Linkage to HIV Care and Early Retention in Care Rates in the Universal Test-and-Treat Era: A Population-based Prospective Study in KwaZulu-Natal, South Africa.

HIV linkage, and retention are key weaknesses in South Africa's national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. We conducted an observational prospective cohort study to investigate LTRIC rates for adults with a new HIV diagnosis in South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status, sex, and age. Of the 5,637 participants recruited, 21.2% had confirmed HIV, of which 70.9% were women, and 46.5% were aged 25-34 years. Although 82.7% of participants were linked-to-care within 3 months, only 46.1% remained-in-care 12 months after initiating ART and 5.2% were deceased. While a significantly higher proportion of men were linked-to-care at 3 months compared to women, a significant proportion of women (49.5%) remained-in-care at 12 months than men (38.0%). Post-secondary education and child support grants were significantly associated with retention. We found high linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required to retain people living with HIV in care, especially during the first year after ART initiation. Our findings suggest that interventions could target men to encourage HIV testing.

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.

A qualitative study exploring infant feeding decision-making between birth and 6 months among HIV-positive mothers.

Despite efforts to support breastfeeding for HIV-positive mothers in South Africa, being HIV-positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision-making about infant feeding practices among HIV-positive mothers in a rural and urban settings in KwaZulu-Natal, South Africa. HIV-positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in-depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV-positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.

Autonomy and infant feeding decision-making among teenage mothers in a rural and urban setting in KwaZulu-Natal, South Africa.

BACKGROUND: The nutritional status of infants born to teenage mothers can be sub-optimal compared to those born to older mothers. One contributing factor is inappropriate feeding practices adopted by teenage mothers. Little is known about how infant feeding decisions are made among teenage mothers, particularly in under resourced settings. In this study we prospectively explored autonomy and infant feeding decision-making among teenage mothers in a rural and urban setting in KwaZulu-Natal, South Africa. METHODS: This study adopted a qualitative longitudinal design. Thirty pregnant participants were recruited to the study cohort, from the catchment area of two hospitals (one urban and one rural). Participants were purposively selected to include teenagers, HIV positive, and working pregnant women. We report findings from ten teenage mothers, aged between 15 and 19 years, who participated in the larger cohort (n = 5 rural; n = 5 urban). Monthly in-depth interviews were conducted with participating mothers for 6 months starting 2 weeks after delivery. All interviews were conducted in the local language, transcribed verbatim and translated into English. Data was coded using NVivo v10 and framework analysis was used. RESULTS: Findings from this study showed that teenage mothers had knowledge about recommended feeding practices. However, our findings suggest that these mothers were not involved in infant feeding decisions once they were at home, because infant feeding decision-making was a role largely assumed by older mothers in the family. Further, the age of the mother and financial dependency diminished her autonomy and ability to influence feeding practices or challenge incorrect advice given at home. Most feeding advice shared by family members was inappropriate, leading to poor infant feeding practices among teenage mothers. Returning to school and fear of breastfeeding in public were also barriers to exclusive breastfeeding. CONCLUSION: Teenage mothers had a limited role in the infant feeding decision-making process. Health workers have an important role to play in ensuring that knowledge about infant feeding is shared with the mother's family where infant feeding choices are made. This will improve support for teenage mothers, and may also positively impact on the nutritional status of children.

Service delivery models that promote linkages to PrEP for adolescent girls and young women and men in sub-Saharan Africa: a scoping review.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is an emerging biomedical prevention intervention. Documenting PrEP service delivery models (SDMs) that promote linkage to and continuation of PrEP will inform guidelines and maximise roll-out. OBJECTIVES: To synthesise and appraise the effectiveness and feasibility of PrEP SDMs designed to promote linkage to PrEP care among adolescent girls and young women (AGYW) and men in sub-Saharan Africa (SSA). ELIGIBILITY CRITERIA: Primary quantitative and qualitative studies published in English and conducted in SSA were included. No restrictions on the date of publication were applied. SOURCES OF EVIDENCE: Methodology outlined in the Joanna Briggs Institute reviewers' manual was followed. PubMed, Cochrane library, Scopus, Web of Science and online-conference abstract archives were searched. CHARTING METHODS: Data on article, population, intervention characteristics and key outcomes was charted in REDCap. RESULTS AND CONCLUSION: Of the 1204 identified records, 37 (met the inclusion criteria. Health facility-based integrated models of PrEP delivery with family planning, maternal and child health or sexual and reproductive services to AGYW resulted in PrEP initiation of 16%-90%. Community-based drop-in centres (66%) was the preferred PrEP outlet for AGYW compared with public clinics (25%) and private clinics (9%). Most men preferred community-based delivery models. Among individuals who initiated PrEP, 50% were men, 62% were <35 years old and 97% were tested at health fairs compared with home testing. Integrated antiretroviral therapy (ART)-PrEP delivery was favoured among serodiscordant couples with 82.9% of couples using PrEP or ART with no HIV seroconversions. PrEP initiation within healthcare facilities was increased by perceived client-friendly services and non-judgemental healthcare workers. Barriers to PrEP initiation included distance to travel to and time spent at health facilities and perceived community stigma. PrEP SDMs for AGYW and men need to be tailored to the needs and preferences for each group. Programme implementers should promote community-based SDMs to increase PrEP initiation among AGYW and men.

