Correction: Retention on ART and viral suppression among patients in alternative models of differentiated HIV service delivery in KwaZulu-Natal, South Africa.

[This corrects the article DOI: 10.1371/journal.pgph.0000336.].

Correction: Acceptability of unsupervised peer-based distribution of HIV oral self-testing for the hard-to-reach in rural KwaZulu Natal, South Africa: Results from a demonstration study.

[This corrects the article DOI: 10.1371/journal.pone.0264442.].

Acceptability of unsupervised peer-based distribution of HIV oral self-testing for the hard-to-reach in rural KwaZulu Natal, South Africa: Results from a demonstration study.

BACKGROUND: Innovative models to distribute oral HIV self-tests (HIVST) provide an opportunity to increase access to HIV testing, especially for hard-to-reach populations. This study aimed to describe the acceptability of unsupervised peer-distribution of HIVST as a method to scale-up HIV testing. METHODS: In this study, lay counsellors or community health workers provided HIVST kits to primary recipients (PRs) for distribution to their sexual partners, anyone in their social network (termed secondary recipients) or for self-testing, from September 2018 to March 2020. The study was conducted in Eshowe and Mbongolwane areas in KwaZulu-Natal, South Africa. A structured questionnaire was administered during the recruitment and passive follow-up, when people came for confirmatory HIV testing. Electronic records were retrospectively examined to determine initiation of antiretroviral treatment (ART) for all HIVST users and non-users. RESULTS: Among 36,708 people approached to be primary recipients, 9,891 (26.9%) accepted; 31,341 HIVST kits were distributed with a median of three (IQR: 2-4) per peer. PRs were predominately recruited at primary health clinics (PHCs). However, acceptability of HIVST was thrice as high at community-based testing sites compared to PHCs (64.5% vs. 21.0%; p<0.001). During the study period, 34,715 adults were tested for HIV at both PHCs and community-based testing sites; of these, 1,089 individuals reported HIVST use. Among HIVST users, 893 (82.0%) returned to the clinic for confirmatory testing after testing negative on HIVST; 196 (17.9%) were confirmed HIV positive following a positive HIVST. After excluding 36/196 (18.4%) participants for whom clinical records could not be found in electronic register and 25/160 (15.6%) who were already on ART before receiving HIVST, 129/135 (95.5%) initiated ART, whereas 2,362/2685 (88%) of HIV positive HIVST non-users-initiated ART. CONCLUSION: Unsupervised peer-distribution of HIVST was feasible and acceptable, with more than 25% accepting to be peer-distributors. Acceptability of HIVST was thrice as high in community sites compared to clinics.

Retention on ART and viral suppression among patients in alternative models of differentiated HIV service delivery in KwaZulu-Natal, South Africa.

Differentiated models of HIV care (DMOC) aim to improve health care efficiency. We describe outcomes of five DMOC in KwaZulu-Natal, South Africa: facility adherence clubs (facility AC) and community adherence clubs (community AC), community antiretroviral treatment (ART) groups (CAG), spaced fast lane appointments (SFLA), and community pick up points (PuP). This retrospective cohort study included 8241 eligible patients enrolled into DMOC between 1/1/2012 and 31/12/2018. We assessed retention in DMOC and on ART, and viral load suppression (<1000 copies/mL). Kaplan-Meier techniques were applied to describe crude retention. Mixed effects parametric survival models with Weibull distribution and clustering on health center and individual levels were used to assess predictors for ART and DMOC attrition, and VL rebound (≥1000 copies/mL). Overall DMOC retention was 85%, 80%, and 76% at 12, 24 and 36 months. ART retention at 12, 24 and 36 months was 96%, 93%, 90%. Overall incidence rate of VL rebound was 1.9 episodes per 100 person-years. VL rebound rate was 4.9 episodes per 100 person-years among those enrolled in 2012-2015, and 0.8 episodes per 100 person-years among those enrolled in 2016-2018 (RR 0.12; 95% CI, 0.09-0.15, p<0.001). Prevalence of confirmed virological failure was 0.6% (38/6113). Predictors of attrition from DMOC and from ART were male gender, younger age, shorter duration on ART before enrollment. Low level viremia (>200-399 copies/mL) was associated with higher hazards of VL rebound and attrition from ART. Concurrent implementation of several DMOC in a large ART program is feasible and can achieve sustained retention on ART and VL suppression.

