Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa?

We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.

Food Insecurity at HIV Diagnosis Associated with Subsequent Viremia Amongst Adults Living with HIV in an Urban Township of South Africa.

We assessed the temporal impact of food insecurity on 12-month antiretroviral (ART) adherence, retention in care, hospitalization, and HIV viremia (> 1000 copies/mL) in ART naïve adults presenting for HIV testing in Umlazi, South Africa. At the time of HIV testing and prior to ART initiation, we determined each participants' food security status using the validated Household Food Insecurity Access Scale (HFIAS). Following HIV testing and ART initiation, we then assessed the above outcomes of each study participant at 3-month intervals for a total of 12 months. Among 2,383 participants with HIV in this study, 253 (10.6%) experienced food insecurity. We found that food insecurity is associated with 20% higher adjusted prevalence odd ratios (aPOR) of having HIV viremia (> 1000 copies/mL) at 12 months following initial diagnosis (aPOR 1.2, 95% CI 1.1-1.4). We found no significant differences in ART adherence, retention in care, and hospitalization occurrences between the food secure and food insecure cohorts.

Symbolic and anticipated HIV stigma are associated with mental health and education in South Africa.

HIV stigma continues to act as a barrier to HIV care in South Africa, necessitating further research on the intersections of socioeconomic factors and the anticipation and expression of stigma surrounding HIV. We measured the prevalence of HIV-related stigma and evaluated factors associated with symbolic and anticipated stigma in Umlazi Township, South Africa from 2013 to 2019, using a validated HIV stigma scale, before undergoing HIV testing. Among 7,724 people evaluated, 1,318 (16.9%) reported symbolic stigma and 2,396 (30.8%) anticipated HIV stigma. Prevalence of symbolic and anticipated stigma were significantly more common among both women and people living with HIV, compared to men and those who tested negative for HIV. In multivariable analyses, higher education and depressive symptoms were the strongest correlates with both symbolic stigma and anticipated stigma. Younger age, not being married, and having a partner who was not living with HIV appeared to be important correlates with anticipated stigma, but not symbolic stigma. Overall, the anticipation of experiencing stigma because of infection with HIV continues to be an important factor in the testing and management of HIV.

The impact of same-day antiretroviral therapy initiation on retention in care and clinical outcomes at four eThekwini clinics, KwaZulu-Natal, South Africa.

BACKGROUND: Same-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients. METHODS: We evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months' observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation. RESULTS: Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002-2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07-4.061), age (OR: 0.941; 95% CI: 0.734-2.791), ART start date (OR: 0.078; 95% CI: 0.042-0.141), partner HIV status (OR: 0.621; 95% CI: 0.387-0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092-0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165-4.928) times more likely to have increased viral load than those who had been returned in care. CONCLUSION: Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care.

Factors Influencing Rapid Antiretroviral Therapy Initiation at Four eThekwini Clinics, KwaZulu-Natal, South Africa.

Timely uptake of Antiretroviral therapy considerably improves the health of people living with the Human Immunodeficiency virus. We conducted a cross-sectional study of newly HIV diagnosed individuals in four clinics in eThekwini municipality, KwaZulu-Natal. Data was collected between June 2020 and December 2020. Participants completed an interviewer-administered questionnaire after HIV testing, on the day of HIV diagnosis. We evaluated factors influencing uptake of same-day ART initiation in eThekwini clinics, KwaZulu Natal, South Africa. Demographic information, health status, sexual behaviour, knowledge of universal test and treat (UTT), ART initiation uptake, and disclosure data was collected. Among the 403 participants, same-day initiation (SDI) was 69.2% (n = 279). We observed the number of sexual partners (aOR 0.35; 95% CI 0.15-0.81), HIV status of the partner (aOR 5.03; 95% CI 2.74-9.26) and knowledge of UTT (aOR 1.97; 95% CI 1.34-2.90) were identified as major factors influencing uptake of same-day ART initiation. More strategies are needed to achieve the SDI uptake within the framework of UTT.

Implementation of South Africa's Central Chronic Medicine Dispensing and Distribution Program for HIV Treatment: A Qualitative Evaluation.

