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HIV-related stigma is a well-documented barrier to HIV testing in South Africa, and may be particularly likely to create reluctance to test among South African men, who have reported feeling blamed for HIV by their partners and communities. The present study presents a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention explicitly designed to reduce stigma as a barrier to testing by asking people to recruit anyone they know to testing, thus allowing them to avoid the potential for increased stigma and/or blame associated with direct risk partner recruitment, and helping to normalize openly discussing HIV among social networks. We examined baseline and 6-10-week follow-up data from a 2022–2023 randomized trial in KwaZulu-Natal, South Africa that recruited 110 individuals who had been newly diagnosed with HIV and randomly assigned them to recruit people to HIV testing either via the E-SNRHT intervention or via risk network recruitment. Participants in the E-SNRHT intervention reported significant decreases in anticipated and enacted HIV-related stigma between baseline and follow-up; and the E-SNRHT intervention was more effective at decreasing enacted HIV-related stigma than was risk network recruitment. Individuals newly diagnosed with HIV by the E-SNRHT intervention reported significant increases in social support between intervention enrollment and follow-up, and all of these individuals reported participating in positive conversations about HIV services with peers in the 6–10 weeks after intervention enrollment. These findings suggest that E-SNRHT is a potentially important strategy to reduce HIV-related stigma as a barrier to HIV testing among peer networks in KwaZulu-Natal. [ABSTRACT FROM AUTHOR]

In the context of a couples cohort established to evaluate an optimised couples-focused behavioural intervention in rural South Africa, we examined: (1) Is couples' relationship quality (RQ) associated with couples HIV testing and counselling (CHTC) uptake? (2) Does CHTC uptake or the intervention components uptake improve subsequent RQ? Enrolled couples, (n = 218), previously naïve to couples HIV testing, were invited to two group sessions and offered four couples counselling sessions (CS1-CS4), as part of the intervention and administered a questionnaire individually at baseline, four weeks, and four months, which included item-scales to measure RQ: satisfaction, intimacy, dyadic trust, conflict, and mutual constructive communication. Logistic models indicated that no baseline RQ measures were significantly associated with CHTC uptake. Linear regression models showed that CHTC uptake before four weeks assessment significantly improved couples' satisfaction and trust at four weeks, and intimacy at four months. Attending at least one CS was associated with increased satisfaction, intimacy, and decreased conflict within couples at four weeks; the improvement in intimacy was sustained at four months. Consistent with the theoretical interdependence model, our findings suggest that CHTC and CS seemed to strengthen aspects of relationship quality, possibly leading to further collaboration in managing lifestyle changes and treatment adherence. [ABSTRACT FROM AUTHOR]

Background: Estimation of prevalence and diagnostic test accuracy in tuberculosis (TB) prevalence surveys suffer from reference standard and verification biases. The former is attributed to the imperfect reference test used to bacteriologically confirm TB disease. The latter occurs when only the participants screening positive for any TB-compatible symptom or chest X-ray abnormality are selected for bacteriological testing (verification). Bayesian latent class analysis (LCA) alleviates the reference standard bias but suffers verification bias in TB prevalence surveys. This work aims to identify best-practice approaches to simultaneously alleviate the reference standard and verification biases in the estimates of pulmonary TB prevalence and diagnostic test performance in TB prevalence surveys. Methods: We performed a secondary analysis of 9869 participants aged ≥15 years from a community-based multimorbidity screening study in a rural district of KwaZulu-Natal, South Africa (Vukuzazi study). Participants were eligible for bacteriological testing using Xpert Ultra and culture if they reported any cardinal TB symptom or had an abnormal chest X-ray finding. We conducted Bayesian LCA in five ways to handle the unverified individuals: (i) complete-case analysis, (ii) analysis assuming the unverified individuals would be negative if bacteriologically tested, (iii) analysis of multiply-imputed datasets with imputation of the missing bacteriological test results for the unverified individuals using multivariate imputation via chained equations (MICE), and simultaneous imputation of the missing bacteriological test results in the analysis model assuming the missing bacteriological test results were (iv) missing at random (MAR), and (v) missing not at random (MNAR). We compared the results of (i)-(iii) to the analysis based on a composite reference standard (CRS) of Xpert Ultra and culture. Through simulation with an overall true prevalence of 2.0%, we evaluated the ability of the models to alleviate both biases simultaneously. Results: Based on simulation, Bayesian LCA with simultaneous imputation of the missing bacteriological test results under the assumption that the missing data are MAR and MNAR alleviate the reference standard and verification biases. CRS-based analysis and Bayesian LCA assuming the unverified are negative for TB alleviate the biases only when the true overall prevalence is <3.0%. Complete-case analysis produced biased estimates. In the Vukuzazi study, Bayesian LCA with simultaneous imputation of the missing bacteriological test results under the MAR and MNAR assumptions produced overall PTB prevalence of 0.9% (95% Credible Interval (CrI): 0.6–1.9) and 0.7% (95% CrI: 0.5–1.1) respectively alongside realistic estimates of overall diagnostic test sensitivity and specificity with substantially overlapping 95% CrI. The CRS-based analysis and Bayesian LCA assuming the unverified were negative for TB produced 0.7% (95% CrI: 0.5–0.9) and 0.7% (95% CrI: 0.5–1.2) overall PTB prevalence respectively with realistic estimates of overall diagnostic test sensitivity and specificity. Unlike CRS-based analysis, Bayesian LCA of multiply-imputed data using MICE mitigates both biases. Conclusion: The findings demonstrate the efficacy of these advanced techniques in alleviating the reference standard and verification biases, enhancing the robustness of community-based screening programs. Imputing missing values as negative for bacteriological tests is plausible under realistic assumptions. [ABSTRACT FROM AUTHOR]

Introduction: Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community‐based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV‐associated TB, particularly among men. Methods: We developed a gender‐stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15−59 in KwaZulu‐Natal, South Africa. We drew model parameters from a community‐based ART initiation and resupply trial in sub‐Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community‐based ART and TPT care programmes during 2018−2027, assuming that community‐based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability‐adjusted life years (DALYs) averted relative to standard, clinic‐based care. We calculated programme costs and incremental cost‐effectiveness ratios from the provider perspective. Results: If community‐based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%−34.1%) and TB mortality by 34.6% (range 24.8%–42.2%) after 10 years. Increasing both ART and TPT uptake through community‐based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%−36.0%) and TB mortality by 36.0% (range 26.9%−43.8%). Community‐based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11–103) after 10 years of community‐based care versus 109 (range 41–182) in standard care. Over 10 years, the mean cost per DALY averted by community‐based ART with TPT care was $846 USD (range $709–$1012). Conclusions: By substantially increasing coverage of ART and TPT, community‐based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV‐associated TB and reduce TB gender disparities. [ABSTRACT FROM AUTHOR]

