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We have only just begun to understand the long-term impact of living with chronic HIV on health and livelihood after a decade of widespread access to treatment in southern Africa. This paper explores health and well-being, disability, and livelihood dynamics among people living with HIV (PLHIV) in a public healthcare setting in South Africa. We undertook a cross-sectional survey among a cohort of 1042 people on ART and explored associations between socio-demographic characteristics, treatment adherence, measures of disability (functional and activity limitations), livelihood resources (capitals) and outcomes, including food security, and exposure to livelihood shocks. A range of dynamic relationships relevant for decision-makers is evident. Age, gender, and marital status all had significant associations with levels of livelihood capitals and outcomes. Those who had been on ART for longer periods of time also had significantly higher aggregate livelihood capital. This was particularly driven by social and financial capital. Livelihoods are built within specific social and health contexts. Of particular importance is that the resources drawn on to build a livelihood differ significantly between men and women, and that different forms of disability also have gender-specific pathways in influencing livelihood and livelihood outcomes. Our results support the need for a gender-sensitive approach to supporting the well-being and livelihoods of PLHIV. Of equal importance is an approach that considers more comprehensively the new experiences of comorbidities and disabilities that may occur with a long life on ART. [ABSTRACT FROM PUBLISHER]

Risky sexual behaviour in PLWHA on antiretroviral therapy threatens both prevention and treatment efforts, but disclosure promises to support safer sexual practices. This paper investigates the association between HIV self-disclosure and consistent condom use in a cohort of public sector patients on antiretroviral (ARV) treatment. Using data from the FEATS cohort study, logistic regression analysis shows that knowledge of your partner's HIV status is positively associated with consistent condom use (OR 2.73, 95% CI 1.37-5.43, p = 0.004) and so too mutual HIV disclosure (OR 3.38, 95% CI 1.60-7.18, p = 0.001). Prevention and treatment programmes, through couple HIV counselling and testing (CHCT) and other assistance programmes, should focus on supporting the mutual disclosure of HIV status among PLWHA on ARV treatment. [ABSTRACT FROM AUTHOR]

Teaching is one of the most stressful occupations, with high stress and burnout levels of teachers necessitating intervention. This is especially relevant for South African teachers tasked with additional responsibilities of dealing with HIV/AIDS issues, as well as attending to normal curricula duties. A burnout prevention intervention, based on Paulo Freire’s adult educational approach, using transpersonal psychology techniques, was introduced to HIV/AIDS coordinator teachers (n = 27) at high-risk schools in the Western Cape, South Africa, who attended six three-hour weekly workshops. This paper presents the bottom-up thematic analyses of the group, as well as individual global analysis (n = 10) of the qualitative data, derived from focus group interviews and workshop evaluations after the intervention, providing insights into the experiences of workshop participants and their teaching contexts. The mind map of one participant is illustrated. The findings of the study confirmed that transpersonal practices (TP) presented in psychoeducation workshops were helpful in mediating stress and burnout in the work and personal contexts of teachers dealing with HIV/AIDS. TP offer practical applications of right brain emotional and social intelligence practices that could be incorporated into care and wellness school programmes for teachers vulnerable to stressors related to HIV/AIDS. [ABSTRACT FROM PUBLISHER]

In order to achieve optimal benefits of antiretroviral therapy (ART), caregivers of children receiving ART are required to attend routine clinic visits monthly and administer medication to the child as prescribed. Yet, the level of adherence to these behaviours varies considerably in many settings. As a way to achieve optimal adherence in rural KwaZulu-Natal, caregivers are required to attend routine counselling sessions at HIV treatment clinics that are centred on imparting information, motivation, and behavioural skills related to medication administration. According to the information-motivation-behavioural skills model, information related to adherence, motivation, and behavioural skills are necessary and fundamental determinants of adherence to ART. The purpose of the study was to observe and document the content of adherence counselling sessions that caregivers attending rural clinics in KwaZulu Natal receive. We observed 25 adherence counselling sessions, which lasted on average 8.1 minutes. Counselling typically consisted of counsellors recording patient attendance, reporting CD4 count and viral load results to caregivers, emphasising dose times, and asking caregivers to name their medications and dosage amounts. Patients were seldom asked to demonstrate how they measure the medication. They were also not probed for problems regarding treatment, even when an unsuppressed VL was reported to a caregiver. This paper calls attention to the sub-optimal level of counselling provided to patients on ART and the urgent need to standardise and improve the training, support, and debriefing provided to counsellors. [ABSTRACT FROM PUBLISHER]

This paper presents the evaluation of post-programme outcomes of the ISIBINDI model, a community-based intervention to promote physical and psychosocial well-being of orphans and vulnerable children (OVC) in South Africa. A mixed methods quasi-experimental design was used to investigate the differences between former ISIBINDI participants (18 years and older) and a control group of similar background. ISIBINDI ex-participants at 12 sites (n= 427) and a control group of non-participants (n= 177) completed a questionnaire which explored level of education and employment, psychosocial well-being and HIV risk behaviour. Focus group discussions were conducted with various stakeholders. Ex-participants reported higher self-esteem and problem-solving abilities, family support and lower HIV risk behaviour than the control group. High levels of unemployment especially in rural areas resulted in unemployment of out-of-school OVC which creates new forms of vulnerability. The benefits of the programme may be compromised by the lack of community resources. An effective exit strategy is needed to contribute to financial independence of OVC after exiting the programme. [ABSTRACT FROM AUTHOR]

