, with successful sequencing of 76/107 samples. We found ≥1 DRM in 22% of participants; 47% were from samples with detectable analyte (efavirenz, nevirapine or lopinavir). Of those with DRM and detectable analyte, 60% showed high-level resistance and reduced predicted virologic response to ≥1 NRTI/NNRTI typically used in first and second-line regimens.

CONCLUSIONS

DRM and predicted reduced susceptibility to first and second-line regimens were common among adults with ART exposure in a rural South African population-based sample. Results underscore the importance of ongoing virologic monitoring, regimen optimization and adherence counseling to optimize durable virologic suppression.

People don't live on the care cascade: The life of the HIV care cascade as an international AIDS policy and its implications

This article analyses how the HIV care cascade, an analytical tool, has become a policy practice that determines the direction and content of international AIDS policy. It traces the development of the cascade through from its emergence around 2011 to its position framing global AIDS policy by 2018. The article distinguishes between the cascade model as a mapping tool and the care cascade as a policy that aims to end the AIDS epidemic. It then argues that the move from an analytical to a policy tool has important implications, both for the scope of policies and for policy-relevant research. It concludes by considering its implications in determining policy direction. The qualitative research that informs the article is based on published care cascade research and policy documents, and observations of the presentations and discussions at the 2012 and 2018 International AIDS Conferences (IAS). The article uses textual analysis to develop its argument.

HIV treatment cascade for older adults in rural South Africa

OBJECTIVES

The HIV treatment cascade is a powerful framework for understanding progress from initial diagnosis to successful treatment. Data sources for cascades vary and often are based on clinical cohorts, population cohorts linked to clinics, or self-reported information. We use both biomarkers and self-reported data from a large population-based cohort of older South Africans to establish the first HIV cascade for this growing segment of the HIV-positive population and compare results using the different data sources.

METHODS

Data came from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) 2015 baseline survey of 5059 adults aged 40+ years. Dried blood spots (DBS) were screened for HIV, antiretroviral drugs and viral load. In-home surveys asked about HIV testing, diagnosis and antiretroviral therapy (ART) use. We calculated proportions and CIs for each stage of the cascade, conditional on attainment of the previous stage, using (1) biomarkers, (2) self-report and (3) both biomarkers and self-report, and compared with UNAIDS 90-90-90 targets.

RESULTS

4560 participants had DBS results, among whom 1048 (23%) screened HIV-positive and comprised the denominator for each cascade. The biomarker cascade showed 63% (95% CI 60 to 66) on ART and 72% (95% CI 69 to 76) of those on ART with viral suppression. Self-reports underestimated testing, diagnosis and ART, with only 47% (95% CI 44 to 50) of HIV-positive individuals reporting ART use. The combined cascade indicated high HIV testing (89% (95% CI 87 to 91)), but lower knowledge of HIV-positive status (71% (95% CI 68 to 74)).

CONCLUSIONS

Older South Africans need repeated HIV testing and sustained ART to reach 90-90-90 targets. HIV cascades relying on self-reports are likely to underestimate true cascade attainment, and biomarkers provide substantial improvements to cascade estimates.

Improvements in the South African HIV care cascade: findings on 90-90-90 targets from successive population-representative surveys in North West Province

INTRODUCTION

To achieve epidemic control of HIV by 2030, countries aim to meet 90-90-90 targets to increase knowledge of HIV-positive status, initiation of antiretroviral therapy (ART) and viral suppression by 2020. We assessed the progress towards these targets from 2014 to 2016 in South Africa as expanded treatment policies were introduced using population-representative surveys.

METHODS

Data were collected in January to March 2014 and August to November 2016 in Dr. Ruth Segomotsi Mompati District, North West Province. Each multi-stage cluster sample included 46 enumeration areas (EA), a target of 36 dwelling units (DU) per EA, and a single resident aged 18 to 49 per DU. Data collection included behavioural surveys, rapid HIV antibody testing and dried blood spot collection. We used weighted general linear regression to evaluate differences in the HIV care continuum over time.

