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Purpose of ReviewDespite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions.Recent FindingsThere are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement.SummaryThere are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.

IntroductionAttrition from HIV treatment is high during patients’ first 6 months after antiretroviral therapy (ART) initiation and patients with less than 6 months on ART are systematically excluded from most differentiated service delivery (DSD) models, which are intended to reduce attrition. Despite eligibility criteria requiring greater than 6 months on ART, some patients enroll earlier. Using routinely-collected medical record data in Zambia, we compared loss to follow-up (LTFU) among patients enrolling in DSD models early (MethodsWe extracted data from electronic medical records for adults (≥15 years) who initiated ART between 01/01/2019 and 31/12/2019 and evaluated LTFU, defined as >90 days late for last scheduled medication pickup, at 18 months for “early enrollers” (DSD enrolment after ResultsFor 6,340 early enrollers and 25,857 established enrollers there were no important differences between the groups in sex (61% female), age (median 37 years), or setting (65% urban). ART refill intervals were longer for established vs early enrollers (72% vs 55% were given 4–6-month refills). LTFU at 18 months was 3% (192/6,340) for early enrollers and 5% (24,646/25,857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio [95% confidence interval] 0.59 [0.50-0.68]).ConclusionsPatients enrolled in DSD models in Zambia with < 6 months on ART were more likely to be retained in care than patients referred after they were established on ART. A limitation of the analysis is that early enrollers may have been selected for DSD participation due to providers’ and patients’ expectations about future retention. Offering DSD model entry to at least some ART patients

Purpose of review Differentiated service delivery (DSD) has emerged as an approach for HIV programs seeking to better serve the needs of people living with HIV, reduce unnecessary burdens on the health system, and improve client outcomes. We reviewed recent evidence that addresses the challenge of DSD scale-up. Recent findings Most current evidence focuses on treatment of clinically stable adult clients in high HIV prevalence settings. Nonetheless, a growing body of research is emerging on how the concept of differentiation is being applied to HIV testing, linkage, and initiation; service delivery to specific demographic groups including key populations - MSM, people who inject drugs, people in prisons, sex workers, and transgender people; service delivery to adolescents and pregnant women; and impact on related medical conditions like advanced HIV. There is also an increasing emphasis on measuring client experience. Key barriers to scale-up include the capacity of monitoring and evaluation systems, access to viral load monitoring and funding for community-led demand generation efforts. Another barrier is the lack of sufficient data to evaluate the various manifestations of the DSD model. Summary Emerging evidence is providing welcome nuance to the discourse on the concept of DSD for HIV. The challenge will be taking evolving DSD concepts from pilot to scale. Countries must review their particular context, define the expected needs of their clients in different settings, introduce appropriate models - and be willing to adjust programming based on quantitative and qualitative outcomes.

Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.

Introduction In response to COVID‐19, national ministries of health adapted HIV service delivery guidelines to ensure uninterrupted access to antiretroviral therapy (ART) and limit the frequency of contact with health facilities. In this commentary, we summarize four ways in which differentiated service delivery (DSD) for HIV treatment has been accelerated during COVID‐19 in policy and implementation in sub‐Saharan Africa (SSA) – (i) expanding eligibility for DSD for HIV treatment, (ii) extending multi‐month dispensing (MMD) and reducing the frequency of clinical consultations, (iii) emphasizing community‐based models and (iv) integrating/aligning with TB preventative therapy (TPT), non‐communicable disease (NCD) treatments and family planning commodities. Discussion Across SSA in 2020, countries both adapted and emphasized policies supporting DSD for HIV treatment in response to COVID‐19. Access to DSD for HIV treatment was expanded by reducing the time required on ART before eligibility and being more inclusive of specific populations including children and adolescents, pregnant and breastfeeding women and those on second‐ and third‐line regimens. Access to extended ART refills, or MMD, was accelerated across many countries. A renewed focus was given to out‐of‐facility community‐based models of ART distribution. In some settings, there was acknowledgement of the need to integrate or align other chronic medications with ART. Conclusions Adaptations to DSD for HIV treatment in response to COVID‐19 have resulted in rapid policy change and in some cases, acceleration of implementation in SSA. As the COVID‐19 pandemic evolves, there is a critical need to assess the impact of these adaptations and, where beneficial, ensure that policies implemented in response to COVID‐19 become the new normal.