This paper reports on Kganya Motsha Adolescent Centre, an adolescent program specifically established to provide voluntary counseling and testing as well as management of HIV-positive young people in Soweto, South Africa. A retrospective cross-sectional analysis, using clinic records of young people accessing services from 2008 to 2012, was conducted. Of the 11,522 who tested, 7689 (67%) were females. The total number of HIV infections was 410, with an HIV prevalence of 3.6% (95% CI 3.2–3.9%). More females (332, 4% vs. 72, 2%;p< 0.0001) were HIV-infected than males. Of those testing HIV positive, 109 (26.5%) had a median CD4 cell count of 491 (IQR 345–686) cells/mm3. Only 12/410 individuals (2.9%) were eligible for antiretroviral treatment and 10 (2.4%) of those successfully received treatment. The program observed that young people testing HIV positive would not return for follow up blood specimens or confirmatory results. Future programs should consider innovative ways of retaining adolescents in care to reduce potential HIV transmissions that could lead to deteriorating health. [ABSTRACT FROM AUTHOR]

Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill-health while trying to maintain healthy relationships. Health-care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions associated with periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), and the attitudes and experiences of health-care providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed that personal, social, and relationship dynamics shape the reproductive decisions of PLHIV, and “unplanned” pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children; rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers toward safer conception. The adoption of a more participatory approach should be employed to equalize client–provider power dynamics and to ensure clients are more involved in decision-making about reproduction and conception. [ABSTRACT FROM AUTHOR]

Social networks and social support are important factors in medication adherence among people living with HIV (PLWH). Social networks can provide emotional, logistic, and material support leading to increased overall engagement in care. Certain populations of PLWH may have more limited access to social support, including those reentering community settings from correctional facilities. During periods of incarceration, social connections with family and friends may be frayed, reduced, or lost. This study, conducted in South Africa, explored the role of social support during community reentry among PLWH being released from correctional facilities. We conducted in-depth interviews with 41 community reentrants living with HIV. Qualitative analysis identified the challenges with establishing social support during reentry and the greater need for social support to remain engaged in HIV care in the community compared to in the correctional facility. These findings highlight challenges during community reentry and the importance of social support for these individuals. [ABSTRACT FROM AUTHOR]

Treatment among pYLHIV focuses on their physical health. However, they also experience depression and anxiety, compounded by developmental challenges and the stress of managing a chronic illness. However, limited services are available to help pYLHIV manage the emotional stressors of living with a stigmatized condition. Data are from 37 caregiver-child dyads in the VUKA EKHAYA study, in Durban, South Africa. Outcomes were self-esteem and stigma. Predictors included symptoms of depression and anxiety, and HIV treatment and transmission knowledge. Outcomes and predictors were standardized (mean: 0, standard deviation: 1). Pearson correlation, bivariate and multivariate associations between predictors and outcomes were examined. Self-esteem was negatively correlated with symptoms of anxiety (r=-0.5675; p<0.001) and depression (r=-0.6836; p<0.001), suggesting higher self-concept was correlated with fewer symptoms. In multivariate analyses, increased depressive and anxiety symptoms were associated with lower self-esteem, B=0.68 and 0.57, respectively. Higher depressive and anxiety symptoms connected to more internalized stigma B=0.38 and 0.34, respectively. Conversely, HIV knowledge was not related to self-esteem or stigma. HIV treatment and transmission knowledge are not enough to reduce stigma and improve the self-esteem of pYLHIV. Integrated mental and physical health care is needed to help pYLHIV manage psychological stressors that can mitigate their emotional wellbeing. [ABSTRACT FROM AUTHOR]

Intervention sustainability is a critical yet understudied aspect of implementation science research. To address this gap, we examined the sustainability of the Women's Health CoOp (WHC), a gender-focused, evidence-based, HIV and alcohol risk-reduction intervention, after an implementation trial. We used a mixed methods design consisting of questionnaires (n = 12), 3 focus groups (n = 11), and a semistructured interview conducted with interventionists implementing the WHC in clinics and substance use treatment programs in Cape Town, South Africa. Five out of 8 facilities implemented the WHC beyond the 6-month implementation period, and 4 were still implementing the WHC as of October 2019. Sustainability ranged from approximately 8 months to more than 3 years. At the most recent assessment, interventionists delivered the intervention to 0–20 participants in the past month. Qualitative findings indicate that long-term sustainability would require support from upper management, staff dedicated to the WHC, and booster trainings. The WHC was sustained postimplementation. Integrating the program into usual care would be feasible; however, human resources, financial, and institutional support would be needed for sustainability. To move implementation science forward, it is essential to determine sustainability beyond the presence and involvement of researchers. [ABSTRACT FROM AUTHOR]

First-time antiretroviral therapy (ART) initiators may be more vulnerable to poor ART adherence because they may be coping with a new HIV diagnosis, facing logistical challenges to accessing and adhering to ART for the first time, and have not yet developed support networks or the skills to support long-term adherence. We recruited 324 participants in two HIV clinics near Cape Town, South Africa. Sociodemographic/psychosocial factors were measured at baseline and self-reported adherence at the 6 month follow-up. We conducted multivariable regression to determine which baseline factors were associated with 6-month adherence. A better patient-clinic relationship score (OR: 1.08 [95% CI: 1.05–1.11]) was associated with higher adherence. A drug use problem (0.51 [0.29–0.87]), higher social isolation (0.93 [0.87–0.99]), and greater number of years living with HIV before initiating ART (0.92 [0.86–1.00]) were associated with adherence levels below 90%. Patient-clinic relationships and social support are key psycho-social factors in early adherence behavior. Reducing drug use problems through targeted screening and early intervention may improve ART adherence. [ABSTRACT FROM AUTHOR]

In South Africa, despite universal antiretroviral therapy (ART) availability, 60% of persons living with HIV (PLWH) ages 15–24 are not on treatment. This qualitative study aimed to identify barriers to ART initiation and the implications for a proposed community-based Youth Treatment Club to improve ART initiation for young PLWH in limited-resource, high HIV-prevalence communities in Cape Town, South Africa. Recruiting participants at community testing sites from 2018 to 2019, we conducted semi-structured interviews, informed by Social Action Theory (SAT), with 20 young adults, ages 18- to 24-years-old, newly diagnosed with HIV, along with 10 healthcare providers. Through systematic qualitative analysis, we found that young PLWH face barriers to treatment initiation in three SAT domains: (1) stigmatizing social norms (social regulation processes); (2) challenges coping with a new diagnosis (self-regulation processes); and (3) anticipated stigma in the clinic environment (contextual factors). Participants shared that a proposed community-based Youth Treatment Club for newly diagnosed youth would be an acceptable strategy to promote ART initiation. They emphasized that it should include supportive peers, trained facilitator support for counseling and education, and a youth-friendly environment. [ABSTRACT FROM AUTHOR]