RESULTS

Overall, 1044 and 971 participants enrolled in 2014 and 2016 respectively with approximately 77% undergoing HIV testing. Despite increases in reported testing, known status among people living with HIV (PLHIV) remained similar at 68.7% (95% Confidence Interval (CI) = 60.9-75.6) in 2014 and 72.8% (95% CI = 63.6-80.4) in 2016. Men were consistently less likely than women to know their status. Among those with known status, PLHIV on ART increased significantly from 80.9% (95% CI = 71.9-87.4) to 91.5% (95% CI = 84.4-95.5). Viral suppression (<5000 copies/mL using DBS) among those on ART increased significantly from 55.0% (95% CI = 39.6-70.4) in 2014 to 81.4% (95% CI = 72.0-90.8) in 2016. Among all PLHIV an estimated 72.0% (95% CI = 63.8-80.1) of women and 45.8% (95% CI = 27.0-64.7) of men achieved viral suppression by 2016.

CONCLUSIONS

Over a period during which fixed-dose combination was introduced, ART eligibility expanded, and efforts to streamline treatment were implemented, major improvements in the second and third 90-90-90 targets were achieved. Achieving the first 90 target will require targeted and improved testing models for men.

Beyond Social Desirability Bias: Investigating Inconsistencies in Self-Reported HIV Testing and Treatment Behaviors Among HIV-Positive Adults in North West Province, South Africa

This mixed-methods study used qualitative interviews to explore discrepancies between self-reported HIV care and treatment-related behaviors and the presence of antiretroviral medications (ARVs) in a population-based survey in South Africa. ARV analytes were identified among 18% of those reporting HIV-negative status and 18% of those reporting not being on ART. Among participants reporting diagnosis over a year prior, 19% reported multiple HIV tests in the past year. Qualitative results indicated that participant misunderstandings about their care and treatment played a substantial role in reporting inaccuracies. Participants conflated the term HIV test with CD4 and viral load testing, and confusion with terminology was compounded by recall difficulties. Data entry errors likely also played a role. Frequent discrepancies between biomarkers and self-reported data were more likely due to poor understanding of care and treatment and biomedical terminology than intentional misreporting. Results indicate a need for improving patient-provider communication, in addition to incorporating objective measures of treatment and care behaviors such as ARV analytes, to reduce inaccuracies.

Returning HIV-1 viral load results to participant-selected health facilities in national Population-based HIV Impact Assessment (PHIA) household surveys in three sub-Saharan African Countries, 2015 to 2016

Introduction

Logistical complexities of returning laboratory test results to participants have precluded most population‐based HIV surveys conducted in sub‐Saharan Africa from doing so. For HIV positive participants, this presents a missed opportunity for engagement into clinical care and improvement in health outcomes. The Population‐based HIV Impact Assessment (PHIA) surveys, which measure HIV incidence and the prevalence of viral load (VL) suppression in selected African countries, are returning VL results to health facilities specified by each HIV positive participant within eight weeks of collection. We describe the performance of the specimen and data management systems used to return VL results to PHIA participants in Zimbabwe, Malawi and Zambia.

Methods

Consenting participants underwent home‐based counseling and HIV rapid testing as per national testing guidelines; all confirmed HIV positive participants had VL measured at a central laboratory on either the Roche CAP/CTM or Abbott m2000 platform. On a bi‐weekly basis, a dedicated data management team produced logs linking the VL test result with the participants’ contact information and preferred health facility; project staff sent test results confidentially via project drivers, national courier systems, or electronically through an adapted short message service (SMS). Participants who provided cell phone numbers received SMS or phone call alerts regarding availability of VL results.

Results and discussion

From 29,634 households across the three countries, 78,090 total participants 0 to 64 years in Zimbabwe and Malawi and 0 to 59 years in Zambia underwent blood draw and HIV testing. Of the 8391 total HIV positive participants identified, 8313 (99%) had VL tests performed and 8245 (99%) of these were returned to the selected health facilities. Of the 5979 VL results returned in Zimbabwe and Zambia, 85% were returned within the eight‐week goal with a median turnaround time of 48 days (IQR: 33 to 61). In Malawi, where exact return dates were unavailable all 2266 returnable results reached the health facilities by 11 weeks.

Conclusions

The first three PHIA surveys returned the vast majority of VL results to each HIV positive participant's preferred health facility within the eight‐week target. Even in the absence of national VL monitoring systems, a system to return VL results from a population‐based survey is feasible, but it requires developing laboratory and data management systems and dedicated staff. These are likely important requirements to strengthen return of results systems in routine clinical care.

