Pandemic preparedness improves national-level SARS-CoV-2 infection and mortality data completeness: a cross-country ecologic analysis.

BACKGROUND: Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic's tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard preparedness measures. METHODS: We examined country-level associations of pandemic preparedness capacities inventories, from the Global Health Security (GHS) Index and Joint External Evaluation (JEE), on SARS-CoV-2 infection and COVID-19 death data completion rates adjusted for income. Analyses were stratified by 100, 100-300, 300-500, and 500-700 days after the first reported case in each country. We subsequently reevaluated the relationship of pandemic preparedness on SARS-CoV-2 infection and age-standardized COVID-19 death rates adjusted for cross-country differentials in data completeness during the pre-vaccine era. RESULTS: Every 10% increase in the GHS Index was associated with a 14.9% (95% confidence interval 8.34-21.8%) increase in SARS-CoV-2 infection completion rate and a 10.6% (5.91-15.4%) increase in the death completion rate during the entire observation period. Disease prevention (infections: ß = 1.08 [1.05-1.10], deaths: ß = 1.05 [1.04-1.07]), detection (infections: ß = 1.04 [1.01-1.06], deaths: ß = 1.03 [1.01-1.05]), response (infections: ß = 1.06 [1.00-1.13], deaths: ß = 1.05 [1.00-1.10]), health system (infections: ß = 1.06 [1.03-1.10], deaths: ß = 1.05 [1.03-1.07]), and risk environment (infections: ß = 1.27 [1.15-1.41], deaths: ß = 1.15 [1.08-1.23]) were associated with both data completeness outcomes. Effect sizes of GHS Index on infection completion (Low income: ß = 1.18 [1.04-1.34], Lower Middle income: ß = 1.41 [1.16-1.71]) and death completion rates (Low income: ß = 1.19 [1.09-1.31], Lower Middle income: ß = 1.25 [1.10-1.43]) were largest in LMICs. After adjustment for cross-country differences in data completeness, each 10% increase in the GHS Index was associated with a 13.5% (4.80-21.4%) decrease in SARS-CoV-2 infection rate at 100 days and a 9.10 (1.07-16.5%) decrease at 300 days. For age-standardized COVID-19 death rates, each 10% increase in the GHS Index was with a 15.7% (5.19-25.0%) decrease at 100 days and a 10.3% (- 0.00-19.5%) decrease at 300 days. CONCLUSIONS: Results support the pre-pandemic hypothesis that countries with greater pandemic preparedness capacities have larger SARS-CoV-2 infection and mortality data completeness rates and lower COVID-19 disease burdens. More high-quality data of COVID-19 impact based on direct measurement are needed.

Migrant men and HIV care engagement in Johannesburg, South Africa.

BACKGROUND: South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. METHODS: We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020-11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. RESULTS: Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported "never visiting a health facility," as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). CONCLUSIONS: Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants' challenges.

Community Mitigation Strategies, Mobility, and COVID-19 Incidence Across Three Waves in the United States in 2020.

BACKGROUND: Summarizing the impact of community-based mitigation strategies and mobility on COVID-19 infections throughout the pandemic is critical for informing responses and future infectious disease outbreaks. Here, we employed time-series analyses to empirically investigate the relationships between mitigation strategies and mobility on COVID-19 incident cases across US states during the first three waves of infections. METHODS: We linked data on daily COVID-19 incidence by US state from March to December 2020 with the stringency index, a well-known index capturing the strictness of mitigation strategies, and the trip ratio, which measures the ratio of the number of trips taken per day compared with the same day in 2019. We utilized multilevel models to determine the relative impacts of policy stringency and the trip ratio on COVID-19 cumulative incidence and the effective reproduction number. We stratified analyses by three waves of infections. RESULTS: Every five-point increase in the stringency index was associated with 2.89% (95% confidence interval = 1.52, 4.26%) and 5.01% (3.02, 6.95%) reductions in COVID-19 incidence for the first and third waves, respectively. Reducing the number of trips taken by 50% compared with the same time in 2019 was associated with a 16.2% (-0.07, 35.2%) decline in COVID-19 incidence at the state level during the second wave and 19.3% (2.30, 39.0%) during the third wave. CONCLUSIONS: Mitigation strategies and reductions in mobility are associated with marked health gains through the reduction of COVID-19 infections, but we estimate variable impacts depending on policy stringency and levels of adherence.