Whilst the HIV response has made significant progress in increasing representation of adults affected by HIV, the meaningful inclusion of children and adolescents has lagged. But this may be a pivotal moment of change. We report on a decade of conducting adolescent advisory groups in South Africa, to reflect on youth advisory processes. Data was collected from 2008 to 2018 from adolescent advisors (n = 60) and researchers (n = 25), and included feedback sessions, social media, anonymous "post-boxes" and interviews. Findings include the value of adolescent involvement in multiple stages of research co-creation and engagement in policy processes, the need for a safe environment and supporting adolescents living in extreme vulnerability. We also discuss the reconfiguring of power and personal relationships, and logistical and financial needs of adolescent advisory groups. Findings suggest that adolescent co-creation of research is feasible, even with very vulnerable adolescents, although ethical considerations need to be carefully addressed. Benefits include increased methodological rigour, enhanced adolescent acceptability of research and the recalibration of research dynamics for the empowerment of their target beneficiaries. Future studies could benefit from meaningfully involving adolescents through youth advisory groups. [ABSTRACT FROM AUTHOR]

Uptake of HIV testing remains low among men in South Africa. As part of a trial, we assessed the acceptability of a theoretically derived and adapted tablet-based-application (EPIC-HIV1) in rural South Africa. We conducted 20 in-depth interviews with men aged ≥18 years and offered a tablet-based survey to all men aged ≥15 years who received EPIC-HIV1 (Sep-Dec 2018). We conducted a descriptive analysis of the survey and used Self-Determination Theory (SDT) to guide our thematic analysis. A total of 232/307 (75%) completed the survey, 55% of whom were aged 15–24 years. 96%[ CI: 92.8–98.2%; n = 223] found EPIC-HIV1 acceptable and 77% [95% CI: 71.8–82.6%; n = 179] found it user-friendly. 222 [96%] reported that EPIC-HIV1 motivated them to test; 83% (192/232) tested for HIV, of which 33% (64/192) were first time testers. Those who did not consent (n = 40) were more likely to have had an HIV-positive test result. Participants reported that the app boosted their confidence to test. However, they were unsure that the app would help them overcome barriers to test in local clinics. Given reach and usability, an adapted SDT male-tailored app was found to be acceptable and could encourage positive health-seeking behavioural change among men. [ABSTRACT FROM AUTHOR]

Lack of condom use by married or cohabiting couples in populations with high rates of HIV infection has become a significant public health issue. This study investigated whether an HIV risk-reduction intervention (RRI) would increase condom use when delivered to serodiscordant couples as a unit. Of the 62 couples that were screened, 30 serodiscordant couples were enrolled in the study, and randomized 2:1 to an immediate intervention-waitlist control study. The 12-week intervention focused on communication, problem-solving, and negotiation skills. Participants were assessed at baseline, three and six months after the intervention. The main outcome measures were consistent condom use, HIV seroconversion and fidelity to the programme. The use of condoms increased for both the intervention and control groups after receiving a 12-week RRI. Group comparisons showed a significant difference at three months, with a significantly higher mean proportion of condom-protected sex acts (p = 0.0119) between the control and intervention groups, the later showing an increase in condom use. No seroconversion was detected, and the overall retention rate of participants was 83.33%. Counselling heterosexual couples as a unit prompted an increase in condom use, but sustained condom use remains a challenge. [ABSTRACT FROM AUTHOR]

Structural interventions for HIV prevention are typically complex and evaluation should include measurement of implementation. In a trial of a structural intervention for HIV prevention in Botswana we trained teachers to use an audio-drama about gender violence and HIV (BVV). We measured the use of BVV by the trained teachers, and the factors related. In three-day workshops we trained guidance teachers in primary and secondary schools to use the 8-episode BVV audio-drama, that covers gender, gender violence and HIV. One to two years later, two interviewers visited schools and administered an electronic questionnaire to the head teacher and to the BVV-trained teacher. Most teachers (70%, 72/103) had used the BVV materials and reported a positive response from students. Primary school teachers were less likely to have used BVV (adjusted odds ratio (ORa) 0.24, 95% cluster adjusted confidence interval (CIca) 0.07-0.88). Teachers in schools with a working MP3 player were more likely to have used BVV (ORa 3.75, 95% CIca 1.11-12.70). Implementation was much lower in one district (ORa 0.12, 95% CIca 0.04-0.36), related to language constraints. The main difficulty was lack of time, especially in primary schools. These findings could inform rollout of the BVV programme in schools. Abbreviations: BVV: Beyond Victims and Villains audio-drama; CI: Confidence interval; OR: Odds ratio [ABSTRACT FROM AUTHOR]