Context matters: Community social cohesion and health behaviors in two South African areas

BACKGROUND

Understanding how social contexts shape HIV risk will facilitate development of effective prevention responses. Social cohesion, the trust and connectedness experienced in communities, has been associated with improved sexual health and HIV-related outcomes, but little research has been conducted in high prevalence settings.

METHODS

We conducted population-based surveys with adults 18-49 in high HIV prevalence districts in Mpumalanga (n = 2057) and North West Province (n = 1044), South Africa. Community social cohesion scores were calculated among the 70 clusters. We used multilevel logistic regression stratified by gender to assess individual- and group-level associations between social cohesion and HIV-related behaviors: recent HIV testing, heavy alcohol use, and concurrent sexual partnerships.

RESULTS

Group-level cohesion was protective in Mpumalanga, where perceived social cohesion was higher. For each unit increase in group cohesion, the odds of heavy drinking among men were reduced by 40% (95%CI 0.25, 0.65); the odds of women reporting concurrent sexual partnerships were reduced by 45% (95%CI 0.19, 1.04; p = 0.06); and the odds of reporting recent HIV testing were 1.6 and 1.9 times higher in men and women, respectively.

CONCLUSIONS

We identified potential health benefits of cohesion across three HIV-related health behaviors in one region with higher overall evidence of group cohesion. There may be a minimum level of cohesion required to yield positive health effects.

Factors that Motivated Otherwise Healthy HIV-Positive Young Adults to Access HIV Testing and Treatment in South Africa

The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm³ who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.

An Adaptive Approach to Locating Mobile HIV Testing Services

BACKGROUND

Public health agencies suggest targeting "hotspots" to identify individuals with undetected HIV infection. However, definitions of hotspots vary. Little is known about how best to target mobile HIV testing resources.

METHODS

We conducted a computer-based tournament to compare the yield of 4 algorithms for mobile HIV testing. Over 180 rounds of play, the algorithms selected 1 of 3 hypothetical zones, each with unknown prevalence of undiagnosed HIV, in which to conduct a fixed number of HIV tests. The algorithms were: 1) Thompson Sampling, an adaptive Bayesian search strategy; 2) Explore-then-Exploit, a strategy that initially draws comparable samples from all zones and then devotes all remaining rounds of play to HIV testing in whichever zone produced the highest observed yield; 3) Retrospection, a strategy using only base prevalence information; and; 4) Clairvoyance, a benchmarking strategy that employs perfect information about HIV prevalence in each zone.

RESULTS

Over 250 tournament runs, Thompson Sampling outperformed Explore-then-Exploit 66% of the time, identifying 15% more cases. Thompson Sampling's superiority persisted in a variety of circumstances examined in the sensitivity analysis. Case detection rates using Thompson Sampling were, on average, within 90% of the benchmark established by Clairvoyance. Retrospection was consistently the poorest performer.

LIMITATIONS

We did not consider either selection bias (i.e., the correlation between infection status and the decision to obtain an HIV test) or the costs of relocation to another zone from one round of play to the next.

CONCLUSIONS

Adaptive methods like Thompson Sampling for mobile HIV testing are practical and effective, and may have advantages over other commonly used strategies.

Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study

BACKGROUND

South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/μl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/μl.

METHODS AND FINDINGS

We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28-41 years), almost 62% were female, and the median CD4+ count was 173 cells/μl (IQR 92-254 cells/μl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/μl versus 214 cells/μl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09-1.55). As such, it remains unclear if early attrition from care was due to a "healthy cohort" effect or to overcrowding as programs expanded to accommodate the broader guidelines for treatment. Our findings were limited by a lack of generalizability (given that these data were from a single high-volume site where testing and treatment were available) and an inability to formally investigate the effect of crowding on the main outcome.

CONCLUSIONS

Over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation, or early ART discontinuation. Those who started treatment in the later cohort appeared to be more likely to discontinue care early, and this outcome appeared to be independent of CD4+ count or WHO stage. Future interventions should focus on those most at risk for early loss from care as programs continue to expand in South Africa.

