Peer-to-Peer Chain Recruitment for Enrolling Young South African Women into an HIV Pre-exposure Prophylaxis (PrEP) Intervention Study: How Did It Perform?

Peer-to-peer chain recruitment has been used for descriptive studies, but few intervention studies have employed it. We used this method to enroll sexually active women ages 18 to 25 into an online Pre-Exposure Prophylaxis (PrEP) information and motivation intervention pilot in eThekwini (Durban), South Africa. Seeds (N = 16) were recruited by study staff and randomized to Masibambane, Ladies Chat, a Gender-Enhanced group-based WhatsApp Workshop (GE), or Individual-Access (IA), a control condition that provided participants with online information/motivation materials only. Each seed could recruit up to three women to participate in the same study condition, with an incentive for each enrolled woman; participants in subsequent waves could choose to recruit or not. We evaluated if peer-to-peer recruitment was self-sustaining and resulted in enrolling women who, in subsequent waves, had less contact with the health care system and less knowledge about PrEP than the initial seeds. Over three recruitment waves beyond the seeds, 84 women were recruited. Almost 90% of women became recruiters, with each recruiting on average 1.90 women and 1.26 eligible enrolled women. The approach was successful at reaching women with less education but not women with less health system contact and PrEP knowledge across waves. IA participants had a slightly higher, though non-significantly different, percentage of individuals who became Peer Health Advocates (PHAs) than GE participants and, on average, they recruited slightly more women who enrolled. Our findings demonstrated that peer-to-peer recruitment is a feasible and self-sustaining way to recruit SA young women into a PrEP intervention study.

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

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

Social resources, resilience, and sexual health among South African adolescent girls and young women: findings from the HERStory study.

Socioecological factors, including social resources, influence South African adolescent girls' and young women's sexual health. Few studies have explored how these multi-level social factors relate to both resilience and sexual health in this community. This study examines if social resources mediate associations between resilience and two sexual health outcomes. A weighted-sample of 7,237 South African girls and young women (aged 15-24 years) completed a cross-sectional survey conducted from 2017 to 2018 which included a validated measure of resilience, along with measures of sexual health and social resources. Using multivariable logistic regression models and bootstrapping methods, two types of social resources were assessed as potential mediators. Increased resilience was negatively associated with early sexual debut and engagement in transactional sex. Social support mediated associations between resilience and engagement in transactional sex but did not mediate associations between resilience and early sexual debut. Of all the types of social support measured, social support from a special person mediated the largest proportion of the association between resilience and transactional sex. Examining underlying social and community dynamics related to resilience and sexual health can guide the development of future contextually-relevant programming and policies.

Disparity between adolescents' health information needs and the information received in a middle-income country.

AIM: This study sought to identify adolescents' health information sources and determine the gap between what adolescents want to hear and what they actually hear from their healthcare providers (HCPs), a proxy for unmet health needs. METHODS: A cross-sectional study was conducted in four high schools conveniently selected in Jamaica to ensure adequate representation in rural and urban locales. Adolescents 11-19 years old with relevant assent/consent completed a paper-based self-administered questionnaire. Questions were adapted from the Young Adult Health Care Survey to determine proportion of adolescents receiving confidential care, the level of counselling offered and difference between location and unmet needs. RESULTS: Adolescents acknowledged multiple sources of information, with urban adolescents reporting television, radio and parents as sources more frequently than in rural setting (p < 0.05). They most commonly wanted to discuss weight management (n = 308, 64.2%), nutrition (n = 418, 87.1%), exercise (n = 361, 75.2%); and emotions they are experiencing (n = 246, 51.3%). Unmet needs differed by location; more rural than urban adolescents found that their desire to discuss school performance (p < 0.05) and sexual orientation (p < 0.05) was unmet, while more urban youth felt their need for discussions about STIs was unmet (p < 0.05), when compared to their rural counterparts. CONCLUSION: This study highlights that while there is some access to health information in Jamaica, especially via television, radio and internet, the needs of the adolescent population remain unmet. HCPs need to employ a patient-centred approach where confidentiality is established and screening is done for unmet needs in an effort to optimize health outcomes.

Sexual Prejudice and Comfort to Provide Services to Men Who Have Sex with Men Among HIV Healthcare Workers in Western Kenya: Role of Interpersonal Contact.