HIV-infected women who have experienced sexual violence face unique challenges in their HIV care engagement and adherence to antiretroviral medications (ARVs). Improving AIDS Care after Trauma (ImpACT) is a brief counseling intervention aimed at reducing the negative impact of sexual trauma and HIV, building coping skills, and improving long-term HIV care engagement. We conducted a randomized controlled pilot trial of ImpACT with 64 women initiating ARVs in Cape Town, South Africa, with results suggesting the intervention can reduce PTSD symptoms and increase motivation to adhere to ARVs. For the current study, we abstracted data from ImpACT worksheets completed by 31 participants during intervention sessions, and qualitative responses from post-intervention surveys, to examine mechanisms, facilitators, and barriers to change in the intervention. Data included participant descriptions of the values informing their care, barriers to participation, and perceived benefits of the intervention related to coping with trauma and improving care engagement. During the first session, women reported feelings of shame, sadness, and anger that led to social isolation, mistrust, and damaged relationships. Barriers to participation included work and school demands, issues with transportation, finances, and discomfort in talking about HIV and trauma, particularly in group sessions. Despite these challenges, several women stated they developed more positive thinking, felt more confident, and improved their interpersonal relationships. Participants also reported substantial positive impact on symptoms of sexual trauma and motivation to continue with long-term HIV care, and clearer understanding of barriers and facilitators to ARV adherence. ImpACT is a promising intervention model for building adaptive coping skills and adherence to HIV treatment, informed by personal values, among women with a history of trauma in this high-risk setting. The data also offer insights into strategies to strengthen the intervention, overcome barriers to participation, encourage the practical application of skills, and promote long-term HIV care engagement. [ABSTRACT FROM AUTHOR]

HIV infections are growing the fastest amongst adolescents, especially in sub Saharan Africa. On reaching adolescence, perinatally-infected youth may have different needs to those who acquired infection behaviourally. Yet both have sub-optimal adherence with implications for their own health as well as onward transmission. This study uses the world's largest community-based study of HIV-positive adolescents from the Eastern Cape, South Africa. Clinic records at N = 53 district health facilities generated a log of all ART-initiated adolescents who were then interviewed in the community: N = 1058 (90%) were tracked and participated. Ethical approval, informed consent and data collector training preceded data gathering. Inventories comprised validated measures of mental health (depression, anxiety, suicidality and internalised stigma), substance use, ART adherence, and clinic attendance. Analyses were conducted using SPSS25 and STATA15. Perinatally-infected adolescents (n = 792, 77.3%) were significantly more likely to be ART adherent (OR = 1.54 95%CI: 1.14-2.07 p = 0.005), retained in healthcare (OR = 1.59 95%CI1.18-2.14 p = 0.002), and treated well by clinic staff (OR = 2.12 95%CI1.59-3.07 p ≤ 0.001). Behaviourally-infected adolescents were more likely to be depressed (B = 0.81 p ≤ 0.001), anxious (B = 1.36 p ≤ 0.001), report internalised stigma (B = 0.91 p ≤ 0.001), express suicidal ideation (OR = 3.65 95%CI: 1.96-6.82 p ≤ 0.001) and report excessive substance use in the past year (OR = 9.37 95%CI5.73-15.35 p ≤ 0.001). Being older explained most of these differences, with female adolescents living with HIV more likely to report suicidal ideation. However, behaviourally-infected adolescents were more likely to report substance use (OR = 2.69 95%CI: 1.48-4.91 p = 0.001), depression (B = 0.406, p = 0.022), anxiety (B = 1.359, p ≤ 0.001), and internalised stigma (B = 0.403, p = 0.007) in multivariate regression analyses, controlling for covariates. Moderation analyses (adjusting for multiple testing) suggest that behaviourally-infected HIV-positive adolescents who are also maternal orphans are more likely to report higher rates of depression (B = 1.075, p < 0.001). These notable differences by mode of infection suggest that studies which conflate HIV-positive adolescents may blur the clinical and psychological experiences of these two different sub-populations. Drivers of non-adherence, poor retention in care, and mental health problems may differ by mode of infection, requiring tailored interventions. Health and social service provision, if it is to be effective, needs to address these different youth profiles to ensure optimal adherence, development and wellbeing throughout the life course. [ABSTRACT FROM AUTHOR]

For patients with AIDS receiving antiretroviral treatment (ART) in South Africa via public clinics, improvements in nutritional status and economic productivity are likely to depend on adherence to drug regimen and quality of diet reflected in protein and micronutrient intakes. This study randomized 643 patients receiving ART from public clinics in the Free State Province into a Control group, a treatment group receiving adherence support, and a treatment group receiving adherence support and a nutritious food supplement. The data on food insecurity levels and time spent on various activities were analyzed for assessing the impact of the intervention programs. The main results were, first, changes between survey rounds 1 and 3 were significant at the 5% level for outcomes such as food insecurity levels and CD4 cell counts. Moreover, there was a significant reduction in food insecurity levels of patients with BMI less than 25 who received the nutritious food supplement. Second, the estimated parameters from models for patients' food insecurity levels showed that household incomes were significantly associated with lower food insecurity levels. Third, patients' BMI was a significant predictor of time spent on sedentary, moderate and overall activity levels, and it was important to separately evaluate the effects of BMI for under-weight and over-weight patients. Overall, the results indicated the need for reducing food insecurity levels, and for designing different interventions for under-weight and over-weight patients with AIDS for enhancing their labor productivity. [ABSTRACT FROM AUTHOR]

We studied 500 South Africans who sought an HIV test in a community outreach setting. On average, both men and women in the sample indicated hazardous and harmful alcohol use, as well as possible alcohol dependence. Men but not women among the sample experienced drug-related problems. Men were 1.64 times more likely than females to report problematic alcohol use and 4.88 times more likely than females to report drug use. Symptoms of posttraumatic stress, anxiety, and depression significantly explained 16.5% of the variance in alcohol misuse. Symptoms of posttraumatic stress significantly explained 23.5% of the variance in drug use. Implications are explored in the context of HIV testing. [ABSTRACT FROM PUBLISHER]

We investigated psychological distress and symptoms of depression and anxiety among 485 South Africans seeking HIV testing. The mean scores of the sample were 45.78 (SD = 16.81) on the Hopkins Symptom Checklist; 15.8 (SD = 12.4) on the Beck Depression Inventory and 12.44 (SD = 13.00) on the Beck Anxiety Inventory, which fell in the elevated, mild and low ranges on these instruments, respectively. For more than a third of participants, symptoms of depression and clinically significant distress were at least moderate and in some cases severe, indicating that they may have benefitted from psychological help. We make the case that symptoms of depression and distress are common among persons seeking HIV testing and are therefore not a consequence of an HIV-positive test result. [ABSTRACT FROM PUBLISHER]