Purpose of review: Lottery incentives are an innovative approach to encouraging HIV prevention, treatment initiation, and adherence behaviours. This paper reviews the latest research on lottery incentives' impact on HIV-related services, and their effectiveness for motivating behaviours to improve HIV service engagement and HIV health outcomes. Recent findings: Our review of ten articles, related to lottery incentives, published between 2018 and 2023 (inclusive) shows that lottery incentives have promise for promoting HIV-related target behaviours. The review highlights that lottery incentives may be better for affecting simpler behaviours, rather than more complex ones, such as voluntary medical male circumcision. This review recommends tailoring lottery incentives, ensuring contextual-relevance, to improve the impact on HIV-related services. Summary: Lottery incentives offer tools for improving uptake of HIV-related services. The success of lottery incentives appears to be mediated by context, the value and nature of the incentives, and the complexity of the target behaviour. [ABSTRACT FROM AUTHOR]

Parents play a critical role in supporting the development of resilience in childhood and early adolescence. Most South Africans lack basic resources, so research into and commitment to resilience is of great importance. This study investigated the styles of parenting experienced by highly resilient South African students. Participants were 136 South African university students aged 18 to 23 (female = 44.9%, black = 66.9%). They completed the Child and Youth Resilience Measure. Further, six of the highest scoring students participated in in-depth semi-structured interviews on their retrospective parenting experiences. Quantitative analysis showed females had a higher mean resilience score than males. Qualitatively, thematic analysis identified the following parenting styles: loving caregiving, and behavioural control. Loving caregiving was expressed through accounts of encouragement, acceptance, and attentive regard. Behavioural control was demonstrated by verbal interactions of discipline, corporal punishment, and curfews. This implies a connection between specific parenting practices and high resilience in students, providing valuable insights for developing programs to boost children's resilience. [ABSTRACT FROM AUTHOR]

Intimate partners play an important role in chronic diseases. Despite the chronic disease burden in sub- Saharan Africa, very few culturally relevant quantitative measures of intimate relationship functioning are available. We conducted an empirical investigation evaluating the psychometric properties of the South African Relationship Functioning Assessment (SARFA) assessing healthy relationship functioning in N = 150 community members (50% women; M age = 27.2 years) living in the Vulindlela area of KwaZulu-Natal, South Africa. Item development was based on prior qualitative research from two South African communities. All assessments were conducted in isiZulu, participants' primary language. An exploratory factor analysis was conducted on the initial 39-item measure. The best-fitting model consisted of one factor with 22 items. The SARFA's internal consistency was a = .94. Convergent validity was observed via significant positive associations (all rs = .38, p < .001) between the SARFA's total score and measures of trust, emotional intimacy, constructive communication, sexual satisfaction, and relationship control (women only). Divergent validity was observed for women only. Encouraging initial psychometric properties of a culturally relevant measure of relationship functioning in KwaZulu-Natal may have relevance to other communities and potential to be used in research involving couples and health in chronic disease-burdened communities. [ABSTRACT FROM AUTHOR]

Background: Pre-exposure Prophylaxis (PrEP) and Treatment as Prevention (TasP) are effective strategies to prevent HIV transmission within serodifferent couples. However, limited usage of PrEP, knowledge and interest has been amongst the barriers for men, alongside testing and treatment adherence. We explored the perceptions of PreP for HIV prevention with Men living with HIV (MWH) who have reproductive goals, to understand awareness and experiences related to PrEP use in the context of HIV prevention with their partners. Methods: We undertook a qualitative study with 25 MWH aged 18 to 65 between April and September 2021 in South Africa. Potential participants were screened for eligibility and scheduled to participate in telephonic interviews. Interviews were audio recorded, transcribed, translated and thematically analysed. Results: Themes were organized into opportunities and barriers that men with HIV articulate as important for using PrEP to meet individual, couple, and community reproductive goals. At the individual level, some men were willing to discuss PrEP with their partners to protect their partners and babies from acquiring HIV. Lack of knowledge about PrEP among men was a potential barrier to promoting PrEP among their female partners. At the couple level, PrEP use was seen as a way to strengthen relationships between partners, signifying care, trust, and protection and was seen as a tool to help serodifferent couples meet their reproductive goals safely. At the community level, PrEP was viewed as a tool to promote HIV testing and prevention efforts, especially among men, but participants emphasized the need for more education and awareness. Conclusion: Despite PrEP implementation in South Africa, awareness of PrEP among men with HIV in rural areas remains low. Engaging MWH to support their partners in accessing PrEP could be an innovative strategy to promote HIV prevention. Additionally, providing men with comprehensive reproductive health information can empower them to make more informed decisions, adopt safer sexual practices, and challenge societal norms and stigmas around HIV. [ABSTRACT FROM AUTHOR]

Background: Couple-based interventions (CBIs), despite strong efficacy in improving numerous HIV risk behaviors, are not widely available and have not been tested to improve women's antiretroviral therapy (ART) adherence. We examined barriers and facilitators to participation in a CBI based on cognitive behavioral couple therapy for women's ART adherence in KwaZulu-Natal, South Africa. Methods: Semi-structured interviews were conducted with women with HIV (n = 15) and men of mixed HIV status (n = 15). Thematic analyses were guided by the Consolidated Framework for Implementation Research. Results: Facilitators mostly related to the couple's relationship, including having an existing healthy relationship, men's desire to support their partners, and a potential opportunity for men's HIV disclosure. Barriers included a lack of understanding of how a CBI approach would be useful for women's ART adherence, sole focus on women if male partners were also living with HIV, and men's lack of prior HIV status disclosure to female partners. Conclusion: Findings indicate that relationship context and the male partner's HIV status need to be addressed during recruitment, enrolment, and during the intervention to promote uptake. [ABSTRACT FROM AUTHOR]