Progress of UNAIDS 90-90-90 targets in a district in KwaZulu-Natal, South Africa, with high HIV burden, in the HIPSS study: a household-based complex multilevel community survey

BACKGROUND

With the goal of eliminating new HIV infections, UNAIDS set the ambitious 90-90-90 targets to be achieved by 2020. We assessed whether these targets are being met among participants of the HIV Incidence Provincial Surveillance System (HIPSS) in a high-burden district of South Africa.

METHODS

We used data from a HIPSS household-based, cross-sectional survey of HIV prevalence and incidence done in the uMgungundlovu district, KwaZulu-Natal, in 2014 and 2015. In randomly selected enumeration areas, 50 households were drawn systematically along a serpentine pattern from a random start point. One eligible individual in each household was asked to provide blood for HIV testing and to complete a questionnaire. If a household refused to participate, the house next to it was approached. Eligible participants were aged 15-49 years, lived in the household, were not planning to move away, and spoke English or Zulu. Viral load was measured in samples positive for HIV. We also assessed participants' HIV linkage to care and treatment. Data were population weighted to allow for multilevel sampling and non-response.

FINDINGS

9812 participants were enrolled, 3547 men (36%) and 6265 women (64%). Overall, 504 of 1014 men (estimate 52%, 95% CI 47-56) and 1833 of 2955 women (65%, 62-67) who were HIV positive knew their HIV status. Of those who knew, 344 of 522 men (69%, 63-75) and 1254 of 1845 women (70%, 68-73) were taking ART. Among recipients of ART, 294 of 341 men (85%, 80-90) and 1117 of 1249 women (90%, 87-92) had viral loads less than 1000 copies per mL. Among all HIV-positive participants, 427 of 1014 men (44%, 39-49) and 1680 of 2955 women (58%, 55-61) had viral loads lower than 1000 copies per mL.

INTERPRETATION

No UNAIDS 90-90-90 targets had been met in our study population. Major campaigns are needed to increase HIV testing, especially among men, and to ensure all HIV-positive patients are taking ART.

FUNDING

Centers for Disease Control and Prevention and the US Presidents Emergency Plan for AIDS Relief (PEPFAR).

Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa

BACKGROUND

The UNAIDS targets for 2020 are to achieve a 90% rate of diagnosis in HIV-positive individuals, to provide antiretroviral treatment (ART) to 90% of HIV-diagnosed individuals and to achieve virological suppression in 90% of ART patients.

OBJECTIVES

To assess South Africa's progress towards the 2020 targets and variations in performance by province.

METHODS

A mathematical model was fitted to HIV data for each of South Africa's provinces, and for the country as a whole. Numbers of HIV tests performed in each province were estimated from routine data over the 2002-2015 period, and numbers of patients receiving ART in each province were estimated by fitting models to reported public and private ART enrolment statistics.

RESULTS

By the middle of 2015, 85.5% (95% CI: 84.5% - 86.5%) of HIV-positive South African adults had been diagnosed, with little variation between provinces. However, only 56.9% (95% CI: 55.3% - 58.7%) of HIV-diagnosed adults were on ART, with this proportion varying between 50.8% in North West and 72.7% in Northern Cape. In addition, 78.4% of adults on ART were virally suppressed, with rates ranging from 69.7% in Limpopo to 85.9% in Western Cape. Overall, 3.39 million (95% CI: 3.26-3.52 million) South Africans were on ART by mid-2015, equivalent to 48.6% (95% CI: 46.0% - 51.2%) of the HIV-positive population. ART coverage varied between 43.0% in Gauteng and 63.0% in Northern Cape.

CONCLUSION

Although South Africa is well on its way to reaching the 90% HIV diagnosis target, most provinces face challenges in reaching the remaining two 90% targets.

The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study

Background

People who inject drugs (PWID) are at continued risk for HIV in the U.S., and experience disparities across the HIV care continuum compared to other high-risk groups. Estimates of the risk of HIV transmission at each stage of the care continuum may assist in identifying public health priorities for averting incident infections among PWID, in addition to transmissions to sexual partners of PWID.

Methods

We created an agent-based model simulating HIV transmission and the HIV care continuum for PWID in New York City (NYC) in 2012. To account for sexual transmission arising from PWID to non-PWID, the simulation included the entire adult NYC population. Using surveillance data and estimates from the National HIV Behavioral Surveillance system, we simulated a dynamic sexual and injecting network. We estimated the proportion of HIV transmission events attributable to PWID in the following categories, those: without an HIV diagnosis (‘Undiagnosed’); diagnosed but not on antiretroviral therapy (ART) (‘Diagnosed − not on ART’); those who initiated ART but were not virally suppressed (‘Unsuppressed’); and, those who achieved viral suppression (‘Suppressed’).

