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

An agricultural livelihood intervention is associated with reduced HIV stigma among people with HIV

OBJECTIVE

HIV stigma undermines antiretroviral treatment (ART) adherence and viral suppression. Livelihood interventions may target drivers of negative attitudes towards people with HIV (PWH) by improving their health and strengthening their economic contributions. We examined the effects of a multisectoral agricultural livelihood intervention on HIV stigma among PWH in western Kenya.

DESIGN

Sixteen health facilities were randomly allocated (1 : 1) to intervention or control arms in Shamba Maisha , a cluster randomized controlled trial that aimed to improve HIV-related health through behavioral, mental health, and nutritional pathways.

METHODS

The intervention included a farming loan and agricultural and financial training. Participants had access to farmland and surface water and were at least 18 years old, on ART for more than 6 months, and moderately-to-severely food insecure. We measured internalized, anticipated, and enacted HIV stigma semiannually over 2 years using validated scales. In blinded intent-to-treat analyses, we compared changes in scores over 24 months by study arm, using longitudinal multilevel difference-in-differences linear regression models that accounted for clustering.

RESULTS

Of 720 enrolled participants (354 intervention), 55% were women, and the median age was 40 years [interquartile range 34-47 years]. Two-year retention was 94%. Compared with the control arm, the intervention resulted in significant decreases ( P  < 0.001) of 0.42 points [95% confidence interval (CI) -0.52 to -0.31) in internalized stigma, 0.43 points (95% CI -0.51 to -0.34) in anticipated stigma, and 0.13 points (95% CI -0.16 to -0.09) in enacted stigma over 24 months.

CONCLUSION

The agricultural livelihood intervention reduced HIV stigma among PWH. Poverty-reduction approaches may be a novel strategy for reducing HIV stigma.

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

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

HIV Care Profiling and Delivery Status in the Mobile Health Clinics of eThekwini District in KwaZulu Natal, South Africa: A Descriptive Evaluation Study

Mobile health clinics (MHCs) serve as an alternative HIV care delivery method for the HIV-burdened eThekwini district. This study aimed to describe and profile the HIV care services provided by the MHCs through process evaluation. A descriptive cross-sectional quantitative evaluation study was performed on 137 MHCs using total population sampling. An online data collection method using a validated 50-item researcher-developed instrument was administered to professional nurses who are MHC team leaders, following ethical approval from the local university and departments of health. Descriptive statistics were used to analyze the data. The results described that HIV care services are offered in open spaces (43%), community buildings (37%), solid built buildings called health posts (15%), vehicles (9%), and tents (2%) with no electricity (77%), water (55%), and sanitation (64%). Adults (97%) are the main recipients of HIV care in MHCs (90%) offering antiretroviral therapy (95%). Staff, monitoring, and retaining care challenges were noted, with good linkage (91%) and referral pathways (n = 123.90%). In conclusion, the standardization and prioritization of HIV care with specific contextual practice guidelines are vital.

ART initiation among women newly diagnosed with HIV in a contraceptive trial in sub-Saharan Africa

Current guidelines recommend starting antiretroviral therapy (ART) as soon as possible after HIV diagnosis to reduce morbidity, mortality and onward HIV transmission. We examined factors influencing ART initiation by women who seroconverted during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial. ECHO, conducted between 2015 and 2018, enrolled HIV-negative, sexually active women, aged 16-35 years, from four African countries. Follow-up was 12-18 months, with quarterly HIV testing. Women with incident HIV infection received extensive counselling by trial staff and referral to local facilities for HIV care. Of 304 women with ≥90 days follow-up time since HIV diagnosis, 186(61.2%) initiated ART within 90 days, 69(22.7%) initiated after 90 days, and 49(16.1%) had not initiated by the end of the study. There were no statistically significant differences in characteristics among women who initiated ART ≤90 days versus those who did not. Frequent reasons for delayed or non-initiation of ART included not feeling ready to start ART and being newly diagnosed. In a large clinical trial, ART initiation was modest within 90 days of HIV diagnosis and grew to 84% with longer observation. Despite extensive counselling on the importance of early ART initiation, personal barriers delayed some women from starting ART.