Introduction: Significant progress has been made in the HIV response in South Africa; however, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. The National Department of Health (NDoH) has introduced community-based and clinic-based HIV differentiated service delivery (DSD) models to tackle suboptimal adherence and retention in care. Nevertheless, differentiated care models require adaptation to better serve clients who struggle with adherence. There is limited research on the acceptability of fee for home delivery of ART in resource-constrained settings. The current study investigates the acceptability of fee for home delivery of ART among people living with HIV in South Africa. Methods: Two mixed-gender focus group discussions (FGDs) took place between June and November 2019, consisting of 10 participants in each group. A purposive sampling strategy was employed to identify and select 10 people living with HIV who were ART-eligible but not in care, and 10 people living with HIV who were currently taking ART and in care. Participants were grouped according to their treatment status. A coding framework, informed by a priori categories and derived from topics in the interview guide, was developed and utilized to facilitate analysis. Results: Participants expressed enthusiasm for having ART home-delivered, as it would save the time spent waiting in long queues at the clinic. However, some participants raised concerns about potential payment difficulties due to high unemployment rates in the community. Some participants believed this would be acceptable, as patients already incur costs for travel and food when visiting the clinic. Participants in both FGDs expressed strong concerns about home delivery of their ART based on fear of accidental disclosure, especially for those who have not disclosed to their immediate families and partners. Conclusion: Our study suggests that charging a fee for home delivery is an acceptable and innovative approach to supporting PLHIV in maintaining adherence to their medication and remaining in care. [ABSTRACT FROM AUTHOR]

During TB-case finding, we assessed the feasibility of implementing the advanced HIV disease (AHD) care package, including VISITECT CD4 Advanced Disease (VISITECT), a semiquantitative test to identify a CD4≤200cells/μl. Adult participants with tuberculosis symptoms, recruited near-facility in Lesotho and South-Africa between 2021–2022, were offered HIV testing (capillary blood), Xpert MTB/RIF and Ultra, and MGIT culture (sputum). People living with HIV (PLHIV) were offered VISITECT (venous blood) and Alere tuberculosis-lipoarabinomannan (AlereLAM, urine) testing. AHD was defined as a CD4≤200cells/μl on VISITECT or a positive tuberculosis test. A CD4≤200cells/μl on VISITECT triggered Immy cryptococcal antigen (Immy CrAg, plasma) testing. Participants were referred with test results. To evaluate feasibility, we assessed i) acceptability and ii) intervention delivery of point-of-care diagnostics among study staff using questionnaires and group discussions, iii) process compliance, and iv) early effectiveness (12-week survival and treatment status) in PLHIV. Predictors for 12-week survival were assessed with logistic regression. Thematic content analysis and triangulation were performed. Among PLHIV (N = 676, 48.6% of 1392 participants), 7.8% were newly diagnosed, 81.8% on ART, and 10.4% knew their HIV status but were not on ART. Among 676 PLHIV, 41.7% had AHD, 29.9% a CD4≤200cells/μl and 20.6% a tuberculosis diagnosis. Among 200 PLHIV tested with Immy CrAg, 4.0% were positive. The procedures were acceptable for study staff, despite intervention delivery challenges related to supply and the long procedural duration (median: 73 minutes). At 12 weeks, among 276 PLHIV with AHD and 328 without, 3.3% and 0.9% had died, 84.8% and 92.1% were alive and 12.0% and 7.0% had an unknown status, respectively. Neither AHD nor tuberculosis status were associated with survival. Implementing AHD care package diagnostics was feasible during tuberculosis-case finding. AHD was prevalent, and not associated with survival, which is likely explained by the low specificity of VISITECT. Challenges with CD4 testing and preventive treatment uptake require addressing. [ABSTRACT FROM AUTHOR]

Children exposed to alcohol in utero may suffer from cognitive and physical sequelae. The most impactful damage in terms of daily functioning is to higher order cognitive functions involved in planning and goal-directed behaviour, referred to as executive functions. Cognitive training interventions are used as a remedial tool for executive function deficits but require implementation by professionals. For the South African context, where resources are limited, a tablet computer-based cognitive training game was developed. This study aimed to establish the feasibility of implementing and evaluating this intervention in South Africa for children exposed to alcohol prenatally. This was a three-arm feasibility randomised control trial comparing an alcohol exposed intervention arm, to an alcohol exposed control arm, and a non-exposed normative arm. Arm allocation was based on self-reported maternal alcohol use during a structured interview. To assess feasibility, we evaluated participant recruitment and barriers to implementation. Executive functions were measured at baseline and following intervention to evaluate the preliminary impact of the intervention. No significant differences were found between the three arms on the post-intervention assessments. The retention rate was acceptable for a randomised control trial; however, there was significant variance in the length of time spent playing the game overall. The majority of participants learned to play the game quickly and progressed through the difficulty levels. In conclusion, a full randomised control trial using the recruitment, randomisation and implementation method would be suitable in the South African context. The statistical outcomes of this trial do not support a full-scale randomised control trial of this intervention. [ABSTRACT FROM AUTHOR]

Purpose of Review: To explore the intersection of chatbots and HIV prevention and care. Current applications of chatbots in HIV services, the challenges faced, recent advancements, and future research directions are presented and discussed. Recent Findings: Chatbots facilitate sensitive discussions about HIV thereby promoting prevention and care strategies. Trustworthiness and accuracy of information were identified as primary factors influencing user engagement with chatbots. Additionally, the integration of AI-driven models that process and generate human-like text into chatbots poses both breakthroughs and challenges in terms of privacy, bias, resources, and ethical issues. Summary: Chatbots in HIV prevention and care show potential; however, significant work remains in addressing associated ethical and practical concerns. The integration of large language models into chatbots is a promising future direction for their effective deployment in HIV services. Encouraging future research, collaboration among stakeholders, and bold innovative thinking will be pivotal in harnessing the full potential of chatbot interventions. [ABSTRACT FROM AUTHOR]

Artificial intelligence (AI) systems for detection of COVID-19 using chest X-Ray (CXR) imaging and point-of-care blood tests were applied to data from four low resource African settings. The performance of these systems to detect COVID-19 using various input data was analysed and compared with antigen-based rapid diagnostic tests. Participants were tested using the gold standard of RT-PCR test (nasopharyngeal swab) to determine whether they were infected with SARS-CoV-2. A total of 3737 (260 RT-PCR positive) participants were included. In our cohort, AI for CXR images was a poor predictor of COVID-19 (AUC = 0.60), since the majority of positive cases had mild symptoms and no visible pneumonia in the lungs. AI systems using differential white blood cell counts (WBC), or a combination of WBC and C-Reactive Protein (CRP) both achieved an AUC of 0.74 with a suggested optimal cut-off point at 83% sensitivity and 63% specificity. The antigen-RDT tests in this trial obtained 65% sensitivity at 98% specificity. This study is the first to validate AI tools for COVID-19 detection in an African setting. It demonstrates that screening for COVID-19 using AI with point-of-care blood tests is feasible and can operate at a higher sensitivity level than antigen testing. [ABSTRACT FROM AUTHOR]