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.

Strengthening health system's capacity for pre-exposure prophylaxis for adolescent girls and young women and adolescent boys and young men in South Africa (SHeS'Cap-PrEP): Protocol for a mixed methods study in KwaZulu-Natal, South Africa.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be used to control HIV incidence especially among people who are at increased risk for HIV such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). In South Africa, various approaches of delivering PrEP have been adopted at different service delivery points (facility-based only, school-based only, community-based only and hybrid school-facility and community-facility models) to overcome challenges associated with individual, structural, and health systems related barriers that may hinder access to and uptake of PrEP among these populations. However, little is known about how to optimize PrEP implementation and operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. This study aims to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation, and adherence among AGYW and ABYM. METHODS AND ANALYSIS: A sequential explanatory mixed-methods study will be conducted in 22 service delivery points (SDPs) in uMgungundlovu district, KwaZulu-Natal, South Africa. We will recruit 600 HIV negative, sexually active, high risk, AGYW (aged 15-24 years) and ABYM (aged 15-35 years). Enrolled participants will be followed up at 1-, 4- and 7-months to determine continuation and adherence to PrEP. We will conduct two focus group discussions (with 8 participants in each group) across four groups (i. Initiated PrEP within 1 month, ii. Did not initiate PrEP within 1 month, iii. Continued PrEP at 4/7 months and iv. Did not continue PrEP at 4/7 months) and 48 in-depth interviews from each of the four groups (12 per group). Twelve key informant interviews with stakeholders working in HIV programs will also be conducted. Associations between demographic characteristics stratified by PrEP initiation and by various service-delivery models will be assessed using Chi-square/Fishers exact tests or t-test/Mann Whitney test. A general inductive approach will be used to analyze the qualitative data. ETHICS AND DISSEMINATION: The protocol was approved by the South African Medical Research Council Health Research Ethics Committee (EC051-11/2020). 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.

Service delivery models for enhancing linkage to and retention in HIV care services for adolescent girls and young women and adolescent boys and young men: a protocol for an overview of systematic reviews.

INTRODUCTION: Recent advances in the HIV care continuum have shown that an individual diagnosed with HIV should be initiated on antiretroviral therapy as soon as possible regardless of the CD4 count levels and retained in HIV care services. Studies have reported large losses in the HIV continuum of care, before and after the era of universal test and treat. Several systematic reviews have reported on the strategies for improving linkage to and retention in HIV treatment and care. The purpose of this overview of systematic reviews is to identify HIV care interventions or service delivery models (SDMs) and synthesise evidence on the effects of these to link adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM) to care and retain them in care. We also aim to highlight gaps in the evidence on interventions and SDMs to improve linkage and retention in HIV care of AGYW and ABYM. METHODS AND ANALYSIS: An electronic search of four online databases: PubMed, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science will be performed to identify systematic reviews on the effects of linkage to and retention in HIV care interventions or SDMs for AGYW aged 15-24 years and ABYM aged 15-35 years. Our findings on the effects of interventions and SDMs will be interpreted considering the intervention and or SDMs' effectiveness by the time period, setting and population of interest. Two or more authors will independently screen articles for inclusion using a priori criteria. ETHICS AND DISSEMINATION: Ethics approval is not required for this study as only published secondary data will be used. Our findings will be disseminated through peer-reviewed publication, conference abstracts and through presentations to stakeholders and other community fora. The findings from this overview of systematic reviews will inform mixed-methods operations research on HIV intervention programming and delivery of HIV care services for AGYW and ABYM in South Africa. PROSPERO REGISTRATION NUMBER: CRD42020177933.

Evidence of past and current collaborations between traditional health practitioners and biomedical health practitioners: a scoping review protocol.

INTRODUCTION: Healthcare seekers around the globe use more than one healthcare system, with most using the traditional and the Western approaches concurrently. To date, little collaboration between the two systems has taken place within the mental health space compared with other areas of medicine. In order to inform integrating plans for traditional health practitioners and biomedical health practitioners in the South African mental health system, it is important to know which models of collaboration are used in other medical settings and contexts. This study aims to document global evidence on collaboration practices between traditional health practitioners and biomedical professionals when working with various health conditions. METHODS AND ANALYSIS: This scoping review will be guided by an improved Arksey and O'Malley framework, the 2010 Levac et al methodological framework and the 2017 Joanna Briggs Institute guidelines. A systematic literature search will be carried out using seven different databases, EMBASE, PubMed, LILACS MEDLINE, APA PsycArticles, CINAHL Plus, Academic Search Complete and Scopus, in addition to the WHO repository, bibliographical search engines, and Open Access Theses and Dissertations. Moreover, the references of relevant publications between January 1978 and March 2020 will be scanned. Two reviewers will independently screen articles for eligibility based on the predetermined inclusion and exclusion criteria. Thematic analysis and descriptive numerical analysis will be performed using ATLAS.ti V.8 and Excel software, respectively. The results for this review will be presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review. ETHICS AND DISSEMINATION: This study will not require ethics approval because publicly available material will be used. Study findings will be published in an open-access journal and be presented to other key health system stakeholders and academic research gatherings.

