Depression and HIV Care-seeking Behaviors in a Population-based Sample in North West Province, South Africa.

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09-1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.

RESUMEN: La depresión está asociada con conductas clave de prevención y tratamiento relacionadas con el VIH en África subsahariana. Nuestro objetivo fue identificar la asociación de los síntomas depresivos con los resultados relacionados con el VIH entre una muestra representativa de personas de 18 a 49 años en Sudáfrica. Utilizando modelos de regresión logística (N = 1044), los síntomas depresivos se asociaron inversamente con los que se informaron que habían probado de VIH alguna vez (AOR 0,92, IC del 95%: 0,85 a 0,99; p = 0,04) y la adherencia al TAR (AOR 0,82, IC del 95%: 0,73 a 0,91; p < 0,01) entre las mujeres. Para los hombres, los síntomas depresivos se asociaron positivamente con la vinculación con cuidado (AOR: 1,21, IC del 95%: 1,09­1,34; p < 0,01). La depresión puede tener un impacto adverso en la adherencia al TAR para las mujeres VIH-positivas y reducir la probabilidad de que las mujeres se hagan la prueba del VIH. Para los hombres VIH-positivos, los resultados sugieren que la depresión fomente una conducta de búsqueda de ayuda, afectando así sus interacciones con el sistema de salud. Estos resultados subrayan la necesidad de que los que proveen servicios médicos tengan en cuenta la salud mental en sus programas que abordan los resultados relacionados con la salud.

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa.

OBJECTIVE: We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART). DESIGN: I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation. METHODS: Eighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status. RESULTS: Overall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC. CONCLUSION: Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs. TRIAL REGISTRATION: NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

Sexual and Physical Violence in Childhood Is Associated With Adult Intimate Partner Violence and Nonpartner Sexual Violence in a Representative Sample of Rural South African Men and Women.

Intimate partner violence, nonpartner sexual violence, and physical and sexual violence against children are significant public health issues in South Africa. Theory suggests that experiencing violence in childhood plays a role in propensity to perpetrate violence or vulnerability to violence in adulthood. Most research to date on this topic has been conducted in high-resource countries or within urban or high-risk populations. We explore the relationship between violence in childhood and violence in adulthood in a community-based sample of 18- to 49-year-old adults in rural South Africa using data from a population-based survey (N = 1,044) in North West province in 2014. We measured childhood violence before age 15 years, experience of nonpartner sexual violence in adulthood, and IPV victimization and perpetration in the last 12 months. We conducted multivariate logistic regression; gender was tested as an effect modifier. All estimates are weighted to the subdistrict population. More women (2.7%) than men (0.8%) reported childhood forced sex, whereas fewer women (2.0%) than men (7.9%) reported childhood physical violence. Women and men reported similar rates of IPV victimization (6.8% vs. 5.4%), IPV perpetration (3.3% vs. 4.8%), and forced sex by a nonpartner (1.6% vs. 1.2%). We found that men and women who experienced childhood violence (combined physical and/or sexual) were significantly more likely to experience forced sex by a nonpartner (men: adjusted odds ratio [aOR] = 5.53, 95% confidence interval [CI] = [1.27, 24.0], p < .05; women: aOR = 51.1, 95% CI = [10.58, 246.3], p < .01) compared with those who did not experience childhood violence. They were also 2.5 times as likely to perpetrate recent IPV (aOR = 2.5, 95% CI = [0.97, 6.7], p = .06) or experience recent IPV (aOR = 2.5, 95% CI = [0.9, 6.9], p = .07), although this finding was marginally significant. These results align with the literature from other settings and population groups.

Engaging HIV-positive clients in care: acceptability and mechanisms of action of a peer navigation program in South Africa.

Antiretroviral therapy (ART) could curtail the HIV epidemic, but its impact is diminished by low uptake. We developed a peer navigation program to enhance engagement in HIV care, ART adherence, and behavioral prevention. In preparation for a randomized controlled trial, the program was piloted over four months at two primary health clinics in South Africa's North West Province. Newly diagnosed, HIV-positive clients met regularly with navigators to address barriers to care, adherence, and prevention. To assess program acceptability and feasibility and characterize the mechanisms of action, we surveyed 25 clients who completed navigation services and conducted interviews with 10 clients, four navigators, and five clinic providers. Clients expressed near universal approval for the program and were satisfied with the frequency of contact with navigators. HIV stigma emerged as a primary driver of barriers to care. Navigators helped clients overcome feelings of shame through education and by modeling how to live successfully with HIV. They addressed discrimination fears by helping clients disclose to trusted individuals. These actions, in turn, facilitated clients' care engagement, ART adherence, and HIV prevention efforts. The findings suggest peer navigation is a feasible approach with potential to maximize the impact of ART-based HIV treatment and prevention strategies.