Continuous monitoring of glucose (CGM) via subcutaneous patch is an accurate self-monitoring tool of blood glucose, but also introduces a range of additional benefits such as real-time feedback. While its value among pregnant women with gestational diabetes mellitus (GDM) is established in high-income countries, little is known about the feasibility and acceptability among pregnant women without GDM in low-resource settings in low- and middle-income countries. This study aims to assess the feasibility and acceptability of CGM with pregnant mothers in South Africa and to explore the value of a collected data set for GDM prevention. Ten women between 12 and 18 weeks pregnant were recruited from the antenatal clinic at Chris Hani Baragwanath Academic Hospital into a prospective mixed-methods pilot study. Demographic and anthropometric data, HbA1c and a lipid panel were collected. Women then wore two consecutive Freestyle Libre 2 patches for a total of 28 days. In-depth interviews were undertaken with all 10 women on study exit to explore themes of acceptability and the use of technology during pregnancy. Thematic analysis was performed on the qualitative data while exploratory data-analysis techniques were applied to the CGM data. Pregnant women (n = 10) had a mean (SD) age of 29.81 years (4.39), with most being unemployed (8), unmarried (8) and without a tertiary degree (7). Analysis suggests that fear of use was greater than the actual discomfort experienced during use of the CGM patch. The main barrier to use was the patch falling off and women being uncomfortable to reapply it. This was borne out by all 10 women wearing the first patch for at least 12 of the 14 days, but only 4 managing the same with patch two – primarily applied by themselves at home. Women expressed support for the use of technology during pregnancy, especially as it related to feeling that their pregnancy was being monitored and that they were being supported. In this pilot study, women overwhelmingly found the wearing of a CGM patch during pregnancy to be acceptable. Feasibility was reasonable with most data being successfully retrieved from the devices over a two-week period. Longer use was found to have additional challenges. The use of CGM patches appear to be a possible candidate for inclusion in GDM prevention or behavioural interventions during pregnancy in South Africa. [ABSTRACT FROM AUTHOR]

Background: In 2018, South Africa developed 24-hour movement behavior guidelines for children from birth to 5 years. This study reports on the stakeholder consultation as part of this development process. Methods: An online survey was completed by 197 participants; 9 focus groups (with parents/caregivers, early childhood development practitioners, and community health workers, total n = 70) were conducted, and a meeting with stakeholders from government and nongovernment organizations (n = 15) was held. Results: In the online survey, stakeholders overwhelmingly agreed with the guidelines (97.0%) and recognized the benefit of putting the guidelines into practice (88.8%). Most online survey respondents (88.3%) reported that the guidelines would benefit all South African children equally. Responses to open-ended questions in the online survey and focus group discussions revealed issues including safety and nutrition of children, perceived parental barriers to using the guidelines, and education. Training and provision of educational materials were identified from all stakeholders as key in the dissemination and implementation of the guidelines. Conclusions: The findings informed the development of the South African 24-hour movement behavior guidelines and revealed several important factors to address in the dissemination and implementation of the guidelines to ensure that they are applicable and equitable in South Africa. [ABSTRACT FROM AUTHOR]

Background: Chest X-ray offers high sensitivity and acceptable specificity as a tuberculosis screening tool, but in areas with a high burden of tuberculosis, there is often a lack of radiological expertise to interpret chest X-ray. Computer-aided detection systems based on artificial intelligence are therefore increasingly used to screen for tuberculosis-related abnormalities on digital chest radiographies. The CAD4TB software has previously been shown to demonstrate high sensitivity for chest X-ray tuberculosis-related abnormalities, but it is not yet calibrated for the detection of non-tuberculosis abnormalities. When screening for tuberculosis, users of computer-aided detection need to be aware that other chest pathologies are likely to be as prevalent as, or more prevalent than, active tuberculosis. However, non--tuberculosis chest X-ray abnormalities detected during chest X-ray screening for tuberculosis remain poorly characterized in the sub-Saharan African setting, with only minimal literature. Case presentation: In this case series, we report on four cases with non-tuberculosis abnormalities detected on CXR in TB TRIAGE + ACCURACY (ClinicalTrials.gov Identifier: NCT04666311), a study in adult presumptive tuberculosis cases at health facilities in Lesotho and South Africa to determine the diagnostic accuracy of two potential tuberculosis triage tests: computer-aided detection (CAD4TB v7, Delft, the Netherlands) and C-reactive protein (Alere Afinion, USA). The four Black African participants presented with the following chest X-ray abnormalities: a 59-year-old woman with pulmonary arteriovenous malformation, a 28-year-old man with pneumothorax, a 20-year-old man with massive bronchiectasis, and a 47-year-old woman with aspergilloma. Conclusions: Solely using chest X-ray computer-aided detection systems based on artificial intelligence as a tuberculosis screening strategy in sub-Saharan Africa comes with benefits, but also risks. Due to the limitation of CAD4TB for non-tuberculosis-abnormality identification, the computer-aided detection software may miss significant chest X-ray abnormalities that require treatment, as exemplified in our four cases. Increased data collection, characterization of non-tuberculosis anomalies and research on the implications of these diseases for individuals and health systems in sub-Saharan Africa is needed to help improve existing artificial intelligence software programs and their use in countries with high tuberculosis burden. [ABSTRACT FROM AUTHOR]

