Enhancing linkage to HIV care in the "Universal Test and Treat" era: Barriers and enablers to HIV care among adults in a high HIV burdened district in KwaZulu-Natal, South Africa

Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the 'Universal Test and Treat' (UTT) strategy - initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients' perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV-positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had been linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors that facilitated or inhibited linkage-to-care were found at individual, family, community, as well as health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, and friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experiences with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system-level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training healthcare providers, community outreach and the provision of psychological, social, and financial support.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Strengthening health system's capacity for linkage to HIV care for adolescent girls and young women and adolescent boys and young men in South Africa (SheS'Cap-Linkage): Protocol for a mixed methods study in KwaZulu-Natal, South Africa

INTRODUCTION

Adolescent girls and young women (AGYW) aged 15-24 years and adolescent boys and young men (ABYM) aged 15-34 years represent one of the populations at highest risk for HIV-infection in South Africa. The National Department of Health adopted the universal test and treat (UTT) strategy in 2016, resulting in increases in same-day antiretroviral therapy initiations and linkage to care. Monitoring progress towards attainment of South Africa's 95-95-95 targets amongst AGYW and ABYM relies on high quality data to identify and address gaps in linkage to care. The aim of this study is to describe the current approaches for engaging AGYW and ABYM in the treatment continuum to generate knowledge that can guide efforts to improve linkage to, and retention in, HIV care among these populations in KwaZulu-Natal, South Africa.

METHODS AND ANALYSIS

This is a mixed methods study, which will be conducted in uMgungundlovu district of KwaZulu-Natal, over a 24-month period, in 22 purposively selected HIV testing and treatment service delivery points (SDPs). For the quantitative component, a sample of 1100 AGYW aged 15-24 years and ABYM aged 15-35 years old will be recruited into the study, in addition to 231 healthcare providers (HCPs) involved in the implementation of the UTT program. The qualitative component will include 30 participating patients who were successfully linked to care, 30 who were not, and 30 who have never tested for HIV. Key informant interviews will also be conducted with 24 HCPs. Logistic regression will be used to model the primary outcomes on SDP types, while a time to event analysis will be conducted using a Cox regression model and adjusting the standard errors of the hazard ratio for the clustering of participants within SDPs. For qualitative data, a general inductive approach of analysis will be used.

DISSEMINATION

Findings from the study will be communicated to the study population and results will be presented to stakeholders and at appropriate local and international conferences. Outputs will also include a policy brief, peer reviewed journal articles and research capacity building through research degrees.

Barriers and Facilitating Factors to HIV Treatment Among Men in a High-HIV-Burdened District in KwaZulu-Natal, South Africa: A Qualitative Study

Despite enormous increases in the proportion of people living with HIV accessing treatment in sub-Saharan Africa, major gender disparities persist, with men experiencing lower rates of testing, linkage to treatment, and retention in care. In this study, we investigated the barriers and facilitating factors to HIV treatment among men in uThukela, a high-HIV-burdened district in KwaZulu-Natal province, South Africa. We conducted a qualitative study including nine Black African male participants who were recruited from 18 health care facilities in uThukela District, KwaZulu-Natal province. In-depth interviews were conducted with participants who linked to care and those who did not link to care at 3-month post HIV diagnosis. We used Atlas.ti for thematic analysis. Data were coded and linked to broader themes emerging across interviews. The median age was 40 years (interquartile range [IQR]: 31-41). This study identified the following key themes which emerged as barriers to HIV treatment among men in uThukela District: lack of emotional readiness, perceived medication side effects, fear of treatment non-adherence, perceived stigma and confidentiality concerns, and poor socioeconomic factors. We identified the following enabling factors to HIV treatment among men: fear of HIV progressing, acceptance of status, disclosure, support from family and friends, positive testing experience, and accessibility of antiretroviral treatment. This study revealed barriers and enabling factors to HIV treatment among men. These factors are important to inform the design of targeted intervention strategies aimed at improving linkage and retention to HIV treatment among men.

Household context and psychosocial impact of childhood multidrug-resistant tuberculosis in KwaZulu-Natal, South Africa

SETTING

Referral hospital for drug-resistant tuberculosis (TB) in KwaZulu-Natal, South Africa.

OBJECTIVES

We conducted interviews with primary care givers of children admitted with multidrug-resistant TB (MDR-TB) during a 3-month period in 2015 to identify broader household challenges.