Validity of Self-Report for Ascertaining HIV Status Among Circular Migrants and Permanent Residents in South Africa: A Cross-Sectional, Population-Based Analysis.

While expanded HIV testing is needed in South Africa, increasing accurate self-report of HIV status is an essential parallel goal in this highly mobile population. If self-report can ascertain true HIV-positive status, persons with HIV (PWH) could be linked to life-saving care without the existing delays required by producing medical records or undergoing confirmatory testing, which are especially burdensome for the country's high prevalence of circular migrants. We used Wave 1 data from The Migration and Health Follow-Up Study, a representative adult cohort, including circular migrants and permanent residents, randomly sampled from the Agincourt Health and Demographic Surveillance System in a rural area of Mpumalanga Province. Within the analytic sample (n = 1,918), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-report were calculated with dried blood spot (DBS) HIV test results as the standard. Among in-person participants (n = 2,468), 88.8% consented to DBS-HIV testing. HIV prevalence was 25.3%. Sensitivity of self-report was 43.9% (95% CI: 39.5-48.5), PPV was 93.4% (95% CI: 89.5-96.0); specificity was 99.0% (95% CI: 98.3-99.4) and NPV was 83.9% (95% CI: 82.8-84.9). Self-report of an HIV-positive status was predictive of true status for both migrants and permanent residents in this high-prevalence setting. Persons who self-reported as living with HIV were almost always truly positive, supporting a change to clinical protocol to immediately connect persons who say they are HIV-positive to ART and counselling. However, 56% of PWH did not report as HIV-positive, highlighting the imperative to address barriers to disclosure.

Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa.

BACKGROUND: While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence. METHODS: Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory. RESULTS: The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers. CONCLUSIONS: This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.

Cyclical Engagement in HIV Care: A Qualitative Study of Clinic Transfers to Re-enter HIV Care in Cape Town, South Africa.

Long-term patient engagement and retention in HIV care is an ongoing challenge in South Africa's strained health system. However, some patients thought to be "lost to follow-up" (LTFU) may have "transferred" clinics to receive care elsewhere. Through semi-structured interviews, we explored the relationship between clinic transfer and long-term patient engagement among 19 treatment-experienced people living with HIV (PLWH) who self-identified as having engaged in a clinic transfer at least once since starting antiretroviral therapy (ART) in Gugulethu, Cape Town. Our findings suggest that patient engagement is often fluid, as PLWH cycle in and out of care multiple times during their lifetime. The linear nature of the HIV care cascade model poorly describes the lived realities of PLWH on established treatment. Further research is needed to explore strategies for reducing unplanned clinic transfers and offer more supportive care to new and returning patients.

"The Money, It's OK but It's not OK": Patients' and Providers' Perceptions of the Acceptability of Cash Incentives for HIV Treatment Initiation in Cape Town, South Africa.

Incentive-based interventions are used to encourage HIV testing, linkage to HIV care, and antiretroviral therapy (ART) adherence. Studies assessing efficacy of cash incentives have raised questions about the perceived ethicality of and attitudes towards incentives. Here we explore patients' and health providers' perspectives of the acceptability of a conditional cash transfer for ART initiation after receiving a positive HIV test through community-based services in resource-poor communities in Cape Town, South Africa. Drawing on in-depth interviews with patients and health care workers (HCWs), we find that, despite the perception that cash incentives are effective in promoting ART initiation, significant ambivalence surrounds the acceptability of such incentives. The receipt of a financial incentive was highly moralized, and fraught with challenges. Increasing the acceptability of cash incentives through careful design and delivery of interventions is central to the potential of this type of intervention for improving outcomes along the HIV care continuum.

HIV Treatment Cascade and PrEP Care Continuum Among Serodiscordant Male Couples in the United States.