Sexual minority men living in Africa, where many countries criminalize same-sex behavior, are vulnerable to HIV and experience significant barriers to HIV care. Sexual prejudice in healthcare settings is a key contributor to these barriers. Building on social psychological models of prejudice and interpersonal contact at the clinic, we examined the associations between healthcare workers' sexual prejudice and their comfort to provide care to MSM, and assessed the moderating role of workers' prior interpersonal contact with MSM. A cross-sectional survey of 147 healthcare workers varying in level of training and expertise working in HIV care organizations was conducted in western Kenya. Sexual prejudice was negatively associated with comfort to provide care to MSM. Prior interpersonal contact with MSM moderated the association between sexual prejudice and comfort to provide care to MSM among nurses/counselors, such that those with low prior contact and high sexual prejudice were the most uncomfortable providing care to MSM. Interventions are needed to address sexual prejudice and encourage positive forms of interpersonal contact with MSM, especially with nurses and counselors who might have more and varied patient interactions, to improve access to the continuum of HIV prevention and care for MSM in Kenya.

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

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

Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings.

Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.

Exploring the why: risk factors for HIV and barriers to sexual and reproductive health service access among adolescents in Nigeria.

BACKGROUND: Early sexual debut, low educational attainment, history of rape and transactional and intergenerational sex have been associated with HIV infection among Nigerian adolescents, especially females. We sought to understand the "why", and how to mitigate against these determinants and barriers to addressing adolescent sexual and reproductive health (SRH) and HIV prevention needs. METHODS: This qualitative study generated data from 49 focus group discussions with male and female adolescents living with and without HIV, healthcare workers, members of civil society organizations working with young people, and parents of adolescents living with HIV. Participants were recruited from all six geopolitical zones in Nigeria. Data was analysed with ATLAS.ti software. Hermeneutic units were created, and codes developed from focus group transcripts. Network View Manager was used to create maps of codes, memos and quotations, and relevant quotes were retrieved from transcripts. RESULTS: Four major themes were identified, relating to individual, parental, community and government roles in reducing the risk of HIV and unplanned pregnancy among adolescents in Nigeria. Individual factors influencing sexual risk behaviours of adolescents include peer pressure, poor risk perception for HIV, and misconceptions about the efficacy of contraceptives and condoms. Respondents entrusted State responsibilities such as facilitation of HIV-affected adolescents' access to education, rather, to individuals, parents and the community; and placed the blame for rape on rape survivors. Findings also highlighted the inadequacy of health systems to address adolescents' needs for treatment of sexually transmitted infections and to provide appropriate education on secondary HIV prevention for those living with HIV. CONCLUSION: Rigorous studies are needed to understand dynamics between adolescents' risk behavior, HIV risk perception, parental roles in mitigating HIV risk in adolescents, and the role of communities and government in HIV prevention and treatment for adolescents in Nigeria.

Exploring the impact of BMI on body dissatisfaction and eating behaviors among Caribbean university women.

This study aimed to examine the role of BMI in body dissatisfaction and eating pathology among 570, Indo-Caribbean and Afro-Caribbean female university students. Participants, 18-59 years, completed self-reports on body image, weight perceptions and eating behaviors. Data analysis included: analysis of variance, multiple regression, and descriptive discriminant analyses. The majority (67.5%) expressed satisfaction with their bodies. Afro-Caribbean participants reported greater body satisfaction than Indo-Caribbean participants (F(2, 554) = 3.51, p = .031). As BMI increased, so too did body dissatisfaction and disordered eating (F(3, 535) = 19.92, p < .001). Participants with obesity reported more body dissatisfaction and disordered eating (M - F(18, 254 384.046) = 1.580, p = .056). BMI should be considered when examining body dissatisfaction and eating pathology among Caribbean female university students, particularly among those with overweight/obesity. In the Caribbean, previous studies indicate an appreciation for the overweight or 'fluffy' female body ideal but more recently the thick ideal, particularly among Black women. More clarity is needed on the current ideal endorsed by BMI and ethnic categories among Caribbean females.Level of evidenceLevel V: cross-sectional descriptive study.

Physical activity and disordered eating behaviours: Are Caribbean adolescents at risk?