We used the Practical, Robust Implementation and Sustainability Model to evaluate implementation of South Africa's Central Chronic Medicine Dispensing and Distribution (CCMDD) program, a differentiated service delivery program which allows clinically stable HIV-positive patients to receive antiretroviral therapy refills at clinic- or community-based pick-up points. Across ten clinics, we conducted 109 semi-structured interviews with stakeholders (pick-up point staff, CCMDD service providers and administrators) and 16 focus groups with 138 patients. Participants had highly favorable attitudes and said CCMDD decreased stigma concerns. Patient-level barriers included inadequate education about CCMDD and inability to get refills on designated dates. Organizational-level barriers included challenges with communication and transportation, errors in medication packaging and tracking, rigid CCMDD rules, and inadequate infrastructure. Recommendations included: (1) provide patient education and improve communication around refills (at the patient level); (2) provide dedicated space and staff, and ongoing training (at the organizational/clinic level); and (3) allow for prescription renewal at pick-up points and less frequent refills, and provide feedback to clinics (at the CCMDD program level).

Experiences of participants in a decentralized antiretroviral therapy program in South Africa during the COVID-19 pandemic.

The COVID-19 pandemic and associated restrictions could adversely affect long-term HIV care. We evaluated the experiences of people receiving antiretroviral therapy (ART) through a decentralized delivery program in South Africa during the COVID-19 pandemic. We telephoned a random subsample of participants enrolled in a prospective cohort study in KwaZulu-Natal in April and May 2020 and administered a semi-structured telephone interview to consenting participants. We completed interviews with 303 of 638 contacted participants (47%); 66% were female, with median age 36y. The most common concerns regarding the COVID-19 pandemic were food running out (121, 40%), fear of becoming infected with COVID-19 (103, 34%), and being unable to work/losing employment or income (102, 34%). Twenty-five (8%) participants had delayed ART pick-up due to the pandemic, while 212 (70%) had new concerns about ART access going forward. Mental health scores were worse during the pandemic compared to baseline (median score 65.0 vs 80.0, p < 0.001). Decentralized ART distribution systems have the potential to support patients outside of health facilities during the COVID-19 pandemic, but economic concerns and mental health impacts related to the pandemic must also be recognized and addressed.

Medical Mistrust and Stigma Associated with COVID-19 Among People Living with HIV in South Africa.

We evaluated COVID-19 stigma and medical mistrust among people living with HIV in South Africa. We conducted telephone interviews with participants in a prospective study of a decentralized antiretroviral therapy program. Scales assessing medical mistrust, conspiracy beliefs, anticipated and internalized stigma, and stereotypes specific to COVID-19 were adapted primarily from the HIV literature, with higher scores indicating more stigma or mistrust. Among 303 participants, the median stigma summary score was 4 [interquartile range (IQR) 0-8; possible range 0-24] and 6 (IQR 2-9) for mistrust (possible range 0-28). A substantial proportion of participants agreed or strongly agreed with at least one item assessing stigma (54%) or mistrust (43%). Higher COVID-19 stigma was associated with female gender and antecedent HIV stigma, and lower stigma with reporting television as a source of information on COVID-19. Further efforts should focus on effects of stigma and mistrust on protective health behaviors and vaccine hesitancy.

Effect of perceived HIV risk on initiation of antiretroviral therapy during the universal test and treat era in South Africa.