Results

We estimated HIV incidence among PWID to be 113 per 100,000 person-years in 2012, with an overall incidence rate for the entire adult NYC population of 33 per 100,000 person-years. Despite accounting for only 33% of the HIV-infected PWID population, the Undiagnosed were associated with 52.6% (95% simulation interval [95% SI]: 47.1–57.0%) of total transmission events. The Diagnosed − not on ART population contributed the second-largest proportion of HIV transmissions, with 36.6% (95% SI: 32.2–41.5%). The Unsuppressed population contributed 8.7% (95% SI: 5.6–11.8%), and Suppressed 2.1% (95% SI: 1.1–3.9%), relatively little of overall transmission.

Conclusions

Among PWID in NYC, more than half (53%) of transmissions were from those who were unaware of their infection status and more than 36% were due to PWID who knew their status, but were not on treatment. Our results indicate the importance of early diagnosis and interventions to engage diagnosed PWID on treatment to further suppress population-level HIV transmission. Future HIV prevention research should focus on the elimination of identified and potential barriers to the testing, diagnosis, and retention of PWID on HIV treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4528-9) contains supplementary material, which is available to authorized users.

Association of Implementation of a Universal Testing and Treatment Intervention With HIV Diagnosis, Receipt of Antiretroviral Therapy, and Viral Suppression in East Africa

IMPORTANCE

Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression.

OBJECTIVE

To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa.

DESIGN, SETTING, AND PARTICIPANTS

Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV serostatus and plasma HIV RNA level were measured annually at multidisease health campaigns followed by home-based testing for nonattendees. All HIV-positive individuals were offered ART using a streamlined delivery model designed to reduce structural barriers, improve patient-clinician relationships, and enhance patient knowledge and attitudes about HIV.

MAIN OUTCOMES AND MEASURES

Primary outcome was viral suppression (plasma HIV RNA<500 copies/mL) among all HIV-positive individuals, assessed at baseline and after 1 and 2 years. Secondary outcomes included HIV diagnosis, ART among previously diagnosed individuals, and viral suppression among those who had initiated ART.

RESULTS

Among 77 774 residents (male, 45.3%; age 15-24 years, 35.1%), baseline HIV prevalence was 10.3% (7108 of 69 283 residents). The proportion of HIV-positive individuals with HIV viral suppression at baseline was 44.7% (95% CI, 43.5%-45.9%; 3464 of 7745 residents) and after 2 years of intervention was 80.2% (95% CI, 79.1%-81.2%; 5666 of 7068 residents), an increase of 35.5 percentage points (95% CI, 34.4-36.6). After 2 years, 95.9% of HIV-positive individuals had been previously diagnosed (95% CI, 95.3%-96.5%; 6780 of 7068 residents); 93.4% of those previously diagnosed had received ART (95% CI, 92.8%-94.0%; 6334 of 6780 residents); and 89.5% of those treated had achieved HIV viral suppression (95% CI, 88.6%-90.3%; 5666 of 6334 residents).

CONCLUSIONS AND RELEVANCE

Among individuals with HIV in rural Kenya and Uganda, implementation of community-based testing and treatment was associated with an increased proportion of HIV-positive adults who achieved viral suppression, along with increased HIV diagnosis and initiation of antiretroviral therapy. In these communities, the UNAIDS population-level viral suppression target was exceeded within 2 years after program implementation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01864683.

Men's Perceptions of Treatment as Prevention in South Africa: Implications for Engagement in HIV Care and Treatment

While South Africa provides universal access to treatment, HIV testing and antiretroviral therapy (ART) uptake remains low, particularly among men. Little is known about community awareness of the effects of treatment on preventing transmission, and how this information might impact HIV service utilization. This qualitative study explored understandings of treatment as prevention (TasP) among rural South African men. Narratives emphasized the know value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics.

Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial

BACKGROUND

HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care-including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care.

METHODS/DESIGN

Using a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18-49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM.

DISCUSSION

Given the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa.

TRIAL REGISTRATION

NCT02197793 Registered July 21, 2014.