Insights into health care seeking behaviour for children in communities in KwaZulu-Natal, South Africa.

BACKGROUND: South African infant and child mortality remains high, with many deaths occurring outside the formal health services. Delayed health care seeking represents a large proportion of these deaths. AIM: To generate knowledge about the role of, and influences on, caregivers with regard to decision-making about when and where to seek care for sick children. SETTING: Two communities in KwaZulu-Natal. METHODS: A qualitative, exploratory design employing participatory research techniques was used to undertake focus group discussions with community members. RESULTS: Health care seeking for a sick child was described as a complex process influenced by multiple carers using multiple providers. Decision-making about seeking health care for a sick child was not an individual effort, but was shared with others in the household and guided by how the symptoms were perceived, either a Western illness or African illness. A sick child could either be treated at home or be taken to a variety of places including clinics, private doctors, traditional healers, faith healers and hospitals. Traditional healers were associated with the treatment of illnesses perceived to be traditional. Few participants said that they would take their child back to the original health provider if the child remained ill, but would move from one provider to another until the child's health improved. CONCLUSION: The formal health system needs to ensure that sick children are identified and managed appropriately to reduce child deaths. Knowledge and understanding of health care seeking behaviour for sick children by carers is an important aspect. Interventions need to be designed with these contextual issues in mind.

Enablers and barriers to success among mothers planning to exclusively breastfeed for six months: a qualitative prospective cohort study in KwaZulu-Natal, South Africa.

BACKGROUND: Exclusive breastfeeding (EBF) for the first six months of life is the most important determinant of child health and development, and is the recommended feeding practice for all mothers. However, EBF rates remain low in South Africa. This study aimed to prospectively explore enablers or barriers to success among mothers who planned to exclusively breastfeed their infants for the first six months of life, in KwaZulu-Natal, South Africa. METHODS: A qualitative, longitudinal cohort design was adopted. Women were recruited during pregnancy from the catchment area of two hospitals (one urban and one rural) and purposively sampled to include working women, teenagers, and HIV positive pregnant women. This analysis relates to 22 women, from 30 women recruited, who planned antenatally to exclusively breastfeed for six months. These mothers were interviewed monthly for six months postpartum. Infant feeding practices were explored at each visit using in-depth interviews and 24 h feeding recall assessment. Framework analysis was conducted for qualitative data, and quantitative data analyzed using descriptive statistics. RESULTS: A total of 125 interviews were conducted between November 2015 and October 2016. Among 22 mothers who planned to exclusively breastfeed for six months, 17 reported adding other food or fluids before six months, and five reported exclusively breastfeeding successfully for the first six months. Key themes showed that all mothers relied strongly on health workers' infant feeding advice and support. All mothers experienced challenges regardless of whether they succeeded in EBF, including inappropriate advice from health workers, maternal-baby issues, pressure from family members and returning to school and work. However, those who were successful at EBF for six months reported that high breastfeeding self-efficacy, HIV status and cultural meaning attached to breastfeeding were underlying factors for success. CONCLUSION: Health workers are key players in providing infant feeding information and support, yet some health workers give mothers infant feeding advice that is not supportive of EBF. Strategies to improve health workers' competency in infant feeding counselling are needed to better prepare pregnant women to overcome common breastfeeding challenges and build mothers' confidence and self-efficacy, thus increasing EBF rates.

Implementation of Point-of-Care Diagnostics in Rural Primary Healthcare Clinics in South Africa: Perspectives of Key Stakeholders.

INTRODUCTION: Key stakeholders' involvement is crucial to the sustainability of quality point-of-care (POC) diagnostics services in low-and-middle income countries. The aim of this study was to explore key stakeholder perceptions on the implementation of POC diagnostics in rural primary healthcare (PHC) clinics in South Africa. METHOD: We conducted a qualitative study encompassing in-depth interviews with multiple key stakeholders of POC diagnostic services for rural and resource-limited PHC clinics. Interviews were digitally recorded and transcribed verbatim prior to thematic content analysis. Thematic content analysis was conducted using themes guided by the World Health Organisation (WHO) quality-ASSURED (Affordable, Sensitive, Specific, User friendly, Rapid and to enable treatment at first visit and Robust, Equipment free and Delivered to those who need it) criteria for POC diagnostic services in resource-limited settings. RESULTS: 11 key stakeholders participated in the study. All stakeholders perceived the main advantage of POC diagnostics as enabling access to healthcare for rural patients. Stakeholders perceived the current POC diagnostic services to have an ability to meet patients' needs, but recommended further improvement of the following areas: research on cost-effectiveness; improved quality management systems; development of affordable POC diagnostic and clinic-based monitoring and evaluation. CONCLUSIONS: Key stakeholders of POC diagnostics in rural PHC clinics in South Africa highlighted the need to assess affordability and ensure quality assurance of current services before adopting new POC diagnostics and scaling up current POC diagnostics.