BACKGROUND: South Africa has not achieved the 90-90-90 goals, in part due to low rates of antiretroviral therapy (ART) initiation among those aware of their HIV status. Perceived risk of HIV at the time of testing may affect likelihood of rapid ART initiation. The purpose of this study was to evaluate factors associated with perceived risk of HIV and the relationship between perceived HIV risk and rapid ART initiation during the universal test and treat era which was adapted in October 2016. METHODS: We conducted a prospective study of adults undergoing HIV testing from October 2016-February 2019 at Ithembalabantu Clinic in Durban. Eligible participants reported not previously being diagnosed with HIV. Before HIV testing, participants were asked to assess their perceived HIV risk on a four-level scale. We categorized "definitely not" and "probably not going to acquire HIV" as a low perceived risk, and "probably will" and "definitely will become HIV-infected" as a high perceived risk of HIV infection. Participants were followed for up to 14 months following HIV testing to assess ART initiation. RESULTS: Among 1519 people newly diagnosed with HIV, 55% were female and mean age was 33 years. Among those, 1382 (90.9%) had a high HIV risk perception and 137 (9.1%) reported low HIV risk perception. In the low risk group individuals were more likely to be female (58% vs 55%), unemployed (62% vs 59%), have a partner with unknown HIV status (61% vs 55%) compared to the high risk group. 83.2% of those with low HIV risk perception reported previously HIV testing compared 91.5% of those with high HIV risk perception. In the multivariate model, males were associated with a higher chances of initiating ART compared to females (adjusted hazard ratio (aHR): 1.187, CI 1.187 (1.060-1.329) and being unemployed (aHR 0.767 CI (0.650-0.905). Those with a low HIV risk perception were less likely to initiate ART 125 (91%) vs 1310 (95%) p = 0.022), and took longer to initiate on ART after HIV diagnosis (11 days' vs 4 days, p = 0.042). CONCLUSION: Factors associated with high HIV risk perception included being unemployed, single, and having a partner of unknown HIV status. People living with HIV (PLHIV) in South Africa who had a low self-perceived risk to HIV infection were less likely to initiate ART. Assessing self-perceived risk of HIV infection may help direct counselling and improve ART initiation to achieve universal 90-90-90 goal.

Clinic-based diabetes screening at the time of HIV testing and associations with poor clinical outcomes in South Africa: a cohort study.

BACKGROUND: HIV clinical care programs in high burden settings are uniquely positioned to facilitate diabetes diagnosis, which is a major challenge. However, in sub-Saharan Africa, data on the burden of diabetes among people living with HIV (PLHIV) and its impact on HIV outcomes is sparse. METHODS: We enrolled adults presenting for HIV testing at an outpatient clinic in Durban. Those who tested positive for HIV-infection were screened for diabetes using a point-of-care hemoglobin A1c (HbA1c) test. We used log-binomial, Poisson, and Cox proportional hazard models adjusting for confounders to estimate the relationship of diabetes (HbA1c ≥ 6.5%) with the outcomes of HIV viral suppression (< 50 copies/mL) 4-8 months after antiretroviral therapy initiation, retention in care, hospitalization, tuberculosis, and death over 12 months. RESULTS: Among 1369 PLHIV, 0.5% (n = 7) reported a prior diabetes diagnosis, 20.6% (95% CI 18.5-22.8%, n = 282) screened positive for pre-diabetes (HbA1c 5.7-6.4%) and 3.5% (95% CI 2.7-4.6%, n = 48) for diabetes. The number needed to screen to identify one new PLHIV with diabetes was 46.5 persons overall and 36.5 restricting to those with BMI ≥ 25 kg/m2. Compared to PLHIV without diabetes, the risk of study outcomes among those with diabetes was not statistically significant, although the adjusted hazard of death was 1.79 (95% CI 0.41-7.87). CONCLUSIONS: Diabetes and pre-diabetes were common among adults testing positive for HIV and associated with death. Clinic-based diabetes screening could be targeted to higher risk groups and may improve HIV treatment outcomes.

Hair salons and stylist-client social relationships as facilitators of community-based contraceptive uptake in KwaZulu-Natal, South Africa: a qualitative analysis.