Excessive physical activity (PA) has been linked to increased risk for disordered eating behaviours and eating disorders. This study investigates the relationship between PA and disordered eating behaviours and attitudes (DEBAs) among Jamaican adolescents. This cross-sectional study included 521 adolescents, 12-19 years. Anthropometric measurements were collected, and adolescents completed questionnaires on disordered eating behaviours (EAT-26), physical activity, self-esteem and affect. Associations were assessed using sex-specific mixed-effect linear and logistic regression models. Participants reported exercising an average of 3 days per week. Adolescents who exercised for a longer duration had greater odds of having elevated EAT-26 scores (at least 1 hour-OR = 2.04; 95% CI = 1.03, 4.06; p = .042), while a higher exercise frequency among males (3-5 days per week) was protective against DEBAs (OR 0.38; 95% CI = 0.16, 0.88; p = .025). Female adolescents reported higher prevalence of elevated EAT-26 scores than males (p < .01). Increased negative affect increased odds of an elevated EAT-26 score. Exercise duration and frequency play a role in disordered eating behaviours in Jamaican adolescents and vary by gender. Our findings have implications for weight management interventions and policies, encouraging healthcare providers to monitor PA levels as well as negative affect in adolescents who display disordered eating behaviours.

Mindfulness-Based College: A Stage 1 Randomized Controlled Trial for University Student Well-Being.

OBJECTIVE: To evaluate effects of a mindfulness-based program, adapted to the young adult life course stage (age, 18-29 years), named Mindfulness-Based College (MB-College). The primary outcome was a young adult health summary score, composed of key health risk factors: body mass index, physical activity, fruit and vegetable intake, alcohol consumption, stress, loneliness, and sleep duration. Secondary outcomes were hypothesized self-regulation mechanisms, including attention control, interoceptive awareness, and emotion regulation. METHODS: This was a stage 1 randomized controlled trial of the 9-week MB-College program (n = 47) versus enhanced usual care control (n = 49) including students from three universities. Assessments were at baseline, during the beginning of the college term when stress is typically lower, and at MB-College completion (3-month follow-up), when term-related stress is typically higher. Intention-to-treat, linear regression analyses estimated the marginal effects of MB-College versus control on the outcomes. RESULTS: MB-College participants (mean age = 20 years, 68% female, 37% racial minorities) demonstrated improved health summary scores at follow-up compared with control participants whose health summary scores worsened (marginal effect for MB-College versus control = 0.23; p = .004). Effects on loneliness were pronounced (marginal effect = -3.11 for the Revised University of Los Angeles Loneliness Scale score; p = .03). Secondary analyses showed significant impacts of MB-College on hypothesized self-regulation mechanisms (e.g., Sustained Attention to Response Task correct no-go percent, p = .0008; Multidimensional Assessment of Interoceptive Awareness, p < .0001; Center for Epidemiologic Studies-Depression scale, p = .03). CONCLUSIONS: Findings of this early stage clinical trial suggest that MB-College may foster well-being in young adults.Trial Registration: NCT03124446.

Systematic review of research focused on pregnant and postpartum women living with HIV: A relational ethics perspective.

Historically, maternal HIV research has focused on prevention of mother-to-child transmission and child outcomes, with little focus on the health outcomes of mothers. Over the course of the HIV epidemic, the approach to including pregnant women in research has shifted. The current landscape lends itself to reviewing the public health ethics of this research. This systematic review aims to identify ethical barriers and considerations for including pregnant and postpartum women living with HIV in treatment adherence and retention research. We completed a systematic literature review following PRISMA guidelines with analysis using a relational ethics perspective. The included studies (n = 7) identified ethical barriers related to (a) women research participants as individuals, (b) partner and family dynamics, (c) community perspectives on research design and conduct, and (d) policy and regulatory implications. These broader contextual factors will yield research responsive to, and respectful of, the needs of pregnant and postpartum women living with HIV. While current regulatory and policy environments may be slow to change, actions can be taken now to foster enabling environments for research. We suggest that a relational approach to public health ethics can best support the needs of pregnant and postpartum women living with HIV; acknowledging this population as systematically disadvantaged and inseparable from their communities will best support the health of this population.

ECD - Pregnancy outcomes of a birth cohort. Are adolescent mothers really at more risk?