A large proportion of HIV infections among men who have sex with men occur within primary partnerships, however, there is a lack of research focused on serodiscordant male couples. We used baseline data collected as part of Project Stronger Together-a randomized controlled trial to improve treatment outcomes among 155 serodiscordant male couples. We described engagement in HIV care/prevention using the HIV treatment cascade and PrEP care continuum. Among partners living with HIV, 86.5% were linked to care, 77.4% retained in care, 81.3% prescribed ART, 60.7% adherent, and 67.7%virally suppressed. Among HIV-negative partners, 62.6% were willing to take PrEP, 48.4% had ever taken PrEP, and 26.5% were adherent to PrEP. Black partners living with HIV had lower odds of being virally suppressed compared to White partners. Our findings provide evidence to suggest designing programs to address the racial disparities in viral suppression, addressing barriers to HIV prevention/treatment, and improving PrEP education.

Patient Transfers and Their Impact on Gaps in Clinical Care: Differences by Gender in a Large Cohort of Adults Living with HIV on Antiretroviral Therapy in South Africa.

For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012-2013 from ART initiation in 2012-2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)-17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2-21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8-10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83-3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.

Better Communication Regarding Sexual Agreements Within Serodiscordant Male Couples Leads to Improved Antiretroviral Therapy Adherence Among the HIV-Positive Partner.

Sexual agreements (SAs)-guidelines that outline what type of sexual behaviors are permissible with sexual partners outside of their primary relationship-are often negotiated within same-sex male relationships to reduce their risk for HIV infection. However, HIV risk is not only a function of sexual behavior, but is also affected by factors such as antiretroviral therapy (ART) adherence. We examined whether HIV-positive partners in serodiscordant male couples who have better communication about SAs and report concordant SAs with their partners have greater odds of being adherent to ART to not only improve their health, but to also reduce the risk of transmitting HIV to partners. We analyzed longitudinal data from 135 HIV-positive partners in serodiscordant male couples recruited from Atlanta, GA, Boston, MA, and Chicago, IL to examine the relationship between optimal ART adherence and two independent variables: communication about SAs and if the couples have discrepant SAs. HIV-positive male partners who reported high levels of communication regarding SAs had nearly three times the odds of optimal adherence to ART compared to those who reported lower levels. The HIV-positive partners with discrepant SAs with their male partner had approximately half the odds of optimal adherence to ART compared to those with concordant SAs. Our findings suggest that integrating communication skills training into dyad-level HIV interventions to improve communication regarding HIV may provide more opportunities for couples to discuss ways of reducing the risk of HIV transmission. Couples may benefit from interventions that assist them in composing SAs.

Internal migration and health in South Africa: determinants of healthcare utilisation in a young adult cohort.

BACKGROUND: In South Africa, human geographic mobility is high as people engage in both permanent and temporary relocation, predominantly from rural to urban areas. Such mobility can compromise healthcare access and utilisation. The objective of this paper is to explore healthcare utilisation and its determinants in a cohort of internal migrants and permanent residents (non-migrants) originating from the Agincourt sub-district in South Africa's rural northeast. METHODS: A 5-year cohort study of 3800 individuals aged 18 to 40 commenced in 2017. Baseline data have been collected from 1764 Agincourt residents and 1334 temporary, mostly urban-based, migrants, and are analysed using bivariate analyses, logistic and multinomial regression models, and propensity score matching analysis. RESULTS: Health service utilisation differs sharply by migrant status and sex. Among those with a chronic condition, migrants had 0.33 times the odds of non-migrants to have consulted a health service in the preceding year, and males had 0.32 times the odds of females of having used health services. Of those who utilised services, migration status was further associated with the type of healthcare utilised, with 97% of non-migrant rural residents having accessed government facilities, while large proportions of migrants (31%) utilised private health services or consulted traditional healers (25%) in migrant destinations. The multinomial logistic regression analysis indicated that, in the presence of controls, migrants had 8.12 the relative risk of non-migrants for utilising private healthcare (versus the government-services-only reference category), and 2.40 the relative risk of non-migrants for using a combination of public and private sector facilities. These findings of differential utilisation hold under statistical adjustment for relevant controls and for underlying propensity to migrate. CONCLUSIONS: Migrants and non-migrants in the study population in South Africa were found to utilise health services differently, both in overall use and in the type of healthcare consulted. The study helps improve upon the limited stock of knowledge on how migrants interface with healthcare systems in low and middle-income country settings. Findings can assist in guiding policies and programmes to be directed more effectively to the populations most in need, and to drive locally adapted approaches to universal health coverage.