Introduction: South Africa has the highest burden of HIV in the world with over 8 million people living with HIV. Young women and girls account for a quarter of new HIV infections while making up only 10% of the population. A key driver of HIV incidence is transactional and survival sex between adolescent girls or young women and older men (the latter referred to as 'sugar-daddies' or 'blessers'). This paper expands on the existing literature on age-disparate and intergenerational relationships to provide social and behavioural interpretations of how young men, commonly omitted from studies on this topic, and women in concurrent relationships with both their peers and older partners perceive and navigate sexual risk. Method: We conducted a qualitative study in a rural setting of uMgungundlovu District, KwaZulu-Natal Province, with purposively selected male and female participants aged 18-24 years old in age-disparate relationships. Semistructured in-depth interviews (IDI) were conducted and analysed using interpretative phenomenological analysis (IPA) to explore existing information, motivations, and behavioural practices around relationships and sexual risk. Results: The themes and related sub-themes found through IPA included the following: (1) navigating dating: narratives that show a strong preference for being in an age-disparate relationship; the challenges that young people face when choosing an older person as a side partner; and social media applications seen as creating opportunities to meet side partners; and (2) the distribution of love and trust in a multi-party sexual network: condom (mis)use differentiates between straights--those in a serious relationship--and sides; and the power of eye-test seroguessing, the praxis of testing people visually for HIV in nullifying existing knowledge about sexual and reproductive health risk. Discussion: This research offers an understanding of how schemas of noncondom use are organised. We observed that while condom-less sex is often viewed as essential to building social capital in a serious relationship, it is not the only factor that determines sexual relationship power. Eye-test seroguessing not only develops consortium (trust, reciprocity, and solidarity), but it fulfils the psycho-social need to belong to a network of serious relationships. Moreover, it is critical to the enactment of masculinities because it consolidates femininity to keep men happy, i.e., by being passive in the sexual encounter, women constrain their self-efficacy to act contrary to the conventions of reputable women. Therefore, it is plausible that in the serosorting that occurs prior to unprotected sexual acts, the power of eye-test seroguessing limits the ability to engage in safe sexual practices. [ABSTRACT FROM AUTHOR]

Introduction: In South Africa, public perceptions of the COVID-19 pandemic and risk mitigation measures remain mixed. To better understand health behaviours in the context of COVID-19, a qualitative study was conducted, which aimed to investigate perceptions relating to the COVID-19 pandemic among the South African adult population. Methods: Twelve online focus groups were conducted across the following age groups: 18–34, 35–54, 55 + years old (total n = 70) in December 2021. Diversity across socioeconomic status, geographical areas, and urban and rural settings was maximised, with an equal representation of men and women. Focus groups were conducted, and audio recorded using an online platform, transcribed verbatim and thematically analysed using MAXQDA. Results: There were mixed perceptions around the pandemic, however, the majority of participants appreciated government actions at the onset of the pandemic and as a result government trust was reported to have initially been high. Nevertheless, as the pandemic progressed, challenges relating to government communication around the pandemic, the inconsistent application of preventative measures by government, the use of soldiers to enforce preventative measures, the banning of alcohol and cigarettes, government corruption and the pervasiveness of social media were reported to have eroded government trust, negatively impacting the uptake of preventative measures. Economic and psychological impacts were experienced differently across income groups. Low-income earners, who already had pre-existing economic challenges reported increased psychological and financial strain. While the once cushioned middle class reported an increase in job insecurity accompanied by psychological challenges. High income earners did not report economic challenges but reported being affected psychologically. Though, low-income earners reported an appreciation of the government financial relief afforded to them middle income earners appeared to not have received adequate financial support. Conclusion: With the existing mistrust of government, there is need for government to leverage existing trusted sources in communities to aid in the implementation of preventative measures. These findings support the development of context specific solutions to address challenges faced at different socioeconomic levels. [ABSTRACT FROM AUTHOR]

Diagnostic accuracy studies in pulmonary tuberculosis (PTB) are complicated by the lack of a perfect reference standard. This limitation can be handled using latent class analysis (LCA), assuming independence between diagnostic test results conditional on the true unobserved PTB status. Test results could remain dependent, however, e.g. with diagnostic tests based on a similar biological basis. If ignored, this gives misleading inferences. Our secondary analysis of data collected during the first year (May 2018 –May 2019) of a community-based multi-morbidity screening program conducted in the rural uMkhanyakude district of KwaZulu Natal, South Africa, used Bayesian LCA. Residents of the catchment area, aged ≥15 years and eligible for microbiological testing, were analyzed. Probit regression methods for dependent binary data sequentially regressed each binary test outcome on other observed test results, measured covariates and the true unobserved PTB status. Unknown model parameters were assigned Gaussian priors to evaluate overall PTB prevalence and diagnostic accuracy of 6 tests used to screen for PTB: any TB symptom, radiologist conclusion, Computer Aided Detection for TB version 5 (CAD4TBv5≥53), CAD4TBv6≥53, Xpert Ultra (excluding trace) and culture. Before the application of our proposed model, we evaluated its performance using a previously published childhood pulmonary TB (CPTB) dataset. Standard LCA assuming conditional independence yielded an unrealistic prevalence estimate of 18.6% which was not resolved by accounting for conditional dependence among the true PTB cases only. Allowing, also, for conditional dependence among the true non-PTB cases produced a 1.1% plausible prevalence. After incorporating age, sex, and HIV status in the analysis, we obtained 0.9% (95% CrI: 0.6, 1.3) overall prevalence. Males had higher PTB prevalence compared to females (1.2% vs. 0.8%). Similarly, HIV+ had a higher PTB prevalence compared to HIV- (1.3% vs. 0.8%). The overall sensitivity for Xpert Ultra (excluding trace) and culture were 62.2% (95% CrI: 48.7, 74.4) and 75.9% (95% CrI: 61.9, 89.2), respectively. Any chest X-ray abnormality, CAD4TBv5≥53 and CAD4TBv6≥53 had similar overall sensitivity. Up to 73.3% (95% CrI: 61.4, 83.4) of all true PTB cases did not report TB symptoms. Our flexible modelling approach yields plausible, easy-to-interpret estimates of sensitivity, specificity and PTB prevalence under more realistic assumptions. Failure to fully account for diagnostic test dependence can yield misleading inferences. [ABSTRACT FROM AUTHOR]

Commercial applications of artificial intelligence (AI) in the form of Large Language Models (LLMs) and Generative AI have taken centre stage in the media sphere, business, public policy, and education. The ramifications for the field of child psychology and psychiatry are being debated and veer between LLMs as potential models for development and applications of generative AI becoming environmental factors for human development. This Editorial briefly discusses developmental research on generative AI and the potential impact of generative AI on the hybrid social world in which young people grow up. We end by considering that the rapid developments justify increasing attention in our field. [ABSTRACT FROM AUTHOR]