This sub-study within the JAKIDS longitudinal cohort study compares medical and psychosocial outcomes of pregnancy in younger adolescent mothers (<16 years), older adolescent mothers (16-19 years) and adult mothers (>19 years) in Jamaica. Participants were recruited from July to September 2011 and included 9521 mother-infant dyads; mean maternal age 26.0 years (SD 6.8). Adolescent mothers represented 19.1% (n = 1822) of the sample - 1704 older adolescent mothers (17.9%) and 118 younger adolescent mothers (1.2%). Participants completed interviewer-administered questionnaires regarding their sexual and reproductive health history, feelings about the current pregnancy, and presence of anxious and depressive symptoms. Data on delivery and perinatal and neonatal outcomes were extracted from hospital charts. Younger adolescent mothers were more likely to deliver preterm (p < 0.001) and low birth weight infants (p < 0.001) than older adolescent and adult mothers. Younger adolescent mothers had lower levels of antenatal anxiety regarding the pregnancy and its outcome (p < 0.001) while prevalence of elevated depressive symptoms antenatally (EPDS ≥11) was similar across age groups. Older adolescent mothers with significant depressive symptoms had increased odds of preterm delivery. These findings call for close antenatal monitoring of younger adolescent mothers and highlight the need for psychological services for all mothers.

"I did not plan that is what hurts": Pregnancy intentions and contraceptive use among pregnant young women in KwaZulu-Natal, South Africa.

Unintended pregnancy impacts many young women in South Africa, and rates of consistent contraceptive use among this population are suboptimal. Limited empirical work has investigated reasons for inconsistency between pregnancy intention and contraceptive use behaviour with data collected during pregnancy. We explored pregnancy intentions and discordance between intentions and contraceptive use prior to conception among young pregnant women in KwaZulu-Natal, South Africa. In-depth qualitative interviews were conducted with 35 women during pregnancy (mean age = 19.3; range = 18-21) in 2011 and 2012. Data were analysed using content analysis. All participants reported unintended pregnancies; almost half were not using contraception near conception. Reasons for not intending to become pregnant spanned personal, social, health, and economic domains. Participants living with HIV (n = 13) expressed specific concerns related to impacts of pregnancy on HIV disease management and fear of transmission of HIV to the infant. Discordance between pregnancy intentions and contraceptive use prior to conception was attributed to personal, social, health and structural domains. Findings indicate a need for interventions that address barriers to contraceptive use in order to minimise unintended pregnancy and support safe, desired pregnancies among young women.

"This is My Life We are Talking About": Adaptive Strategies for HIV Care Retention and Treatment Adherence Among Postpartum Women Living with HIV in Cape Town, South Africa.

INTRODUCTION: Retaining postpartum women living with HIV in ongoing care is critical for the health of the mother-child dyad but low adherence to antiretroviral therapy (ART) and retention in HIV care are a global concern. This issue is particularly salient in South Africa, where approximately 50% of women fall out of the care cascade by 6 months postpartum. The purpose of this secondary analysis is to understand the strategies that women use to navigate HIV care during the postpartum period. METHODS: This study was conducted in Gugulethu, in Cape Town, South Africa. In-depth interviews were conducted with 21 study participants at 18-months postpartum. Participants were interviewed about their perceptions and experiences of their postpartum HIV care, and barriers and facilitators to their adherence and retention. RESULTS: All participants reported using care navigation strategies across a spectrum of individual, interpersonal and structural levels to remain retained in care and adherent to ART. Participants expressed the importance of individual empowerment and knowledge of treatment benefits for their HIV care. Interpersonal relationships were discussed as a pathway to access both psychosocial and tangible support. Participants described overcoming structural barriers to care through creative problem solving and identified opportunities for care delivery improvement. DISCUSSION: Participants described a wide range of overlapping and interconnected care navigation strategies. Consistent with the assets model, participants discussed their own capacity and that of their communities to engage in lifelong HIV care. Better understanding of potentially successful individual care navigation strategies should guide future intervention work. TRIAL REGISTRATION: ClinicalTrials.gov NCT01933477.

'I feel like a person has a right to use a product to protect themselves ': a qualitative study of the risk-benefit calculus on women's contraceptive use and choice.