Same-day antiretroviral therapy is associated with increased loss to follow-up in South African public health facilities: a prospective cohort study of patients diagnosed with HIV.

INTRODUCTION: South Africa introduced Universal Test and Treat in 2016 including antiretroviral therapy (ART) initiation on the same-day as HIV diagnosis. Our study sought to evaluate the impact of same-day ART initiation on loss to follow-up (LTFU) and mortality comparing with patients who initiated ART after their HIV diagnosis. METHODS: We conducted a file review of patients with a HIV diagnosis and ART start date on file between September 2016 and May 2018 in six high HIV burden districts. Our primary outcome was LTFU (>90 days from the last clinical visit or drug pick-up until database closure 31 July 2018). The secondary outcome was mortality after ART initiation. Time to outcome was assessed comparing same-day vs. one to seven, eight to twenty-one and ≥ twenty-two days to ART initiation using Kaplan-Meier estimators stratified by sex. We investigated predictors using univariate and multivariable Cox proportional hazards models, adjusting for a priori characteristics. RESULTS: Overall, 92,609 ART patients contributed 43,922 person-years from ART initiation, with a median follow-up time of 246 days (IQR = 112 to 455). Of these patients, 33,399 (36%) initiated ART on the same-day as their HIV diagnosis date and had a median follow-up time of 174 days (IQR = 85 to 349). Same-day patients were predominantly non-pregnant females (56%) and aged 25 to 34 years (40%). Same-day ART initiation increased from 2.8% in September 2016 to 7.1% in April 2018. In same-day patients, 33% (n = 11,114) were classified as LTFU with a median time of 55 days (IQR = 1 to 185), compared to 371 mean days (IQR = 161 to 560) in patients who initiated ≥22 days after diagnosis. A similar proportion of LTFU was observed for patients who initiated later: 31% 1 to 21 day and 33% ≥22 day. Same-day ART patients had an increased risk of LTFU vs. ≥1 day (adjusted hazard ratio (aHR) = 1.28, 95% CI = 1.24 to 1.33) adjusting for covariates. Although all-cause mortality was slightly lower in same-day patients (0.9%) vs. >1 day (1.4%; aHR = 0.87, 95% CI = 0.72 to 1.05) adjusting for covariates. Men had highest risk of mortality and LTFU. CONCLUSIONS: Same-day ART increased the risk of LTFU, but same-day patients experienced slightly lower mortality. Same-day patients may require additional counselling and interventions to improve retention. Additional research is needed on targeted interventions, including differentiated care, to reduce LTFU in patients initiating ART same-day.

HIV Positivity and Referral to Treatment Following Testing of Partners and Children of PLHIV Index Patients in Public Sector Facilities in South Africa.

BACKGROUND: There is an imperative need for innovative interventions to identify people living with HIV and initiate them on antiretroviral therapy. The objective of this study was to determine the feasibility of providing index partner/child testing of people living with HIV. METHODS: We trained 86 nurses and counsellors in 56 public health facilities in 6 high HIV burden Districts in South Africa 2017 to provide index partner/child testing (tracing and testing of partners/children of people living with HIV). We collected programmatic data including index partner/child HIV positivity by age, gender, and location of testing. In subanalyses, we evaluated factors associated with identifying HIV-positive partners and children in separate models using multivariable logistic regression. RESULTS: We tested 16,033 partners and children of index patients between October 2017 and June 2018. Most of those tested were women (61%) and 20-39 years old (39%). Overall, 6.4% were 10-14 years old, 9.5% were 15-19 years, and 8% were ≥50 years. HIV positivity was 38% [95% confidence interval (CI) = 36% to 40%]. In children ages 10-14 years, 13% were HIV-infected (95% CI = 11% to 14%). In subanalyses, HIV positivity in partners was associated with their increased age [adjusted odds ratio (aOR) for increase in 5-year age category = 1.21; 95% CI = 1.04 to 1.42], female gender (aOR = 1.38; 95% CI = 1.04 to 1.82), and index partner bringing the partner in for HIV testing vs. referring the partner through the provider or recommending testing to the partner (aOR = 1.94, 95% CI = 1.43 to 2.63), adjusting for location of testing. Almost all patients diagnosed (97%) were referred to antiretroviral therapy. CONCLUSIONS: Providing index partner/child testing was feasible and we identified a very high yield when testing partners and children of index patients. Index partner and children testing should be offered to all patients living with HIV to improve case finding.