Retaining high levels of patients in care who are virally suppressed over long treatment periods has been an important challenge for antiretroviral treatment (ART) programmes in sub-Saharan Africa, the region having the highest HIV burden globally. Clinic-linked community-based adherence support (CBAS) programmes provide home-based adherence and psychosocial support for ART patients. However, there is little evidence of their longer-term impact. This study assessed the effectiveness of CBAS after eight years of ART. CBAS workers are lay healthcare personnel providing regular adherence and psychosocial support for ART patients and their households through home visits addressing household challenges affecting adherence. A multicentre cohort study using routinely collected data was undertaken at six public ART sites in a high HIV-prevalence South African district. Patient retention, loss to follow-up (LTFU), viral suppression and CD4 cell restoration were compared between patients with and without CBAS, using competing-risks regression, linear mixed models and log-binomial regression. 3861 patients were included, of whom 1616 (41.9%) received CBAS. Over 14,792 patient-years of observation, the cumulative incidence of LTFU was 37.3% and 46.2% amongst patients with and without CBAS, respectively, following 8 years of ART; adjusted subhazard ratio (CBAS vs. no CBAS) = 0.74 (95% CI: 0.66–0.84;P < .0001). Amongst patients on ART for 6.5–8 years, proportions not achieving viral suppression were 11.4% and 19.4% in patients with and without CBAS, respectively; adjusted risk ratio = 0.47 (95% CI: 0.26–0.86;P = .015). Annual CD4 cell increases from baseline were 62.8 cells/µL/year and 51.5 cells/µL/year amongst patients with and without CBAS, respectively, after 6.5 years or more (P = .034). After adjustment, annual CD4 cell recovery was 15.1 cells/µL/year (95% CI: 2.7–27.6) greater in CBAS patients (P = .017). ART patients who received CBAS had improved long-term patient retention, viral suppression and immunological restoration. CBAS is an intervention that can improve longer-term ART programme outcomes in resource-limited settings. [ABSTRACT FROM AUTHOR]

Globally intimate partner violence (IPV) is a public health problem that can be perpetrated by both males and females, although males are more likely to inflict severe IPV-related injuries on their female partners. In low- and middle-income countries like South Africa, few studies have conducted research to determine whether IPV perpetration by men may be a risk factor for engaging in other risk behaviours. The aim of this study is to determine whether IPV perpetration by men is a risk factor for engaging in other risk behaviours with a particular focus on risky sexual behaviours and alcohol misuse. The data for this study were drawn from a multilevel intervention study, which addressed the nexus of alcohol abuse and HIV prevention among men in South Africa. Men were screened and recruited from informal drinking places within 12 communities situated in one of the oldest, predominantly Xhosa-speaking African townships in Cape Town. Univariate and multivariate logistic regression models were used to analyse the associations between IVP and potential explanatory variables. Of the 975 men included in the survey, 39.9% reported to have been involved in Intimate Partner Violence. IPV perpetration was significantly more likely among men who reported having a child [OR 1.51 (1.07-2.14) p = .019], having a casual sexual partner [OR 1.51 (1.11-2.05) p = .008], and those with possible alcohol dependence [OR 3.46 (1.17-10.20) p = .024]. IPV was significantly less likely among men with matric educational qualification than those with no education [OR 0.30 (95% CI: 0.09-1.02) p = .053] and among those who reported using a condom at last sex [OR 0.69 (0.50-0.97) p = .034]. We therefore recommend that interventions aimed at reducing IPV need to address risky sexual and drinking behaviours amongst men simultaneously, while also focusing on intimate relationship power dynamics and gendered norms amongst couples. [ABSTRACT FROM AUTHOR]

Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews find no effective adolescent adherence-promoting interventions. Social protection has demonstrated benefits for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10–19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa’s Eastern Cape were traced and interviewed in 2014–2015 (n= 1175 eligible). About 90% of the eligible sample was included (n= 1059). Social protection provisions were “cash/cash in kind”: government cash transfers, food security, school fees/materials, school feeding, clothing; and “care”: HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p= .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1–3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42–.76,p< .001); HIV support group attendance (aOR .60, CI .40–.91,p< .02), and high parental/caregiver supervision (aOR .56, CI .43–.73,p< .001). Combination social protection showed additive benefits. With no social protection, non-adherence was 54%, with any one protection 39–41%, with any two social protections, 27–28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of “cash plus care”, may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents. [ABSTRACT FROM PUBLISHER]

Children affected by HIV and AIDS have significantly higher rates of mental health problems than unaffected children. There is a need for research to examine how social support functions as a source of resiliency for children in high HIV-prevalence settings such as South Africa. The purpose of this research was to explore how family social support relates to depression, anxiety, and post-traumatic stress (PTS). Using the ecological model as a frame, data were drawn from a 2011 cross-sectional study of 1380 children classified as either orphaned by AIDS and/or living with an AIDS sick family member. The children were from high-poverty, high HIV-prevalent rural and urban communities in South Africa. Social support was analyzed in depth by examining the source (e.g. caregiver, sibling) and the type (e.g. emotional, instrumental, quality). These variables were entered into multiple regression analyses to estimate the most parsimonious regression models to show the relationships between social support and depression, anxiety, and PTS symptoms among the children. Siblings emerged as the most consistent source of social support on mental health. Overall caregiver and sibling support explained 13% variance in depression, 12% in anxiety, and 11% in PTS. Emotional support was the most frequent type of social support associated with mental health in all regression models, with higher levels of quality and instrumental support having the strongest relation to positive mental health outcomes. Although instrumental and quality support from siblings were related to positive mental health, unexpectedly, the higher the level of emotional support received from a sibling resulted in the child reporting more symptoms of depression, anxiety, and PTS. The opposite was true for emotional support provided via caregivers, higher levels of this support was related to lower levels of all mental health symptoms. Sex was significant in all regressions, indicating the presence of moderation. [ABSTRACT FROM PUBLISHER]