Pre/post evaluation of a pilot prevention with positives training program for healthcare providers in North West Province, Republic of South Africa.

BACKGROUND: Prevention interventions for people living with HIV/AIDS are an important component of HIV programs. We report the results of a pilot evaluation of a four-hour, clinic-based training for healthcare providers in South Africa on HIV prevention assessments and messages. This pre/post pilot evaluation examined whether the training was associated with providers delivering more prevention messages. METHODS: Seventy providers were trained at four public primary care clinics with a high volume of HIV patients. Pre- and post-training patient exit surveys were conducted using Audio-Computer Assisted Structured Interviews. Seven provider appropriate messaging outcomes and one summary provider outcome were compared pre- and post-training using Poisson regression. RESULTS: Four hundred fifty-nine patients pre-training and 405 post-training with known HIV status were interviewed, including 175 and 176 HIV positive patients respectively. Among HIV positive patients, delivery of all appropriate messages by providers declined post-training. The summary outcome decreased from 56 to 50%; adjusted rate ratio 0.92 (95% CI = 0.87-0.97). Sensitivity analyses adjusting for training coverage and time since training detected fewer declines. Among HIV negative patients the summary score was stable at 32% pre- and post-training; adjusted rate ratio 1.05 (95% CI = 0.98-1.12). CONCLUSIONS: Surprisingly, this training was associated with a decrease in prevention messages delivered to HIV positive patients by providers. Limited training coverage and delays between training and post-training survey may partially account for this apparent decrease. A more targeted approach to prevention messages may be more effective.

Improving Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) Treatment Monitoring in South Africa: Evaluation of an Advanced TB/HIV Course for Healthcare Workers.

BACKGROUND: South Africa has dual epidemics of human immunodeficiency virus (HIV) and tuberculosis (TB). Nurse-focused training was combined with onsite mentoring for nurses to improve HIV and TB care. A pre-/postevaluation was conducted in 3 districts in South Africa to assess the effects of the course on clinical patient monitoring and integration of TB and HIV care. METHODS: Two cross-sectional, unmatched samples of patient charts at 76 primary healthcare facilities were collected retrospectively in 2014 to evaluate the impact of training on treatment monitoring. Proportions of HIV patients receiving a viral load test 6 months after initiating antiretroviral therapy (ART) and TB patients receiving end of intensive phase sputum testing were compared pre- and posttraining. Analysis of creatinine clearance testing and integration of TB and HIV care were also performed. RESULTS: Data were analyzed from 1074 pretraining and 1048 posttraining records among patients initiating ART and from 1063 pretraining and 1008 posttraining among patients initiating TB treatment. Documentation of a 6-month viral load test was 36.3%, and a TB test at end of intensive phase was 70.7%, and neither increased after training. Among patients with a viral load test, the percentage with viral load less than 50 copies/mL increased from 48.6% pretraining compared with 64.2% posttraining (P = .001). Integration of TB and HIV care such as isoniazid preventive therapy increased significantly. CONCLUSIONS: The primary outcome measures did not change after training. However, the evaluation documented many other improvements in TB and HIV care that may have been supported by the course.

A situational analysis methodology to inform comprehensive HIV prevention and treatment programming, applied in rural South Africa.

Successful HIV prevention programming requires engaging communities in the planning process and responding to the social environmental factors that shape health and behaviour in a specific local context. We conducted two community-based situational analyses to inform a large, comprehensive HIV prevention programme in two rural districts of North West Province South Africa in 2012. The methodology includes: initial partnership building, goal setting and background research; 1 week of field work; in-field and subsequent data analysis; and community dissemination and programmatic incorporation of results. We describe the methodology and a case study of the approach in rural South Africa; assess if the methodology generated data with sufficient saturation, breadth and utility for programming purposes; and evaluate if this process successfully engaged the community. Between the two sites, 87 men and 105 women consented to in-depth interviews; 17 focus groups were conducted; and 13 health facilities and 7 NGOs were assessed. The methodology succeeded in quickly collecting high-quality data relevant to tailoring a comprehensive HIV programme and created a strong foundation for community engagement and integration with local health services. This methodology can be an accessible tool in guiding community engagement and tailoring future combination HIV prevention and care programmes.

Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa.

BACKGROUND: Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming. METHODS: We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression. RESULTS: We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter. CONCLUSIONS: Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.

Evaluation of short message service and peer navigation to improve engagement in HIV care in South Africa: study protocol for a three-arm cluster randomized controlled trial.