BACKGROUND: South Africa faces a high burden of unmet contraceptive need, particularly among adolescent girls and young women. Providing contraception in community-based venues may overcome barriers to contraceptive access. Our objective was to explore the potential impact of the social environment and stylist-client interactions on perceived accessibility of contraceptives within hair salons. METHODS: We conducted 42 semi-structured, in-depth interviews with salon clients (100% identified as female, 100% identified as Black, median age 27.1 years) and 6 focus groups with 43 stylists (95% identified as female, 98% identified as Black, median age 29.6 years) in and around Umlazi Township, Durban, KwaZulu-Natal to explore perspectives on offering contraceptive services in hair salons. We used an inductive and deductive approach to generate the codebook, identified themes in the data, and then organized findings according to Rogers' Individual Adoption Model as applied to community-based health prevention programs. Twenty-five percent of transcripts were coded by two independent coders to ensure reliability. RESULTS: We identified elements of the salon environment and stylist-client relationships as facilitators of and barriers to acceptability of salon-based contraceptive care. Factors that may facilitate perceived contraceptive accessibility in salons include: the anonymous, young, female-centered nature of salons; high trust and kinship within stylist-client interactions; and mutual investment of time. Stylists may further help clients build comprehension about contraceptives through training. Stylists and clients believe salon-based contraceptive delivery may be more accessible due to contraceptive need facilitating client buy-in for the program, as well as a salon environment in which clients may encourage other clients by voluntarily sharing their own contraceptive decisions. The non-judgmental nature of stylist-client relationships can empower clients to make contraceptive decisions, and stylists seek to support clients' continued use of contraceptives through various adherence and support strategies. Some stylists and clients identified existing social barriers (e.g. confidentiality concerns) and made recommendations to strengthen potential contraceptive delivery in salons. CONCLUSION: Stylists and clients were highly receptive to contraceptive delivery in salons and identified several social facilitators as well as barriers within this setting. Hair salons are community venues with a social environment that may uniquely mitigate barriers to contraceptive access in South Africa.

Women in South Africa experience high rates of unintended pregnancies. Because of high HIV prevalence within the country, women who experience unplanned pregnancies may also be vulnerable to HIV. Studies have detailed the barriers women in South Africa face in accessing contraceptives, including poverty, cultural norms around contraceptive use, lack of confidential spaces, and negative experiences with healthcare workers. In response, we propose the provision of contraceptive and preventive HIV care in salons­places that may be more convenient, accessible, and comfortable for women to acquire contraceptives. In this analysis, we aimed to understand how the salon social environment and client­stylist relationships may lower barriers women face when accessing contraceptives, using a framework for how individuals adopt new interventions. We conducted in-depth interviews with 42 salon clients and six focus group discussions with 43 stylists and used content analysis to explore themes within the data. Overall, participants identified components of the salon environment and stylist­client relationships that may facilitate how clients learn and make decisions about contraceptive use. These included perceptions of: salons being anonymous and centered around young, female clients; and stylists and clients recognizing contraceptive need within the community, being invested in salon services, and building trusted relationships. Although overall buy-in was high, some stylists and clients also identified barriers such as confidentiality concerns, negative views on stylists, and discomfort with discussing contraceptives. Overall, our study identifies hair salons as promising spaces for women in South Africa to seek contraceptive care.

Cryptococcal antigenemia is associated with meningitis or death in HIV-infected adults with CD4 100-200 cells/mm3.

BACKGROUND: Cryptococcal antigen (CrAg) screening with fluconazole prophylaxis has been shown to prevent cryptococcal meningitis and mortality for people living with HIV (PLWH) with CD4 < 100 cells/mm3. While cryptococcal meningitis occurs in individuals with CD4 100-200 cells/mm3, there is limited evidence that CrAg screening predicts cryptococcal meningitis or mortality among this group with moderate immunosuppression. Current IDSA and WHO clinical guidelines recommend restricting CrAg screening to PLWH with CD4 < 100 cells/mm3. METHODS: We conducted a prospective cohort study of PLWH 18+ years who had not initiated ART in South Africa. We followed participants for 14 months to determine onset of cryptococcal meningitis or all-cause mortality. At study completion, we retrospectively tested stored serum samples for CrAg using an enzyme immunoassay (EIA). We calculated CD4-stratified incidence rates of outcomes and used Cox proportional hazards to measure associations between CrAg positivity and outcomes. RESULTS: We enrolled 2383 PLWH, and 1309 participants had serum samples tested by CrAg EIA. The median CD4 was 317 cells/mm3 (interquartile range: 173-491 cells/mm3). By CD4 count at baseline, there were 209 individuals with a CD4 count of 100-200 cells/mm3 and available CrAg test results. Of these, four (1.9%) tested positive. Two of four (IR: 58.8 per 100 person-years) CrAg+ participants and 11 of 205 (IR: 5.6 per 100 person-years) CrAg- participants developed cryptococcal meningitis or died for an overall rate of death or cryptococcal meningitis that was 10.0-times higher for those who were CrAg+ (95% confidence interval: 2.2-45.3). Among those with CD4 < 100 cell/mm3 and CrAg EIA test results (N = 179), ten (5.6%) participants tested CrAg+. Among this group, seven of ten (IR: 137.6 per 100 person-years) CrAg+ participants and 26 of 169 (IR: 17.8 per 100 person-years) CrAg- participants developed cryptococcal meningitis or died, for a rate of death or cryptococcal meningitis that was 6.3-times higher for those who were CrAg+ (95% confidence interval: 2.7-14.6). CONCLUSIONS: Although few PLWH with moderate immunosuppression screened CrAg positive, a positive CrAg test was predictive of increased risk of cryptococcal meningitis or death. Similar to those with a CD4 < 100 cell/mm3, systematic CrAg screening may reduce morbidity and mortality in PLWH with CD4 100-200 cells/mm3.