Increasing numbers of perinatally HIV (PHIV+)-infected youth are surviving into adulthood with better access to treatment. However, few studies examine positive outcomes in the face of adversity (resilience) for PHIV+ youth. Social Action Theory (SAT) provided the theoretical framework for this study of PHIV + youth in South Africa (SA), allowing examination of contextual, social, and self-regulatory factors that influence behavioral health. Data were from youth and caregiver baseline interviews, simply pooled from a pilot (N=66) and larger (n=111) randomized control trial (RCT) of the VUKA Family program. For this analysis, outcomes included emotional and behavioral functioning (total difficulties), and prosocial behaviors. Potential SAT correlates included socio-demographics; caregiver health and mental health; parent-child relationship factors; stigma, and child coping, support; and self-esteem. Regression analyses adjusted for age, gender, and study revealed significant associations at the contextual, social, and self-regulation level. Lower total child difficulties scores were associated with lower caregiver depression (β = 3.906,p < .001), less caregiver-reported communication about difficult issues (β = 1.882, p = .009) and higher youth self-esteem (β =-0.119, p = .020). Greater prosocial behaviors were associated with greater caregiver-reported communication (β = 0.722, p = .020) and child use of wishful thinking for coping (β = 5.532, p = .009). Less youth depression was associated with higher caregiver education (β =−0.399, p = .010), greater caregiver supervision (β =−1.261, p = .012), more social support seeking (β =−0.453, p = .002), higher youth self-esteem (β =−0.067, p < .001), lower internalized stigma (β = 0.608, p = .040), and child use of resignation for coping (β = 1.152, p = .041). Our data support evidence-based family interventions that also promote youth self-regulation skills to enhance the health and mental health of PHIV+ youth. [ABSTRACT FROM PUBLISHER]

HIV counseling and testing (HCT) is critical for children in generalized epidemic settings, but significant shortfalls in coverage persist, notably among orphans and others at disproportionate risk of infection. This study investigates the impact of a home visiting program in South Africa on orphaned and vulnerable children’s uptake of HCT. Using propensity score matching, survey data for children receiving home visits from trained community-based care workers were compared to data from children living in similar households that had not yet received home visits (n = 1324). Home visits by community-based care workers increased the odds of a child being tested by 97% (OR = 1.97, 95% CI = 1.34–2.92). The home visitation program had an especially pronounced effect on orphans, more than doubling their odds of being tested (OR = 2.12, 95% CI = 1.00–4.47) compared to orphans living in similar households that did not receive home visits. Orphan status alone had no effect on HCT independent of program exposure, suggesting that the program was uniquely able to increase testing in this subgroup. Results highlight the potential for increasing HCT access among children at high risk through targeted community-based initiatives. [ABSTRACT FROM PUBLISHER]

Although HIV/AIDS constitute a significant health burden among children in South Africa, testing and counselling of exposed children are inadequate. It is therefore imperative that factors relating to paediatric HCT services offered by health workers are examined. This study was conducted to explore and describe the perceptions and experiences of trained professional nurses regarding HIV counselling and testing among children. We conducted six focus group discussions among trained professional nurses in health facilities in a district in Free State Province, South Africa. All verbatim transcripts were analysed with a thematic approach and emergent codes were applied. Forty-seven trained professional nurses participated in the study and two of them were males. The age of the participants ranges from 38 to 60 years while the median age was 50 years. Most participants in the focus groups explained how HCT occurs during regular health talks and that lay counsellors are doing most of the counselling. While a few participants thought that children should not be bothered with HCT, most of them seek consent from caregivers for HIV test for children. While children whose parents are negative are usually not tested, most children are tested only when they become ill. Identified barriers to HCT among children include refusal of consent, work overload, lack of encouragement, and poor record keeping. Participants recommended improvement of issues relating to community mobilization and increasing trained staff strength for optimal paediatric HCT service delivery. Developing guidance and policies with respect to obtaining consent, recruiting more health providers, and addressing structural issues in the society to reduce stigma and discrimination were identified as key priority issues by majority of the participants. The perspectives of these participants who provide paediatric HCT services offer vital insight which may be useful to inform policy interventions. [ABSTRACT FROM PUBLISHER]

The current study sought to explore the association between primary caregiver depressive symptoms and the psychological functioning in children vertically infected with human immunodeficiency virus (HIV) living in Eastern Cape, South Africa. A cross-sectional data were collected using the Beck Depression Inventory and Strength and Difficulties Questionnaire in a sample of 152 caregiver/child dyads. The results revealed that poorer psychological functioning in children was significantly associated with depressive symptoms in caregivers. This relationship existed whether or not the child was raised by a biological or non-biological caregiver as well as for both genders. Younger children's psychological functioning was more negatively influenced than that of older children raised by a caregiver with depressive symptoms. In the context of a large treatment gap for common mental disorders in South Africa, there is a need for interventions to address maternal mental health in families infected and affected by the HIV/AIDS pandemic as a mental health promotion strategy given that HIV-infected children are a particularly vulnerable population for poor mental and behavioural health outcomes. [ABSTRACT FROM PUBLISHER]

Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (β = −.48,p = .05) and girls reported more consistent condom (β = 1.37,p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population. [ABSTRACT FROM PUBLISHER]