BACKGROUND: In countries with a high burden of HIV, such as South Africa, where the epidemic remains the world's largest, improving early uptake of and consistent adherence to antiretroviral therapy could bring substantial HIV prevention gains. However, patients are not linked to or retained in care at rates needed to curtail the epidemic. Two strategies that have demonstrated a potential to stem losses along the HIV care cascade in the sub-Saharan African context are use of text messaging or short message service (SMS) and peer-navigation services. METHODS/DESIGN: We designed a cluster randomized trial to assess the efficacy of an SMS intervention and a peer-navigation intervention to improve retention in care and treatment, timely linkage to care and treatment, medication adherence, and prevention behaviors in South Africa. Eighteen primary and community healthcare clinics in Rustenburg and Moses Kotane Sub-districts in the North West Province were randomized to one of three conditions: SMS intervention (n = 7), peer navigation intervention (n = 7), or standard of care (n = 4). Approximately 42 participants are being recruited at each clinic, which will result in a target of 750 participants. Eligible participants include patients accessing HIV testing or care in a study clinic, recently diagnosed with HIV, aged 18 years or older, and with access to a cellular telephone where they are willing to receive automated SMS with HIV-related messaging. Data collection includes extraction of visit information from clinical files and participant surveys at baseline, 6 months, and 12 months. Intent-to-treat (ITT) analysis will explore differences between randomization arms and the primary outcome of patient retention in care at 12 months following enrollment. We will also explore secondary outcomes including participants' a) timely linkage to care (within 3 months of HIV diagnosis), b) adherence to treatment based on self-report and clinic's medication dispensation dates, and c) condom-use behaviors. DISCUSSION: The findings will allow us to compare the efficacy of two complementary interventions, one that requires fewer resources to implement (SMS) and one (peer navigation) that offers more flexibility in terms of the patient barriers to care that it can address. TRIAL REGISTRATION: NCT02417233, registered 12 December 2014.

Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa.

BACKGROUND: Stigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted. METHODS: We conducted a "situational analysis"--a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services. RESULTS: Findings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services. CONCLUSIONS: We conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths' accessing health care.

Need for improvements in clinical practice to retain patients in pre-antiretroviral therapy care: Data from rural clinics in North West Province, South Africa.

We examined current challenges with patient engagement in HIV prevention and care in South Africa by assessing the procedures of eight public health clinics in the North West Province. Procedures consisted of (1) an inventory/audit of the HIV Counseling and Testing, pre-antiretroviral therapy (pre-ART), and antiretroviral therapy (ART) patient registers; (2) extraction of data from a convenience sample of 39 HIV-positive patient files; and (3) 13 key informant interviews with clinic staff to characterize retention and re-engagement practices for patients. Incomplete registers revealed little evidence of follow-up services, particularly for pre-ART patients. The more detailed examination of patient files indicated substantial disparities in the proportion of pre-ART versus ART patients retained in care. Key informant interviews contextualized the data, with providers describing multiple procedures for tracking and ensuring service delivery for ART patients and fewer procedures to retain pre-ART patients. These findings suggest that enhanced strategies are needed for ensuring continued engagement in HIV care, with a particular emphasis on improving the retention of pre-ART patients. The preventive benefits of ART scale-up may not be achieved if improvements are not made in the proportion of earlier-stage HIV-positive patients who are successfully engaged in care.

Informing comprehensive HIV prevention: a situational analysis of the HIV prevention and care context, North West Province South Africa.

OBJECTIVE: Building a successful combination prevention program requires understanding the community's local epidemiological profile, the social community norms that shape vulnerability to HIV and access to care, and the available community resources. We carried out a situational analysis in order to shape a comprehensive HIV prevention program that address local barriers to care at multiple contextual levels in the North West Province of South Africa. METHOD: The situational analysis was conducted in two sub-districts in 2012 and guided by an adaptation of WHO's Strategic Approach, a predominantly qualitative method, including observation of service delivery points and in-depth interviews and focus groups with local leaders, providers, and community members, in order to recommend context-specific HIV prevention strategies. Analysis began during fieldwork with nightly discussions of findings and continued with coding original textual data from the fieldwork notebooks and a select number of recorded interviews. RESULTS: We conducted over 200 individual and group interviews and gleaned four principal social barriers to HIV prevention and care, including: HIV fatalism, traditional gender norms, HIV-related stigma, and challenges with communication around HIV, all of which fuel the HIV epidemic. At the different levels of response needed to stem the epidemic, we found evidence of national policies and programs that are mitigating the social risk factors but little community-based responses that address social risk factors to HIV. CONCLUSIONS: Understanding social and structural barriers to care helped shape our comprehensive HIV prevention program, which address the four 'themes' identified into each component of the program. Activities are underway to engage communities, offer community-based testing in high transmission areas, community stigma reduction, and a positive health, dignity and prevention program for stigma reduction and improve communication skills. The situational analysis process successfully shaped key programmatic decisions and cultivated a deeper collaboration with local stakeholders to support program implementation.