Coronavirus Disease 2019 Epidemic Doubling Time in the United States Before and During Stay-at-Home Restrictions.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread rapidly in the United States since January 2020. METHODS: We estimated mean epidemic doubling time, an important measure of epidemic growth, nationally, by state, and in association with stay-at-home orders. RESULTS: The epidemic doubling time in the United States was 2.68 days (95% confidence interval [CI], 2.30-3.24 days) before widespread mitigation efforts, increasing by 460% to 15 days (12.89-17.94 days) during the mitigation phase. Among states without stay-at-home orders, the median increase in doubling time was 60% (95% CI, 9.2-223.3), compared with 269% (95% CI, 277.0-394.0) for states with stay-at-home orders. CONCLUSIONS: Statewide mitigation strategies were strongly associated with increased epidemic doubling time.

Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study.

BACKGROUND: Syringe services programs (SSPs) are effective venues for delivering harm-reduction services to people who inject drugs (PWID). However, SSPs often face significant barriers to implementation, particularly in the absence of known human immunodeficiency virus (HIV) outbreaks. METHODS: Using an agent-based model, we simulated HIV transmission in Scott County, Indiana, a rural county with a 1.7% prevalence of injection drug use. We compared outcomes arising in the absence of an SSP, in the presence of a pre-existing SSP, and with implementation of an SSP after the detection of an HIV outbreak among PWID over 5 years following the introduction of a single infection into the network. RESULTS: In the absence of an SSP, the model predicted an average of 176 infections among PWID over 5 years or an incidence rate of 12.1/100 person-years. Proactive implementation averted 154 infections and decreased incidence by 90.3%. With reactive implementation beginning operations 10 months after the first infection, an SSP would prevent 107 infections and decrease incidence by 60.8%. Reductions in incidence were also observed among people who did not inject drugs. CONCLUSIONS: Based on model predictions, proactive implementation of an SSP in Scott County had the potential to avert more HIV infections than reactive implementation after the detection of an outbreak. The predicted impact of reactive SSP implementation was highly dependent on timely implementation after detecting the earliest infections. Consequently, there is a need for expanded proactive SSP implementation in the context of enhanced monitoring of outbreak vulnerability in Scott County and similar rural contexts.

Estimating retention in HIV care accounting for clinic transfers using electronic medical records: evidence from a large antiretroviral treatment programme in the Western Cape, South Africa.

BACKGROUND: Estimates of retention in antiretroviral treatment (ART) programmes may be biased if patients who transfer to healthcare clinics are misclassified as lost to follow-up (LTFU) at their original clinic. In a large cohort, we estimated retention in care accounting for patient transfers using medical records. METHODS: Using linked electronic medical records, we followed adults living with HIV (PLWH) in Cape Town, South Africa from ART initiation (2012-2016) through database closure at 36 months or 30 June 2016, whichever came first. Retention was defined as alive and with a healthcare visit in the 180 days between database closure and administrative censoring on 31 December 2016. Participants who died or did not have a healthcare visit in > 180 days were censored at their last healthcare visit. We estimated the cumulative incidence of retention using Kaplan-Meier methods considering (i) only records from a participant's ART initiation clinic (not accounting for transfers) and (ii) all records (accounting for transfers), over time and by gender. We estimated risk differences and bootstrapped 95% confidence intervals to quantify misclassification in retention estimates due to patient transfers. RESULTS: We included 3406 PLWH initiating ART. Retention through 36 months on ART rose from 45.4% (95% CI 43.6%, 47.2%) to 54.3% (95% CI 52.4%, 56.1%) after accounting for patient transfers. Overall, 8.9% (95% CI 8.1%, 9.7%) of participants were misclassified as LTFU due to patient transfers. CONCLUSIONS: Patient transfers can appreciably bias estimates of retention in HIV care. Electronic medical records can help quantify patient transfers and improve retention estimates.