Tuberculosis-related stigma among adults presenting for HIV testing in KwaZulu-Natal, South Africa.

BACKGROUND: Tuberculosis (TB)-related stigma presents a major barrier to care of persons with TB through its impact on treatment initiation and retention in care. This is particularly challenging in settings with high prevalence of both TB and HIV where fear of HIV/AIDS can amplify stigma surrounding TB. The purpose of this study was to validate a TB stigma scale for use among persons presenting for outpatient HIV screening in the Umlazi township of South Africa and evaluate factors associated with TB-related stigma in this high HIV burden setting. METHODS: In this cross-sectional study, we measured TB-related stigma in adults prior to HIV testing using a 12-item scale designed to assess experienced and felt TB-related stigma. RESULTS: Among 848 adults, mean age was 32 years, 54% were male, and the median TB stigma score was 19 of 36 (interquartile range 15-23). We identified two factors in the stigma scale which had excellent reliability (Cronbach's alpha 0.85, 0.89). Persons with high TB stigma were more likely to be male (adjusted relative risk ratio [aRRR] 1.56, 95% confidence interval [CI] 1.11-2.28) and have accurate knowledge of TB transmission (aRRR 1.90, 95% CI 1.16-3.10) as compared to those with low stigma. Variables not significantly associated with stigma in the multivariate model included education, income, prior TB or HIV diagnoses, and depression. CONCLUSIONS: Male sex and TB knowledge were associated with higher TB stigma in an outpatient HIV clinic in a South African township. Identifying risk factors associated with stigma will be important to guide stigma reduction interventions.

Test and Treat TB: a pilot trial of GeneXpert MTB/RIF screening on a mobile HIV testing unit in South Africa.

BACKGROUND: Community-based GeneXpert MTB/RIF testing may increase detection of prevalent TB in the community and improve rates of TB treatment completion. METHODS: We conducted a pilot randomized trial to evaluate the impact of GeneXpert screening on a mobile HIV testing unit. Adults (≥18y) underwent rapid HIV testing and TB symptom screening and were randomized to usual mobile unit care (providing sputum on the mobile unit sent out for GeneXpert testing) or the "Test & Treat TB" intervention with immediate GeneXpert testing. Symptomatic participants in usual care produced sputum that was sent for hospital-based GeneXpert testing; participants were contacted ~ 7 days later with results. In the "Test & Treat TB" intervention, HIV-infected or HIV-uninfected/TB symptomatic participants underwent GeneXpert testing on the mobile unit. GeneXpert+ participants received expedited TB treatment initiation, monthly SMS reminders and non-cash incentives. We assessed 6-month TB treatment outcomes. RESULTS: 4815 were eligible and enrolled; median age was 27 years (IQR 22 to 35). TB symptoms included cough (5%), weight loss (4%), night sweats (4%), and fever (3%). 42% of eligible participants produced sputum (intervention: 56%; usual care: 26%). Seven participants tested GeneXpert+, six in the intervention (3%, 95% CI 1%, 5%) and one in usual care (1%, 95% CI 0%, 6%). 5 of 6 intervention participants completed TB treatment; the GeneXpert+ participant in usual care did not. CONCLUSION: GeneXpert MTB/RIF screening on a mobile HIV testing unit is feasible. Yield for GeneXpert+ TB was low, however, the "Test & Treat TB" strategy led to high rates of TB treatment completion. TRIAL REGISTRATION: This study was registered on November 21, 2014 at ClinicalTrials.gov ( NCT02298309 ).