Background: Of the 8 million people in South Africa living with HIV, 74% of persons living with HIV are on antiretroviral therapy (ART) and 65% are virally suppressed. Detectable viral load results in HIV-associated morbidity and mortality and HIV transmission. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load. HIV differentiated service delivery (DSD) has simplified ART delivery for clients who achieve viral suppression and engage in care. However, DSD needs adaptation to serve clients who are not engaged in care. Methods: A Sequential Multiple Assignment Randomized Trial will be undertaken in KwaZulu-Natal, South Africa, to test adaptive ART delivery for persons with detectable viral load and/or who are not engaged in care. The types of differentiated service delivery (DSD) which will be examined in this study are clinic-based incentives, community-based smart lockers, and home delivery. The study plans to enroll up to 900 participants-people living with HIV, eligible for ART, and who are not engaged in care. The study aims to assess the proportion of ART-eligible persons living with HIV who achieve viral suppression at 18 months. The study will also evaluate the preferences of clients and providers for differentiated service delivery and evaluate the cost-effectiveness of adaptive HIV treatment for those who are not engaged in care. Discussion: To increase population-level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates the evaluation of a stepped, adaptive approach to achieving viral suppression with "right-sized" interventions for patients most in need of effective and efficient HIV care delivery strategies. Trial registration: ClinicalTrials.gov NCT05090150. Registered on October 22, 2021 [ABSTRACT FROM AUTHOR]

Despite significant gains in HIV testing, treatment and prevention in sub-Saharan Africa, male engagement and retention in HIV care remains a challenge. We conducted in-depth interviews with 25 men with HIV (MWH) living in rural South Africa to explore how men's reproductive goals could inform approaches to engage men and their female partners in HIV care and prevention. Themes were organised into opportunities and barriers for HIV care, treatment and prevention that men articulated as important to their reproductive goals at the individual, couple and community levels. At the individual level, men are motivated to remain healthy so they can raise a healthy child. At the couple level, the importance of maintaining a healthy partner to raise children may promote serostatus-disclosure, testing and encourage men to support partners to access HIV prevention. At the community level, men described the need to be seen as fathers who provide for their families as important motivators to engage in care. Men also articulated barriers including low knowledge about antiretroviral-based HIV prevention, lack of trust within partnerships and community stigma. Addressing reproductive goals of MWH may be an untapped path for promoting male engagement in HIV care and prevention for their partners. [ABSTRACT FROM AUTHOR]

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This Viewpoint describes ways in which artificial intelligence–powered large language models may be used to improve the delivery of mental health services worldwide. [ABSTRACT FROM AUTHOR]

Background: There is an increasingly urgent gap in knowledge regarding the translation of effective HIV prevention and care programming into scaled clinical policy and practice. Challenges limiting the translation of efficacious programming into national policy include the paucity of proven efficacious programs that are reasonable for clinics to implement and the difficulty in moving a successful program from research trial to scaled programming. This study aims to bridge the divide between science and practice by exploring health care providers' views on what is needed to implement new HIV programs within existing HIV care.Methods: We conducted 20 in-depth interviews with clinic managers and clinic program implementing staff and five key informant interviews with district health managers overseeing programming in the uMgungundlovu District of KwaZulu-Natal Province, South Africa. Qualitative data were analyzed using a template approach. A priori themes were used to construct templates of relevance, including current care context for HIV and past predictors of successful implementation. Data were coded and analyzed by these templates.Results: Heath care providers identified three main factors that impact the integration of HIV programming into general clinical care: perceived benefits, resource availability, and clear communication. The perceived benefits of HIV programs hinged on the social validation of the program by early adopters. Wide program availability and improved convenience for providers and patients increased perceived benefit. Limited staffing capacity and a shortage of space were noted as resource constraints. Programs that specifically tackled these constraints through clinic decongestion were reported as being the most successful. Clear communication with all entities involved in clinic-based programs, some of which include external partners, was noted as central to maximizing program function and provider uptake.Conclusions: Amid the COVID-19 pandemic, new programs are continuously being developed for implementation at the primary health care level. A better understanding of the factors that facilitate and prevent programmatic success will improve public health outcomes. Implementation is likely to be most successful when programs capitalize on endorsements from early adopters, tackle resource constraints, and foster greater communication among partners responsible for implementation. [ABSTRACT FROM AUTHOR]

Background: Between 2012 and 2015, the Uthando Lwethu (UL) study demonstrated that a theory-based behavioural couples-focused intervention significantly increased participation in couples HIV testing and counselling (CHTC) among South African couples who had never previously tested for HIV together or mutually disclosed their HIV status, 42% compared to 12% of the control group at 9 months follow-up. Although effective, we were nonetheless concerned that in this high prevalence setting the majority (58%) of intervention couples chose not to test together. In response we optimised the UL intervention and in a new study, 'Igugu Lethu', we are evaluating the success of the optimised intervention in promoting CHTC.Methods: One hundred eighty heterosexual couples, who have been in a relationship together for at least 6 months, are being recruited and offered the optimised couples-focused intervention. In the Igugu Lethu study, we have expanded the health screening visit offered to couples to include other health conditions in addition to CHTC. Enrolled couples who choose to schedule CHTC will also have the opportunity to undertake a random blood glucose test, blood pressure and BMI measurements, and self-sample for STI testing as part of their health screening. Individual surveys are administered at baseline, 4 weeks and 4 months follow-up. The proportion of couples who decide to test together for HIV will be compared to the results of the intervention arm in the UL study (historical controls). To facilitate this comparison, we will use the same recruitment and follow-up strategies in the same community as the previous UL study.Discussion: By strengthening communication and functioning within the relationship, the Igugu Lethu study, like the previous UL study, aims to transform the motivation of individual partners from a focus on their own health to shared health as a couple. The Igugu Lethu study findings will answer whether the optimised couples-focused behavioural intervention and offering CHTC as part of a broader health screening for couples can increase uptake of CHTC by 40%, an outcome that would be highly desirable in populations with high HIV prevalence.Trial Registration: Retrospectively registered. ISRCTN Registry ISRCTN 46162564 Registered on 26th May 2022. [ABSTRACT FROM AUTHOR]