CONTEXTE: Les estimations de la rétention dans les programmes de traitement antirétroviral (ART) peuvent être biaisées si les patients qui sont transférés dans des cliniques de soins de santé sont classés à tort comme perdus au suivi (PS) dans leur clinique d'origine. Dans une large cohorte, nous avons estimé la rétention dans les soins en tenant compte des transferts de patients à l'aide des dossiers médicaux. MÉTHODES: A l'aide de dossiers médicaux électroniques reliés entre eux, nous avons suivi des adultes vivant avec le VIH (PVVIH) à Cape Town, en Afrique du Sud, depuis le début de l'ART (2012-2016) jusqu'à la clotûre de la base de données à 36 mois ou au 30 juin 2016, selon la première éventualité. La rétention a été définie comme étant en vie et avec une visite médicale dans les 180 jours entre la clôture de la base de données et recensement administrative le 31 décembre 2016. Les participants qui sont décédés ou qui n'ont pas eu de visite médicale dans un délai de plus de 180 jours ont été recensés lors de leur dernière visite médicale. Nous avons estimé l'incidence cumulative de la rétention en utilisant les méthodes de Kaplan-Meier en considérant: (i) uniquement les dossiers de la clinique d'initiation de l'ART d'un participant (sans tenir compte des transferts) et (ii) tous les dossiers (en tenant compte des transferts), au cours du temps et par sexe. Nous avons estimé les différences de risque et avons considéré des intervalles de confiance à 95% pour quantifier les erreurs de classification dans les estimations de rétention dues aux transferts de patients. RÉSULTAT: Nous avons inclus 3.406 PVVIH qui ont commencé un ART. La rétention sous ART est passée de 45,4% (IC 95%: 43,6-47,2) à 54,3% (IC 95%: 52,4-56,1) après avoir tenu compte des transferts de patients. Dans l'ensemble, 8,9% (IC 95%: 8,1-9,7) des participants ont été classés à tort dans la catégorie PS en raison des transferts de patients. CONCLUSIONS: Les transferts de patients peuvent biaiser sensiblement les estimations de la rétention dans les soins liés au VIH. Les dossiers médicaux électroniques peuvent aider à quantifier les transferts de patients et à améliorer les estimations de rétention.

Quantifying the HIV treatment cascade in a South African health sub-district by gender: retrospective cohort study.

OBJECTIVES: To quantify the HIV care cascade in a Cape Town sub-district to understand rates of linkage to and engagement in HIV care. METHODS: We used routinely collected data to reconstruct the treatment cascade for 8382 infected individuals who tested HIV + in 2012/2013. We obtained data on patient gender, year of initial HIV-positive test, age at testing and initial CD4 cell count and defined five stages of the HIV care cascade. We quantified attrition across cascade stages. RESULTS: Two-thirds of the sample (5646) were women. Men were older at time of first testing (36.5 vs. 31.3 years) and had more advanced HIV disease at diagnosis (298 vs. 404 CD4 cells/µL for women). The median duration of follow-up was 818 days. Among women, 90.5% attended an initial HIV care visit, 54.6% became eligible for antiretroviral therapy under local guidelines during follow-up, 49.3% initiated ART and 45.6% achieved a therapeutic response. Among men, 88.0% attended an initial HIV care visit, 67.4% became ART eligible during follow-up, 48.0% initiated ART and 42.4% achieved a therapeutic response. Approximately 3% of women and 5% of men died during follow-up. CONCLUSIONS: We were able to reconstruct the HIV treatment cascade using routinely collected data. In this setting, rates of engagement in care differ by gender in key stages of the cascade, with men faring worse than women at each cascade point. This highlights the need for interventions aimed at encouraging earlier testing, linkage, ART initiation and retention among men.