Contraception, HIV Services, and PrEP in South African Hair Salons: A Qualitative Study of Owner, Stylist, and Client Perspectives.

Women experience challenges engaging with the healthcare system, but frequently utilize hair salons; these are promising venues for family planning and HIV prevention services. Our objective was to assess the acceptability of nurse-offered contraceptive and PrEP services at hair salons in Durban, South Africa. We interviewed salon owners (N = 10) and clients (N = 42) and conducted focus groups with hair stylists (N = 43 stylists; 6 focus groups across five hair salons) to explore barriers and facilitators to providing contraception and PrEP in salons. After developing a codebook, we performed content analysis to identify themes within each conceptual area; 10% of transcripts were coded by two coders to ensure reliability. Content was analyzed according to the following categories: (1) facilitators of and (2) barriers to utilizing these services, and (3) factors to consider for program implementation. Participants identified convenience and female-oriented, supportive atmosphere as facilitators to offering HIV and contraceptive services in salons. Owners and stylists noted that establishing legitimacy was important for program success, including providing promotional pamphlets and employing nurses. Clients cited privacy concerns surrounding HIV testing in a public space as a significant barrier to using these services. Overall, participants were enthusiastic about the program. Convenience and a conducive environment were noted as facilitators to receiving health services in the hair salon; attention will have to be directed to establishing privacy and program legitimacy. Hair salons represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection.

Depression and Anxiety as Risk Factors for Delayed Care-Seeking Behavior in Human Immunodeficiency Virus-Infected Individuals in South Africa.

Background: Facility- and community-based efforts to improve human immunodeficiency virus (HIV) testing in sub-Saharan Africa may benefit from understanding how mental health influences HIV care-seeking behavior. Methods: We conducted a study among adults presenting for HIV testing in the Umlazi township of South Africa. Prior to testing, we measured depression using the 9-item Patient Health Questionnaire and anxiety using the 7-item Generalized Anxiety Disorder scale. We categorized patients as delayed presenters (presenting to clinic >3 months after first HIV-positive test), late testers (presenting within 3 months of diagnosis with a CD4 count ≤200 cells per µL), or neither. We used multinomial logistic regression adjusting for sociodemographic and behavioral characteristics to determine the effects of depression and anxiety on HIV care-seeking behavior. Results: Among 1482 HIV-infected adults, 59% were female and mean age was 33 years. The prevalence of depression in the cohort was 33% and anxiety was 9%. In adjusted models, mild to moderate depression was not associated with delayed presentation or late testing. HIV-infected adults with severe depression had 3.6 greater odds (95% confidence interval [CI], 1.2-10.2) of delayed presentation and 2.2 greater odds (95% CI, 1.01-4.8) of late testing compared with those without depression. Individuals with generalized anxiety had 2.3 greater odds (95% CI, 1.3-4.2) of delayed presentation compared with those without anxiety. Conclusions: Severe depression was associated with delayed presentation and late testing, while anxiety was associated only with delayed presentation. Screening for mental health services may improve antiretroviral therapy initiation and linkage to care following HIV testing.

An assessment on the implementation of same day antiretroviral therapy initiation in eThekwini clinics, KwaZulu-Natal, South Africa.