Hegemonic masculine norms (HMN), which promote sexual risk-taking among males and the subordination of women, are believed to play a key role in the HIV epidemic among heterosexual couples in South Africa (SA). Sexual communication self-efficacy (SCSE) (i.e., a couple's confidence in their ability to communicate about HIV prevention) may be a key leverage point for increasing HIV prevention behaviors among this population. We interviewed 163 sexually active heterosexual couples in Soweto, SA to investigate the association between SCSE, HMN, and consistent condom use. We collected information on demographics, relationship dynamics, and sexual activity. We utilized the SCSE scale to measure couples' SCSE, and a subscale of the Gender Equitable Men scale to measure HMN among males. We performed bivariate and multivariable analyses to determine the association of consistent condom use with couples' SCSE as well as the male partner's endorsement of HMN. We found that couples with higher SCSE have greater odds of consistent condom use (adjusted odds ratio [AOR] = 1.30, 95% CI: 1.15–1.47). Furthermore, male endorsement of HMN was found to be negatively associated with consistent condom use among couples (AOR = 0.47, 95% CI: 0.24–0.89). Joint HIV serostatus was not significantly associated with the outcome. Future interventions that equip heterosexual couples with sexual communication skills, while simultaneously promoting more gender equitable norms, may increase consistent condom use and thereby reduce the transmission of HIV among this at-risk population. [ABSTRACT FROM PUBLISHER]

South Africa has experienced declining marriage rates and the increasing practice of cohabitation without marriage. This study aims to improve the understanding of the relationship between marital status and HIV in South Africa, an HIV hyperendemic country, through an analysis of findings from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. The nationally representative population-based cross-sectional survey collected data on HIV and socio-demographic and behavioural determinants in South Africa. This analysis considered respondents aged 16 years and older who consented to participate in the survey and provided dried blood spot specimens for HIV testing (N = 17,356). After controlling for age, race, having multiple sexual partners, condom use at last sex, urban/rural dwelling and level of household income, those who were married living with their spouse had significantly reduced odds of being HIV-positive compared to all other marital spouses groups. HIV incidence was 0.27% among respondents who were married living with their spouses; the highest HIV incidence was found in the cohabiting group (2.91%). Later marriage (after age 24) was associated with increased odds of HIV prevalence. Our analysis suggests an association between marital status and HIV prevalence and incidence in contemporary South Africa, where odds of being HIV-positive were found to be lower among married individuals who lived with their spouses compared to all other marital status groups. HIV prevention messages therefore need to be targeted to unmarried populations, especially cohabitating populations. As low socio-economic status, low social cohesion and the resulting destabilization of sexual relationships may explain the increased risk of HIV among unmarried populations, it is necessary to address structural issues including poverty that create an environment unfavourable to stable sexual relationships. [ABSTRACT FROM PUBLISHER]

HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one's HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight fifty eight HIV-positive adolescents (10–19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers.N = 128 (14.9%) of the total sample had ever had sex, whileN = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner's status, and 35.5% had disclosed to their partners. For adolescents, knowing one's status was associated with safer sex (OR = 4.355, CI 1.085–17.474,p = .038). Neither knowing their partner's status, nor disclosing one's HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

To explore the barriers and facilitators of linkage to and retention in care amongst persons who tested positive for HIV, qualitative research was conducted in a home-based HIV counselling and testing (HBCT) project with interventions to facilitate linkages to HIV care in rural KwaZulu-Natal, South Africa. The intervention tested 1272 adults for HIV in Vulindlela of whom 32% were HIV positive, received point-of-care (POC) CD4 testing and referral to local HIV clinics. Those testing positive also received follow-up visits from a counsellor to evaluate linkages to care. The study employed a qualitative methodology collecting data through in-depth semi-structured interviews. Respondents included 25 HIV-positive persons who had tested as part of HBCT project, 4 intervention research counsellors who delivered the HBCT intervention and 9 government clinic staff who received referrals for care. The results show that HBCT helped to facilitate linkage to care through providing education and support to help overcome fears of stigma and discrimination. The results show the perceived value of receiving a POC CD4 result during post-test counselling, both for those newly diagnosed and those previously diagnosed as HIV positive. The results also demonstrate that in-depth counselling creates an “educated consumer” facilitating engagement with clinical services. The study provides qualitative insights into the acceptability of confidential HBCT with same day POC CD4 testing and counselling as factors that influenced HIV-positive persons’ decisions to link to care. This model warrants further evaluation in non-research settings to determine impact and cost-effectiveness relative to other HIV testing and referral strategies. [ABSTRACT FROM AUTHOR]

Although there is a high prevalence of anxiety and depression amongst people receiving antiretroviral treatment (ART), many patients are not screened, diagnosed or referred for mental health problems. This study aims to determine whether public sector health care workers in South Africa observe, screen, diagnose and refer ART patients that show symptoms of common mental disorders. It also aims to ascertain the extent of mental health training received by public sector health care workers working in ART. The study was cross-sectional in design. Self-administered questionnaires were completed by 40 nurses and structured interviews were conducted with 23 lay workers across the five districts in the Free State between July 2009 and October 2009. STATA version 12 was used to perform statistical data analysis. The health care workers reported observing a high frequency of symptoms of common mental disorders among public sector ART patients. While 70% of nurses screened and diagnosed, only 40% of lay workers screened and diagnosed patients on ART for a mental disorder. Health care workers who had received training in mental health were more likely to screen or diagnose a mental disorder, but only 14% of the workers had received such training. We recommend that health care workers should receive task-specific training to screen and/or diagnose patients on ART for common mental disorders using the guidelines of the South African HIV Clinicians Society. A positive diagnosis should be referred to a health care practitioner for appropriate evidence-based treatment in the form of medication or psychotherapy. [ABSTRACT FROM PUBLISHER]