OBJECTIFS: Quantifier la cascade des soins du VIH dans un sous-district de Cape Town pour comprendre les taux de liaisons et d'engagement avec les soins du VIH. MÉTHODES: Nous avons utilisé des données collectées en routine pour reconstruire la cascade de traitement pour 8.382 personnes infectées, testées positives pour le VIH en 2012/13. Nous avons obtenu des données sur le sexe du patient, l'année du premier test positif pour le VIH, l'âge au moment de ce test et le nombre initial de cellules CD4, et avons défini cinq étapes de la cascade des soins du VIH. Nous avons quantifié l'attrition au long des étapes de la cascade. RÉSULTATS: Deux tiers de l'échantillon (5.646) étaient des femmes. Les hommes étaient plus âgés au moment du premier test (36,5 contre 31,3 ans) et avaient la maladie du VIH plus avancée au moment du diagnostic (298 contre 404 cellules CD4/µL pour les femmes). La durée médiane de suivi était de 818 jours. Parmi les femmes, 90,5% ont pris part à une première visite pour des soins du VIH, 54,6% sont devenues éligibles au traitement antirétroviral selon les directives locales au cours du suivi, 49,3% ont commencé une ART et 45,6% ont atteint une réponse thérapeutique. Chez les hommes, 88,0% ont pris part à une première visite pour les soins du VIH; 67,4% sont devenus éligibles à l'ART au cours du suivi, 48,0% ont commencé l'ART et 42,4% ont atteint une réponse thérapeutique. Environ 3% des femmes et 5% des hommes sont décédés au cours du suivi. CONCLUSIONS: Nous avons pu reconstruire la cascade de traitement du VIH en utilisant des données collectées en routine. Dans ce contexte, les taux d'engagement dans les soins diffèrent selon le sexe dans les étapes clés de la cascade, les hommes s'en tirant moins bien que les femmes à chaque point de la cascade. Cela met en évidence la nécessité d'interventions visant à encourager le dépistage précoce, la liaison, l'initiation de l'ART et la rétention chez les hommes.

Improving Monitoring of Engagement in HIV Care for Women in Option B+: A Pilot Test of Biometric Fingerprint Scanning in Lilongwe, Malawi.

Sustained engagement in HIV care is critical to the success of Option B+ for HIV-infected pregnant women. However, monitoring women's engagement in care across clinics and over time is challenging due to migration and clinic transfers. Improved strategies to identify and monitor women's engagement in HIV care across a network of clinics are needed, but have not been pilot tested. We evaluated the feasibility and acceptability of biometric fingerprint scanning to identify women and monitor HIV visit attendance among women in Option B+. Over a 3-month period, we enrolled HIV-infected pregnant women receiving care at two antenatal clinics in Lilongwe, Malawi and monitored their engagement in care using biometric fingerprint scanning and the standard-of-care electronic medical record (EMR) monitoring system. Biometric data was collected by trained research assistants, who uploaded and synced data across study sites daily using wireless internet. We collected data weekly on the biometric scanner performance, reliability, and usability. We assessed the feasibility and acceptability of using biometric fingerprint scanning to record HIV visits during exit interviews with a sample of participants and healthcare workers and by comparing visit concordance between the biometric fingerprint scanning and EMR systems. We enrolled 314 HIV-infected pregnant women and 51 HCWs (n = 365 total participants). The majority of participants felt the biometric fingerprint scanning system was easy to use (64%), required no additional assistance (69%) and met their expectations (76%). No major issues with data security, privacy, or scanner functionality were reported by HIV-infected women or healthcare workers. Of the 542 HIV visits captured during the study period among women in Option B+, 80% were recorded in the biometric fingerprint system versus 51% in the EMR system (PR 1.57, 95% CI 1.43, 1.72, p-value < 0.05). Among HIV-infected pregnant women engaged in HIV care, biometric fingerprint scanning is a feasible and acceptable way to monitor HIV visits and may improve the ability to monitor women's engagement in HIV care over time and across clinics. Biometric fingerprint scanning should be scaled-up and evaluated as an implementation strategy to support sustained engagement in HIV care for women during the perinatal period.

"A way of escaping": a qualitative study exploring reasons for clinic transferring and its impact on engagement in care among women in Option B.