The impacts of early pregnancy and young motherhood on everyday life, including interpersonal and individual behavior, are not well-known. Passive digital sensing on mobile technology including smartphones and passive Bluetooth beacons can yield information such as geographic movement, physical activity, and mother-infant proximity to illuminate behavioral patterns of a mother's everyday in Nepal. We contribute to mixed-methods research by triangulating passive sensing data (GPS, accelerometry, Bluetooth proximity) with multiple forms of qualitative data to characterize behavioral patterns and experiences of young motherhood in the first year postpartum. We triangulated this digital information in a constant comparative analysis with in-depth interviews, daily diaries, and fieldnotes. We reveal typical behavioral patterns of rural young mothers and highlight opportunities for integrating this information to improve health and well-being. [ABSTRACT FROM AUTHOR]

This scoping review synthesises evidence on mHealth in South Africa specifically related to the use and application of mobile technology, the population groups targeted, and the health outcomes measured. Three scholarly databases were searched, data was extracted using standard scoping review methods. Of 287 peer-reviewed articles, 36 articles meeting inclusion criteria were analysed. Mobile applications and short-messaging services were the primary technologies employed by mHealth interventions which increasingly incorporates bi-directional communication. Published research has increased since 2016 with the majority of studies carried out in three provinces, the Western Cape, KwaZulu-Natal, and Gauteng. This paper provides an overview of mHealth in South Africa with recommendations for mHealth integration into private and public healthcare. [ABSTRACT FROM AUTHOR]

Introduction: To sustainably provide good quality care to increasing numbers of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in resource-limited settings, care delivery must shift from a "one-size-fits-all" approach to differentiated service delivery models. Such models should reallocate resources from PLHIV who are doing well to groups of PLHIV who may need more attention, such as those with treatment failure. The VIral load Triggered ART care Lesotho (VITAL) trial assesses a viral load (VL)-, participant's preference-informed, electronic health (eHealth)-supported, automated differentiated service delivery model (VITAL model). With VITAL, we aim to assess if the VITAL model is at least non-inferior to the standard of care in the proportion of participants engaged in care with viral suppression at 24 months follow-up and if it is cost-saving. Methods: The VITAL trial is a pragmatic, multicenter, cluster-randomized, non-blinded, non-inferiority trial with 1:1 allocation conducted at 18 nurse-led, rural health facilities in two districts of northern Lesotho, enrolling adult PLHIV taking ART. In intervention clinics, providers are trained to implement the VITAL model and are guided by a clinical decision support tool, the VITALapp. VITAL differentiates care according to VL results, clinical characteristics, sub-population and participants' and health care providers' preferences. Expected outcomes: Evidence on the effect of differentiated service delivery for PLHIV on treatment outcomes is still limited. This pragmatic cluster-randomized trial will assess if the VITAL model is at least non-inferior to the standard of care and if it is cost saving. Trial registration: The study has been registered with clinicaltrials.gov (Registration number NCT04527874; August 27, 2020). [ABSTRACT FROM AUTHOR]

Introduction: UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection. Difficulties in linking to care following a positive HIV test have impeded progress towards meeting treatment targets. Community‐based HIV services may reduce linkage barriers and have been associated with high retention and favourable clinical outcomes. We use qualitative data from The Delivery Optimization of Antiretroviral Therapy (DO ART) Study, a three‐arm randomized trial of community ART initiation, monitoring and re‐supply conducted in western Uganda and KwaZulu‐Natal South Africa, to identify mechanisms through which community ART delivery may improve treatment outcomes, defined as viral suppression in people living with HIV (PLHIV). Methods: We conducted open‐ended interviews with a purposeful sample of 150 DO ART participants across study arms and study sites, from October 2016 to November 2019. Interviews covered experiences of: (1) HIV testing; (2) initiating and refilling ART; and (3) participating in the DO ART Study. A combined inductive content analytic and thematic approach was used to characterize mechanisms through which community delivery of ART may have contributed to viral suppression in the DO ART trial. Results: The analysis yielded four potential mechanisms drawn from qualitative data representing the perspectives and priorities of DO ART participants. Empowering participants to schedule, re‐schedule and select the locations of community‐based visits via easy phone contact with clinical staff is characterized as flexibility. Integration refers to combining the components of clinic‐based visits into single interaction with a healthcare provider. Providers" willingness to talk at length with participants during visits, addressing non‐HIV as well as HIV‐related concerns, is termed "a slower pace". Finally, increased efficiency denotes the time savings and increased income‐generating opportunities for participants brought about by delivering services in the community. Conclusions: Understanding the mechanisms through which HIV service delivery innovations produce an effect is key to transferability and potential scale‐up. The perspectives and priorities of PLHIV can indicate actionable changes for HIV care programs that may increase engagement in care and improve treatment outcomes. [ABSTRACT FROM AUTHOR]

Background: Passive sensor data from mobile devices can shed light on daily activities, social behavior, and maternal-child interactions to improve maternal and child health services including mental healthcare. We assessed feasibility and acceptability of the Sensing Technologies for Maternal Depression Treatment in Low Resource Settings (StandStrong) platform. The StandStrong passive data collection platform was piloted with adolescent and young mothers, including mothers experiencing postpartum depression, in Nepal.Methods: Mothers (15-25 years old) with infants (< 12 months old) were recruited in person from vaccination clinics in rural Nepal. They were provided with an Android smartphone and a Bluetooth beacon to collect data in four domains: the mother's location using the Global Positioning System (GPS), physical activity using the phone's accelerometer, auditory environment using episodic audio recording on the phone, and mother-infant proximity measured with the Bluetooth beacon attached to the infant's clothing. Feasibility and acceptability were evaluated based on the amount of passive sensing data collected compared to the total amount that could be collected in a 2-week period. Endline qualitative interviews were conducted to understand mothers' experiences and perceptions of passive data collection.Results: Of the 782 women approached, 320 met eligibility criteria and 38 mothers (11 depressed, 27 non-depressed) were enrolled. 38 mothers (11 depressed, 27 non-depressed) were enrolled. Across all participants, 5,579 of the hour-long data collection windows had at least one audio recording [mean (M) = 57.4% of the total possible hour-long recording windows per participant; median (Mdn) = 62.6%], 5,001 activity readings (M = 50.6%; Mdn = 63.2%), 4,168 proximity readings (M = 41.1%; Mdn = 47.6%), and 3,482 GPS readings (M = 35.4%; Mdn = 39.2%). Feasibility challenges were phone battery charging, data usage exceeding prepaid limits, and burden of carrying mobile phones. Acceptability challenges were privacy concerns and lack of family involvement. Overall, families' understanding of passive sensing and families' awareness of potential benefits to mothers and infants were the major modifiable factors increasing acceptability and reducing gaps in data collection.Conclusion: Per sensor type, approximately half of the hour-long collection windows had at least one reading. Feasibility challenges for passive sensing on mobile devices can be addressed by providing alternative phone charging options, reverse billing for the app, and replacing mobile phones with smartwatches. Enhancing acceptability will require greater family involvement and improved communication regarding benefits of passive sensing for psychological interventions and other health services. Registration International Registered Report Identifier (IRRID): DERR1-10.2196/14734. [ABSTRACT FROM AUTHOR]