RESULTS

We interviewed 26 care givers, most of whom were women (85%). Most households had been decimated by TB/MDR-TB and human immunodeficiency virus (HIV) infection, and were dependent upon government grants. In 54% of cases, parents were absent due to illness or death, or their whereabouts were not known. The median age of the children treated for MDR-TB was 8 years (range 2-14); 72% were HIV-co-infected. Four themes emerged in the interviews: 1) the psychosocial impact of hospitalisation and separation on the child and the household, 2) the psychosocial impact of MDR-TB on children and 3) on care givers, and 4) the economic hardship of affected households. Children had to contend with multiple diseases and medications, and personal family losses; they faced behavioural, emotional and cognitive difficulties. Care givers were often anxious and concerned about the child's longer-term prospects, while the cost of hospital visits exacerbated the pre-existing economic vulnerability of affected households.

CONCLUSION

The socio-economic impact of childhood MDR-TB reverberates beyond diseased children to their affected households. Enhanced social protection, psychosocial support and treatment literacy would create the foundations for family-centred care.

HIV Serostatus Disclosure to Sexual Partners Among Sexually Active People Living with HIV in South Africa: Results from the 2012 National Population-Based Household Survey

This paper explores the prevalence and correlates of HIV seropositive status disclosure to sexual partners by people living with HIV (PLHIV) in South Africa. Secondary analysis of the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey was conducted on data obtained from 934 sexually active PLHIV aged 15 years and older who responded to the question about HIV seropositive status disclosure. Overall, a large majority of respondents (77.1 %) reported disclosing their HIV-positive status to all their current sex partners. Multiple regression analysis, after adjustments for sex, marital status and locality type, revealed that those who were living together, going steady, and those who were single were all 60 % [adjusted odds ratio (AOR) = 0.4, 95 % CIs 0.20-0.78; AOR = 0.4, 95 % CIs 0.24-0.77; and AOR = 0.4, 95 % CIs 0.19-1.00, all ps < 0.05] less likely to disclose their HIV positive status to their partners compared to those who were married. Those who lived in rural formal areas were 70 % less likely to disclose their HIV status to their partners compared to those who stayed in urban formal areas (AOR = 0.3, 95 % CI 0.17-0.69, p < 0.001). Those who had correct HIV knowledge and rejection of myths were 2.0 times more likely to disclose their HIV status to their partners compared to those who did not have correct HIV knowledge and rejection of myths (AOR = 2.0, 95 % CI 1.04-3.68, p < 0.05). In conclusion, intervention programmes which help improve HIV seropositive status disclosure are needed by PLHIV who are not married, live in rural formal areas, and have incorrect HIV knowledge and rejection of myths.

Exploring the relationships among food insecurity, alcohol use, and sexual risk taking among men and women living in South African townships

South African townships have among the highest rates of HIV infection in the world. Considerable research on understanding the high rates of HIV transmission in this country has identified alcohol use as a critical factor in driving the HIV epidemic. Although the relationship between alcohol use and sexual risk-taking is well documented, less is known about how other factors, such as food insecurity, might be important in understanding alcohol's role in sexual risk-taking. Furthermore, prior research has highlighted how patterns of alcohol use and sexual risk-taking tend to vary by gender. We examined how food insecurity is related to both alcohol use and sexual risk-taking. We administered anonymous community surveys to men (n = 1,137) and women (n = 458) residing within four contiguous Black African townships outside of Cape Town, South Africa. In multivariate linear regression, we found that food insecurity was related to having higher numbers of male sex partners and condom-protected sex acts among women only. These relationships, however, were fully mediated by women's alcohol use. Among men, we found that food insecurity was negatively related to unprotected sex; that is, men with greater food security reported more unprotected sex acts. Unlike the results found among women, this relationship was not mediated by alcohol use. Food insecurity appears to be an important factor in understanding patterns of sexual risk-taking in regards to gender and alcohol use, and may serve as an important point of intervention for reducing HIV transmission rates.

Collective efficacy and HIV prevention in South African townships

South African townships have high HIV prevalence and a strong need for collective action to change normative sexual risk behaviors. This study investigated the relationship between perceptions of individuals about collective efficacy in the community's ability to prevent HIV and their personal HIV risk behaviors. Men (n = 1,581) and women (n = 718) completed anonymous surveys within four Black African Townships in Cape Town, South Africa from June 2008 to December 2010. Measures included demographics, alcohol use, attitudinal and behavioral norms, sexual health communications, and sexual risk behaviors. In multivariate logistic regressions, men were more likely to endorse collective efficacy if they were married, drank less often in alcohol serving establishments, believed that fewer men approve of HIV risk behaviors, talk more with others about HIV/AIDS, and had more sex partners in the past month. Women were more likely to endorse collective efficacy if they drank alcohol less often, talked more with others about HIV/AIDS, had more sex partners in the past month, but reported fewer unprotected sex acts in the past month. Community level interventions that strengthen collective efficacy beliefs will have to consider both protective and risk behaviors associated with believing that the community is ready and capable of preventing HIV.