Clinic transfers among women in Option B+ are frequent, often undocumented, and may lead to suboptimal engagement in care and HIV outcomes. The reasons women move between HIV clinics are not well understood. We conducted four focus group discussions (FGD) among HIV-infected pregnant women in Option B+ and four FGDs and five in-depth interviews among healthcare workers (HCWs) at two large ART clinics in Lilongwe, Malawi. Mobility and fear of inadvertent HIV disclosure, particularly due to seeing neighbors or acquaintances at a clinic, were key drivers of transferring between HIV clinics. Women were aware of the need to obtain a formal transfer, but in practice this was often not feasible and led women to self-transfer clinics. Self-transferring to a new clinic frequently resulted to re-testing and re-initiating ART and concerns about disruptions in ART. Strategies to monitor women's engagement in HIV care without requiring a formal transfer are urgently needed.

Beyond mobile phones: exploring using technology to support sustained engagement in care for HIV-infected women on antiretroviral therapy.

Disengagement from HIV care has emerged as a challenge to the success of universal test and treat strategies for HIV-infected women. Technology may enhance efforts to monitor and support engagement in HIV care, but implementation barriers and facilitators need to be evaluated. We conducted a mixed-method study among HIV-infected, pregnant women and healthcare workers (HCWs) in Malawi to evaluate barriers and facilitators to three technologies to support monitoring HIV care: (1) text messaging, (2) SIM card scanning and (3) biometric fingerprint scanning. We included 123 HIV-infected, pregnant women and 85 HCWs in a survey, 8 focus group discussions and 5 in-depth interviews. Biometric fingerprint scanning emerged as the preferred strategy to monitor engagement in HIV care. Among HCWs, 70% felt biometrics were very feasible, while 48% thought text messaging and SIM card scanning were feasible. Nearly three quarters (72%) of surveyed women reported they would be very comfortable using biometrics to monitor HIV appointments. Barriers to using text messaging and SIM card scanning included low phone ownership (35%), illiteracy concerns, and frequent selling or changing of mobile phones. Future work is needed to explore the feasibly of implementing biometric fingerprint scanning or other technologies to monitor engagement in HIV care.

A Systematic Review and Meta-analysis of Antiretroviral Therapy (ART) Adherence Interventions for Women Living with HIV.

A systematic review and meta-analysis was conducted to determine the efficacy of women-focused ART adherence interventions. Included studies (a) reported on a behavioral ART adherence intervention for cis-women living with HIV, (b) measured ART adherence as an outcome, and (c) employed a randomized controlled trial design. Thirteen studies were included in the meta-analysis. Overall, interventions significantly improved ART adherence compared to control conditions (random-effects d = 0.82, 95% CI [0.18, 1.45], p = 0.01), however, this was largely driven by two studies that had effect sizes greater than 3 standard errors above the mean effect size. Key moderators were location, recruitment method, group-based intervention, and alteration of the healthcare system. Innovative behavioral interventions that focus on young women and adolescents, target the critical periods of pregnancy and postpartum and test the integration of multiple levels of intervention to create lasting effects on ART adherence are needed.

Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.

Linkage to care from mobile clinics is often poor and inadequately understood. This multimethod study assessed linkage to care and antiretroviral therapy (ART) uptake following ART-referral by a mobile clinic in Cape Town (2015/2016). Clinic record data (N = 86) indicated that 67% linked to care (i.e., attended a clinic) and 42% initiated ART within 3 months. Linkage to care was positively associated with HIV-status disclosure intentions (aOR: 2.99, 95% CI 1.13-7.91), and treatment readiness (aOR: 2.97, 95% CI 1.05-8.34); and negatively with good health (aOR: 0.35, 95% CI 0.13-0.99), weekly alcohol consumption (aOR: 0.35, 95% CI 0.12-0.98), and internalised stigma (aOR: 0.32, 95% CI 0.11-0.91). Following linkage, perceived stigma negatively affected ART-initiation. In-depth interviews (N = 41) elucidated fears about ART side-effects, HIV-status denial, and food insecurity as barriers to ART initiation; while awareness of positive ART-effects, follow-up telephone counselling, familial responsibilities, and maintaining health to avoid involuntary disclosure were motivating factors. Results indicate that an array of interventions are required to encourage rapid ART-initiation following mobile clinic HIV-testing services.