The World Health Organization (WHO) recommends same-day initiation (SDI) of antiretroviral therapy (ART) for all individuals diagnosed with HIV irrespective of CD4+ count or clinical stage. Implementation of program is still far from reaching its goals. This study assessed the level of implementation of same day ART initiation. A longitudinal study was conducted at four primary healthcare clinics in eThekwini municipality KwaZulu-Natal. Data was collected between June 2020 to October 2020 using a data extraction form. Data on individuals tested HIV positive, number of SDI of ART; and clinicians working on UTT program were compiled from clinic registers, and Three Interlinked Electronic Registers.Net (TIER.Net). Non-governmental organisations (NGO) supporting the facility and services information was collected. Among the 403 individuals who tested HIV positive, 279 (69.2%) were initiated on ART on the same day of HIV diagnosis from the four facilities. There was a significant association between health facility and number of HIV positive individuals initiated on SDI (chi-square=10.59; P-value=0.008). There was a significant association between facilities with support from all NGOs and ART SDI (chi-square=10.18; P-value=0.015. There was a significant association between staff provision in a facility and SDI (chi-square=7.51; P-value=0.006). Urban areas clinics were more likely to have high uptake of SDI compared to rural clinics (chi-square=11,29; P-value=0.003). Implementation of the Universal Test and Treat program varies by facility indicating the need for the government to monitor and standardize implementation of the policy if the program is to yield success.

Uptake of community- versus clinic-based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa.

INTRODUCTION: South Africa's government-led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community- or clinic-based pick-up points intended to increase convenience and decongest clinics. To understand CCMDD pick-up point use among people living with HIV, we evaluated factors associated with uptake of a community- versus clinic-based pick-up point at CCMDD enrolment. METHODS: We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non-pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu-Natal. We identified factors associated with community-based pick-up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self-perceived barriers to care, self-efficacy, HIV-related discrimination, and perceived benefits and challenges of CCMDD. RESULTS AND DISCUSSION: Among 1521 participants, 67% were females, with median age 36 years (IQR 30-44). Uptake of a community-based pick-up point was associated with younger age (aOR 1.18 per 10-year decrease, 95% CI 1.05-1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10-1.83) versus being unemployed, no self-perceived barriers to care (aOR 1.42, 95% CI 1.09-1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03-2.01) or 40 (aOR 1.91, 95% CI 1.39-2.63) versus 10-35 on the self-efficacy scale, where higher scores indicate greater self-efficacy. Additional factors included more convenient pick-up point location (aOR 2.32, 95% CI 1.77-3.04) or hours (aOR 5.09, 95% CI 3.71-6.98) as perceived benefits of CCMDD, and lack of in-clinic follow-up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30-8.31). CONCLUSIONS: Uptake of community-based pick-up was associated with younger age, full-time employment, and systemic and structural factors of living with HIV (no self-perceived barriers to care and high self-efficacy), as well as perceptions of CCMDD (convenient pick-up point location and hours, lack of in-clinic follow-up). Strategies to facilitate community-based pick-up point uptake should be tailored to patients' age, employment, self-perceived barriers to care and self-efficacy to maximize the impact of CCMDD in decongesting clinics.

Depression and anxiety as barriers to art initiation, retention in care, and treatment outcomes in KwaZulu-Natal, South Africa.