HIV risks associated with patronizing alcohol serving establishments in South African Townships, Cape Town

Alcohol use has been closely linked with HIV risk behaviors in South Africa. The places where people drink are often the same settings in which they meet new sex partners and may contribute independently to sexual risk. This current study examines the independent effects of patronizing alcohol serving establishments (shebeens) and alcohol use in predicting HIV risk behaviors. Men (n = 981) and women (n = 492) were recruited from inside shebeens and surrounding areas proximal to shebeens in eight separate neighborhoods in a Township in Cape Town, South Africa. Anonymous community surveys measured demographic characteristics, alcohol use, shebeen attendance, and sexual risk behaviors. Comparisons of 1210 (82 %) participants who patronized shebeens in the past month with 263 (18 %) participants who did not patronize shebeens demonstrated higher rates of alcohol use frequency and quantity, more sexual partners, and higher rates of vaginal intercourse without condoms for the patrons. Multiple linear regression analysis found shebeen attendance in the past month predicted greater sexual risk for HIV beyond demographic characteristics and alcohol use. Social influences and environmental factors in shebeens could be contributing to sexual risk behavior independently of alcohol consumption. Further research is needed to understand the environmental factors of shebeens that promote and influence HIV risk behaviors.

Patterns of alcohol use and sexual behaviors among current drinkers in Cape Town, South Africa

OBJECTIVE

This study examined the association between alcohol use and sexual behaviors among South African adults who reported current drinking.

METHOD

Street-intercept surveys were administered to adults residing in neighborhoods in a South African township.

RESULTS

Analyses were restricted to participants reporting current drinking (N=1285; mean age=32; 27% women; 98% Black). Most participants (60%) reported heavy episodic drinking (i.e., 5 or more drinks on a single occasion) at least once per week in the past 30 days. Compared to non-heavy episodic drinkers, participants who reported heavy episodic drinking were more likely to drink before sex (79% vs. 66%) and have sex with a partner who had been drinking (59% vs. 44%). Overall, drinking before sex (self or partner) and heavy episodic drinking was associated with multiple sexual partners, discussing condom use with sexual partner(s), and proportion of protected sex. The frequency of condom use varied among participants with steady, casual, or both steady and casual sexual partners.

CONCLUSIONS

Alcohol use among South African adults is associated with sexual risk behaviors, but this association differs by partner type. Findings suggest the need to strengthen alcohol use components in sexual risk reduction interventions especially for participants with both steady and casual sex partners.

Heterosexual anal intercourse and HIV infection risks in the context of alcohol serving venues, Cape Town, South Africa

Background

The most efficient sexual behavior for HIV transmission is unprotected receptive anal intercourse. However, it is unclear what role heterosexual unprotected anal sex is playing in the world's worst HIV epidemics of southern Africa. The objective is to examine the prevalence of heterosexual unprotected anal intercourse among men and women who drink at informal alcohol serving establishments (shebeens) in South Africa.

Methods

Cross-sectional surveys were collected from a convenience sample of 5037 patrons of 10 shebeens in a peri-urban township of Cape Town, South Africa. Analyses concentrated on establishing the rates of unprotected anal intercourse practiced by men and women as well as the factors associated with practicing anal intercourse.

Results

We found that 15% of men and 11% of women reported anal intercourse in the previous month, with 8% of men and 7% of women practicing any unprotected anal intercourse. Multiple logistic regression showed that younger age, having primary and casual sex partners, and meeting sex partners at shebeens were independently associated with engaging in anal intercourse. Mathematical modeling showed that individual risks are significantly impacted by anal intercourse but probably not to the degree needed to drive a generalized HIV epidemic.

Conclusions

Anal intercourse likely plays a significant role in HIV infections among a small minority of South Africans who patronize alcohol serving establishments. Heterosexual anal intercourse, the most risky sexual behavior for HIV transmission, should not be ignored in HIV prevention for South African heterosexuals. However, this relatively infrequent behavior should not become the focus of prevention efforts.