Background Reducing pregnancy risk requires a multidimensional approach to sexual and reproductive health product development. The purpose of this analysis is to identify, compare, and contrast women's pre-use beliefs and attitudes about three different forms of contraceptives: intravaginal rings; spermicide in conjunction with condoms; and oral contraceptive pills - and explore how those attitudes and beliefs, along with actual method-use experience, may affect potential choices in contraceptive method moving forward. The relationship of beliefs and attitudes to their risk-benefit calculations when using these methods was also considered.? METHODS: Women used one or more contraceptive methods, each for 3-6 months. Qualitative data from individual in-depth interviews completed after each 3-month use period were analysed using a summary matrix framework. Data were extracted and summarised into themes. Each woman's experiences were compared among the methods she used; comparisons were also made across participants. RESULTS: The data consist of 33 90-120 min in-depth qualitative interviews from 16 women aged 20-34 years, in which they discussed various elements of their method use experience. One prominent theme was identified: the influence of attitudes and beliefs on the risk-benefit calculus. There were six key elements within the theme: pregnancy prevention; dosing and the potential for user error; side-effects; familiarity; disclosure; and sexual partnerships. CONCLUSIONS: Women weighed perceived risks and benefits in their decision-making and, ultimately, their contraception choices. Understanding women's beliefs and attitudes that contribute to a calculation of risk-benefit can inform the development of sexual and reproductive health products.

Disordered eating behaviours and attitudes among adolescents in a middle-income country.

PURPOSE: Adolescent-disordered eating behaviours and attitudes (DEBA) are noted to be increasing in prevalence internationally. The aim of this study was to explore the DEBAs among Jamaican adolescents and identify those adolescents most at risk. METHODS: 521 high school participants (females, n = 292), ages 11-19 years, completed measures assessing socio-demographic factors, self-esteem, symptoms of anxiety and depression, behavioural factors, and anthropometry. Weight-related behaviours and attitudes were explored using the Eating Attitudes Test (EAT-26). RESULTS: Thirty-one percent of participants reported engaging in at least one disordered eating behaviour, with bingeing as the most common. Female participants had significantly higher mean body mass index (p < 0.01) and mean EAT-26 score (p < 0.05) compared to males. Adolescents with EAT-26 score ≥ 20 were more desirous of being thinner (p < 0.01) and having a lighter skin complexion (p < 0.05). A greater proportion of adolescents with an EAT-26 score ≥ 20 had engaged in self-harm (p < 0.05), had smoked cigarettes (p < 0.05), had been sexually active (p < 0.01), and gave a history of sexual abuse (p < 0.01). Adolescents with overweight/obesity reported higher use of chemical weight manipulation (laxatives, diuretics, and diet pills) (p = 0.01). CONCLUSIONS: Our data are consistent with the global figures showing both male and female adolescents endorsing disordered eating behaviours and attitudes (DEBAs). While this study highlights weight and shape dissatisfaction and associated DEBAs, it also raises the concern of an association with skin bleaching and elevated EAT-26 scores among Jamaican adolescents. LEVEL OF EVIDENCE: Level V: cross-sectional descriptive study.

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

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

The Role of Gender in Patient-Provider Relationships: A Qualitative Analysis of HIV Care Providers in Western Kenya with Implications for Retention in Care.

The disproportionate burden of HIV among women in sub-Saharan Africa reflects underlying gender inequities, which also impact patient-provider relationships, a key component to retention in HIV care. This study explored how gender shaped the patient-provider relationship and consequently, retention in HIV care in western Kenya. We recruited and consented 60 HIV care providers from three facilities in western Kenya affiliated with the Academic Model Providing Access to Healthcare (AMPATH). Trained research assistants conducted and audio recorded 1-h interviews in English or Swahili. Data were transcribed and analyzed in NVivo using inductive thematic analysis. Gender constructs, as culturally defined, emerged as an important barrier negatively impacting the patient-provider relationship through three main domains: (1) challenges establishing clear roles and sharing power due to conflicting gender versus patient/provider identities, (2) provider frustration over suboptimal patient adherence resulting from gender-influenced contextual barriers, and (3) negative provider perceptions shaped by differing male and female approaches to communication. Programmatic components addressing gender inequities in the health care setting are urgently needed to effectively leverage the patient-provider relationship and fully promote long-term adherence and retention in HIV care.

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

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