A case-control study was conducted to describe the frequency with which structural- and individual-level barriers to adherence are experienced by people receiving antiretroviral (ARV) treatment and to determine predictors of non-adherence. Three hundred adherent and 300 non-adherent patients from 6 clinics in Cape Town completed the LifeWindows Information-Motivation-Behavioral Skills ART Adherence Questionnaire, the Substance Abuse and Mental Illness Symptoms Screener and the Structural Barriers to Clinic Attendance (SBCA) and Medication-taking (SBMT) scales. Overall, information-related barriers were reported most frequently followed by motivation and behaviour skill defects. Structural barriers were reported least frequently. Logistic regression analyses revealed that gender, behaviour skill deficit scores, SBCA scores and SBMT scores predicted non-adherence. Despite the experience of structural barriers being reported least frequently, structural barriers to medication-taking had the greatest impact on adherence (OR: 2.32, 95% CI: 1.73 to 3.12), followed by structural barriers to clinic attendance (OR: 2.06, 95% CI: 1.58 to 2.69) and behaviour skill deficits (OR: 1.34, 95% CI: 1.05 to 1.71). Our data indicate the need for policy directed at the creation of a health-enabling environment that would enhance the likelihood of adherence among antiretroviral therapy users. Specifically, patient empowerment strategies aimed at increasing treatment literacy and management skills should be strengthened. Attempts to reduce structural barriers to antiretroviral treatment adherence should be expanded to include increased access to mental health care services and nutrition support. [ABSTRACT FROM PUBLISHER]

The promotion of physical activity is encouraged in people living with HIV and AIDS (PLWHA) as a means of promoting wellness and health. Adherence to programmes that promote exercise is often reduced, and home-based programmes are suggested to improve adherence. This study investigated the personal and environmental factors that cause barriers and facilitators of physical activity in a home-based pedometer walking programme as a means of highlighting adherence challenges. An observational study nested in a randomised controlled trial was conducted in a cohort of South African PLWHA on antiretroviral therapy over a six-month period. Descriptive analysis and qualitative content analysis of 42 participants who underwent physical activity modification assisted with data review. The mean age of the sample was 38.7 (±8.9) years, consisted mostly of women (n= 35; 83.3%) who were employed (n= 19; 45.2%) but earning very little (less than R500 per month) and often single or widowed (n= 23; 54.8%). Barriers to physical activity identified included physical complaints, e.g., low-energy levels; psychological complaints, e.g., stress levels; family responsibility, e.g., being primary caregivers; the physical environment, e.g., adverse weather conditions; social environment, e.g., domestic abuse and crime; and workplace, e.g., being in a sedentary job. Facilitators of physical activity included support and encouragement from friends and family, religious practices during worship and community environment, e.g., having access to parks and sport fields. The study is of benefit as it highlights personal and environmental factors that need to be considered when developing or implementing a home-based walking programme in PLWHA. [ABSTRACT FROM PUBLISHER]

Depression and other health problems are common co-morbidities among persons living with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS). The aim of this study was to investigate depression, health status, and substance use in relation to HIV-infected and uninfected individuals in South Africa. Using a cross-sectional case-control design, we compared depression, physical health, mental health, problem alcohol use, and tobacco use in a sample of HIV-infected (N= 143) and HIV-uninfected (N= 199) respondents who had known their HIV status for two months. We found that depression was higher, and physical health and mental health were lower in HIV-positive than HIV-negative individuals. Poor physical health also moderated the effect of HIV infection on depression; HIV-positive individuals were significantly more depressed than HIV-negative controls, but only when general physical health was also poor. We did not find an association between alcohol or tobacco use and HIV status. These results suggest the importance of incorporating the management of psychological health in the treatment of HIV. [ABSTRACT FROM AUTHOR]

Alcohol use is associated with compromised antiretroviral therapy (ART) adherence. We aimed to identify patterns and predictors of ART use among alcohol drinkers. Using purposive sampling, we recruited 304 male and female patients from two ART clinics in Tshwane, South Africa. Interviews were conducted using a structured questionnaire comprising measures of demographic factors, psychosocial factors (i.e., ART adherence, self-efficacy beliefs, alcohol and ART interactions beliefs, ART-alcohol outcome expectancy, attitude towards drinking alcohol and taking ART and HIV stigma) and alcohol use (AUDIT). Data were analysed using descriptive statistics and three multivariate linear regressions. Forty percent of the sample reported drinking alcohol. Half of the drinkers endorsed one of three unique patterns of ART use: (1) dosing ART earlier than required (2) taking ART while drinking alcohol and (3) skipping ART doses. The other half endorsed combinations of ART use on drinking days, for example, earlier ART dosing and taking ART while drinking alcohol was the most common combination. High adherence perseverance (a self-efficacy subscale) and a non-favourable attitude towards drinking alcohol and taking ART predicted the unique pattern of taking ART early when planning to drink alcohol. The unique pattern of taking ART despite drinking alcohol was predicted by higher levels of education (marginal significance) and experiencing low HIV stigma. A high score on the AUDIT and experience of high stigma predicted the unique pattern of skipping ART doses when drinking alcohol. Patterns of ART taking in alcohol drinkers in this sample are varied, and not always mutually exclusive. This apparent complexity of medication taking patterns among alcohol drinkers warrants further exploration. Furthermore, the finding that different psychosocial factors predict different ART-taking patterns suggests a need for programmes to improve alcohol-related non-adherence to ART to be multifaceted. [ABSTRACT FROM PUBLISHER]

HIV stigma plays a major role in the etiology of psychological distress among persons living with HIV, but may be ameliorated by social support. This cross-sectional study examined whether social support mediates or moderates the relationship between HIV stigma and psychological symptoms. We recruited a convenience sample of 210 individuals living with HIV in three peri-urban communities in the Western Cape, South Africa. People living with HIV and AIDS (PLWHA) completed self-report questionnaires that assessed HIV-related stigma, social support, post-traumatic stress disorder (PTSD) and depression. Product-term regression analyses showed that social support played a mediating role in the relationship between HIV-related stigma and symptoms of PTSD (not depression). Social support did not, however, moderate the relationship between HIV-related stigma and PTSD or depression. The results indicate that perceived HIV-related stigma may decrease PLWHA's perceived level of social support, which in turn may increase PTSD symptoms. Moreover, these findings suggest that despite the protective role of social support, there are other factors that affect the relationship between HIV-related stigma and mental health that hinder the buffering role of social support in this relationship. These findings may have implications for designing and implementing interventions that increase perceived social support and decrease perceived HIV-related stigma, which in turn may decrease symptoms of PTSD among PLWHA. [ABSTRACT FROM PUBLISHER]