Sub-Saharan Africa has been heavily impacted by the HIV/AIDS epidemic. Social data (e.g., social media, internet search, wearable device, etc) show great promise assisting in public health and HIV surveillance. However, research on this topic has primarily focused in higher resource settings, such as the United States. It is especially important to study the prevalence and potential use of these data sources and tools in low- and middle-income countries (LMIC), such as Sub-Saharan Africa, which have been heavily impacted by the HIV epidemic, to determine the feasibility of using these technologies as surveillance and intervention tools. Accordingly, we 1) described the prevalence and characteristics of various social technologies within South Africa, 2) using Twitter, Instagram, and YouTube as a case study, analyzed the prevalence and patterns of social media use related to HIV risk in South Africa, and 3) mapped and statistically tested differences in HIV-related social media posts within regions of South Africa. Geocoded data were collected over a three-week period in 2018 (654,373 tweets, 90,410 Instagram posts and 14,133 YouTube videos with 1,121 comments). Of all tweets, 4,524 (0.7%) were found to related to HIV and AIDS. The percentage was similar for Instagram 95 (0.7%) but significantly lower for YouTube 18 (0.1%). We found regional differences in prevalence and use of social media related to HIV. We discuss the implication of data from these technologies in surveillance and interventions within South Africa and other LMICs. [ABSTRACT FROM AUTHOR]

The Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) Partnership is an initiative to reduce new HIV infections in Adolescent Girls and Young Women (AGYW) in 15 sub-Saharan countries. It is implemented through the delivery of a comprehensive package of evidence-based approaches and interventions in health, but also with an emphasis on addressing key drivers of high HIV prevalence in AGYW including poverty, gender inequality, sexual violence, lack of education, and social isolation and exclusion, which limit access to information, support, services, and livelihood opportunities. This study aimed to investigate the DREAMS initiative in Lesotho by comparing AGYW and their caregivers who had received two or more of the intervention services to match peers who had not yet participated in the program. A random sample of 150 AGYW were selected from implementing partner intervention lists, 126 (84%) of whom were enrolled. While HIV status was unknown, Dreamers across all age groups reported lower levels of sexual risk (OR 1.28; CI 1.01–1.63) and higher levels of self-efficacy (OR 0.85; CI 0.78–0.93). Dreamers were also more likely to have access to savings (Chi-Square 9.1, df 3, p < 0.05) as well as a plan for how to spend the money they earn (Chi-Square 11.0, df 4, p < 0.05). The parenting program was less successful with no meaningful difference being observed between the two groups of caregivers. These findings suggest that such AGYW in Lesotho who have participated in the initiative have shown improvements in their psychosocial and financial wellbeing as compared to their peers. [ABSTRACT FROM AUTHOR]

There has been a recent increase in debates on the ethics of social media research, passive sensor data collection, and big data analytics. However, little evidence exists to describe how people experience and understand these applications of technology. This study aimed to passively collect data from mobile phone sensors, lapel cameras, and Bluetooth beacons to assess people's understanding and acceptance of these technologies. Seven households were purposefully sampled and data collected for 10 days. The study generated 48 hr of audio data and 30,000 images. After participant review, the data were destroyed and in-depth interviews conducted. Participants found the data collected acceptable and reported willingness to participate in similar studies. Key risks included that the camera could capture nudity and sex acts, but family review of footage before sharing helped reduce concerns. The Emanuel et al. ethics framework was found to accommodate the concerns and perspectives of study participants. [ABSTRACT FROM AUTHOR]

This study uses the bioecological framework and methodology to select items for and to test a multidimensional structure of a measure of children's economic well-being in a multi-community sample of children (7–11 years) and their households (N = 1958) from KwaZulu-Natal, a poor and under-served region of South Africa. Economic well-being was assessed using questionnaires completed by children's caregivers and household heads. Exploratory factor analysis of four random split halves identified three dimensions of economic well-being: Fiscal Appraisal (subjective experiences of access to/allocation of resources), Material Assets (durable goods and living environment), and Fiscal Capacity (traditional measures of poverty: income, expenditures, employment). Confirmatory factor analysis verified the higher order model of economic well-being with the three dimensions. Invariance testing using multiple group factor analysis indicated confidence for use of this measure with varying types of communities in South Africa. The results reflect the multidimensional nature of economic well-being. Thus, the often-used money metric measures of poverty likely paint an incomplete picture of children's actual economic well-being. Because our sample consists of impoverished households, our measure of economic well-being is sensitive to variation at the deep end of poverty. Implications for theory and future research are discussed. [ABSTRACT FROM AUTHOR]

Community-based HIV testing and counseling (HTC) programs have become an important part of the healthcare system in South Africa and other low- and middle-income countries with a high HIV prevalence and strained primary healthcare system. Current HTC programs excel at identifying people living with HIV (PLH) but leave gaps in linkage to care and antiretroviral therapy (ART) as most HTC programs do not have the capacity to ensure that linkage has occurred. This article presents the protocol for an mHealth study, that is, pilot testing a mobile platform in KwaZulu-Natal (KZN), South Africa, to improve linkage to care and ART adherence after home-based HTC. Testing data are shared with designated clinics. PLH are identified using fingerprint scans, mobile numbers, or South African IDs. If PLH do not present at a designated clinic after testing HIV positive, study field staff are sent SMS alerts to prompt follow-up visits. Similarly, if PLH do not refill ART prescriptions after their initial 1-month dose runs out, SMS alerts that are sent to field staff. This paper presents the mHealth study protocol and baseline sample characteristics (N = 101 PLH). Analyses will summarize rates of linkage to care and ART prescription refills. Cost-effectiveness analyses will examine the costs and benefits of linkage and ART adherence using our mHealth system. Linkage to care rates will be compared between our study and a historical control, that is, provided by a prior HTC program that was conducted in KZN without our mHealth system (n = 615). [ABSTRACT FROM AUTHOR]