BACKGROUND: Since mental health may influence HIV care among people living with HIV (PLHIV), we sought to evaluate the impact of anxiety and depression on ART initiation and HIV-related outcomes. METHODS: We conducted a prospective cohort study of PLHIV in the Umlazi Township of KwaZulu-Natal, South Africa. We measured depression using the Patient Health Questionnaire (PHQ-9) and anxiety using the Generalized Anxiety Disorder (GAD-7) scale, both of which have been validated in sub-Saharan Africa, among all patients prior to receiving a positive HIV test. We then followed those who tested HIV+ for 12 months to determine their time to ART initiation, missing clinic visits or refills, retention in care, hospitalization, and death. We used logistic regression models, adjusted for socio-demographic characteristics such as age and sex, to examine the effects of baseline measures of depression and anxiety on ART initiation and HIV treatment outcomes. FINDINGS: Among 2,319 adult PLHIV, mean age was 33 years (SD=9.3 years), 57% were female, and baseline median CD4 count was 317 cells/mm3 (IQR=175-491 cells/mm3). In univariate analyses, depression was associated with slower rates of ART initiation. In adjusted models, PLHIV with depression had lower odds of initiating ART within 90 days of HIV testing (aOR=0.60, 95% CI=0.46, 0.79, p<0.01), and lower odds of being retained in care (aOR=0.77, 95% CI=0.60, 0.99, p = 0.04). By the end of the 12-month study period, odds of ART initiation among PLHIV with depression were higher than the first 90 days but still significantly lower compared to those without depression (aOR=0.72, 95% CI=0.52, 0.99, p = 0.04). Among PLHIV who initiated ART, depression was associated with a lower odds of missing clinic visits (aOR=0.54, 95% CI= 0.40, 0.73, p<0.01). Anxiety was strongly correlated with depression (r = 0.77, p<0.01) and had similar effects on HIV-related outcomes. INTERPRETATIONS: The presence of depression is a significant barrier to ART initiation and retention in care among adult PLHIV in South Africa. Mental health screenings around the time of HIV testing may help improve linkage and HIV-related outcomes. FUNDING: This work was supported by the Infectious Disease Society of America Education & Research Foundation and National Foundation for Infectious Diseases (PKD); Massachusetts General Hospital Executive Committee on Research (PKD); the Harvard University Center for AIDS Research [AI060354] (PKD); and the National Institute of Allergy and Infectious Diseases [AI108293, AI143351] (PKD). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or other funding agencies.

Laboratory Reflex and Clinic-Based Point-of-Care Cryptococcal Antigen Screening for Preventing Meningitis and Mortality Among People Living With HIV.

INTRODUCTION: Cryptococcosis remains a leading cause of meningitis and mortality among people living with HIV (PLHIV) worldwide. We sought to evaluate laboratory-based cryptococcal antigen (CrAg) reflex testing and a clinic-based point-of-care (POC) CrAg screening intervention for preventing meningitis and mortality among PLHIV in South Africa. METHODS: We conducted a prospective pre-post intervention study of adults presenting for HIV testing in Umlazi township, South Africa, over a 6-year period (2013-2019). Participants were enrolled during 3 phases of CrAg testing: CrAg testing ordered by a clinician (clinician-directed testing, 2013-2015); routine laboratory-based CrAg reflex testing for blood samples with CD4 ≤100 cells/mm3 (laboratory reflex testing, 2015-2017); and a clinic-based intervention with POC CD4 testing and POC CrAg testing for PLHIV with CD4 ≤200 cells/mm3 with continued standard-of-care routine laboratory reflex testing among those with CD4 ≤100 cells/mm3 (clinic-based testing, 2017-2019). The laboratory and clinical teams performed serum CrAg by enzyme immunoassay and lateral flow assay (Immy Diagnostics, Norman, OK). We followed up participants for up to 14 months to compare associations between baseline CrAg positivity, antiretroviral therapy and fluconazole treatment initiation, and outcomes of cryptococcal meningitis, hospitalization, and mortality. RESULTS: Three thousand one hundred five (39.4%) of 7877 people screened were HIV-positive, of whom 908 had CD4 ≤200 cells/mm3 and were included in the analyses. Laboratory reflex and clinic-based testing increased CrAg screening (P < 0.001) and diagnosis of CrAg-positive PLHIV (P = 0.011). When compared with clinician-directed testing, clinic-based CrAg testing showed an increase in the number of PLHIV diagnosed with cryptococcal meningitis (4.5% vs. 1.5%; P = 0.059), initiation of fluconazole preemptive therapy (7.2% vs. 2.5%; P = 0.010), and initiation of antiretroviral therapy (96.8% vs. 91.3%; P = 0.012). Comparing clinic-based testing with laboratory reflex testing, there was no significant difference in the cumulative incidence of cryptococcal meningitis (4.5% vs. 4.1%; P = 0.836) or mortality (8.1% vs. 9.9%; P = 0.557). CONCLUSIONS: Laboratory reflex and clinic-based CrAg testing facilitated the diagnosis of HIV-associated cryptococcosis and fluconazole initiation but did not reduce cryptococcal meningitis or mortality. In this nonrandomized cohort, clinical outcomes were similar between laboratory reflex testing and clinic-based POC CrAg testing.