Introduction The antiretroviral therapy (ART) adherence club (AC) model has supported clinically stable HIV patients’ retention with group ART refills and psychosocial support. Reducing visit frequency by increasing ART refills to six months could further benefit patients and unburden health systems. We conducted a pragmatic non‐inferiority cluster randomized trial comparing standard of care (SoC) ACs and six‐month refill intervention ACs in a primary care facility in Khayelitsha, South Africa. Methods Existing community‐based and facility‐based ACs were randomized to either SoC or intervention ACs. SoC ACs met five times annually, receiving two‐month refills with a four‐month refill over year‐end. Blood was drawn at one AC visit with a clinical assessment at the next. Intervention ACs met twice annually receiving six‐month refills, with an individual blood collection visit before the annual clinical assessment AC visit. The first study visits were in October and November 2017 and participants followed for 27 months. We report retention in care, viral load completion and viral suppression (

Differentiated service delivery (DSD)—a “patient-centered approach that simplifies and adapts HIV services across the cascade to serve the needs of people living with HIV (PLHIV) better and reduce unnecessary burdens on the health system1”— has emerged as a core tenet of HIV programs in resource-limited settings.2–4 Practically speaking, DSD is operationalized by adjusting the frequency of visits, the location of service delivery, the cadre of health care worker, and the package of services according to the needs of different groups of PLHIV. Varying the configuration of these factors results in DSD treatment models that often separate clinical visits from antiretroviral therapy (ART) refills including “fast track” refill pick-ups in the facility or community, client-managed community adherence groups and health care worker managed groups.5 Efforts are ongoing to define the extent and impact of DSD scale-up in sub-Saharan Africa.6,7 Current data are sufficient to show that the numbers of people receiving extended medication refills, which is one component of DSD, has risen dramatically. A recent analysis of US President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries (excluding South Africa) reported an increase in the percentage of patients receiving 3 or more months of refills from 46% to 69% between October 2019 and June 2020.8 The COVID-19 epidemic accelerated this rapid change in dispensing practices and the uptake and adaptation of various DSD models across sub-Saharan Africa.9 Preliminary data evaluating the outcomes of DSD treatment programs across multiple countries10 support the concept that continued scale-up of DSD is critical to attaining the ambitious coverage, retention, and quality targets of the global HIV response.11 However, simplifying ART delivery for clinically stable PLHIV is not sufficient to meet all of their health care needs, which often include prevention and treatment of tuberculosis (TB), routine preventive and primary care, family planning (FP), and noncommunicable disease (NCD) services. Providing for these comprehensive needs is essential to the goals of the growing movement to implement Universal Health Care (UHC),12 and integrating some of these services into DSD platforms is a promising avenue to achieve such coverage.13 In this commentary, we highlight opportunities to address the unmet need for coordination of HIV and other priority services and propose a transition from an HIV-focused “DSD 1.0” to a truly patient-centered “DSD 2.0” that is inclusive of additional chronic care services. An initial focus could be on PLHIV, but DSD 2.0 provides a platform for offering any longitudinal or chronic care service to the general population. The goal would remain the same: to scale-up an evidence-based patient-centered approach that reduces unnecessary burdens for individuals and the health system. The proposed DSD framework thus provides an opportunity for the HIV and UHC agendas—which can seem to be at odds at first glance—to leverage each other and achieve greater collective impact.14 A Call for DSD 2.0 UNAIDS has set aspirational goals to end the AIDS epidemic by 2030.11 Global stakeholders are further proposing plans to sustain HIV epidemic control, but the definition of sustainability and the roadmap for achieving it remain unresolved.2,15 It is clear that the historically vertical approach to HIV programming does not naturally lend itself to sustainability in a world whose attention is rapidly shifting toward UHC goals. This shift away from vertical programming is likely to be accelerated by the COVID-19 pandemic, which has emphasized the importance of resilient and integrated national health systems.16 DSD 1.0's intentionally narrow focus on simplifying HIV services and reducing unnecessary burdens on the health care system was critical for building consensus, establishing an evidence base, and driving efforts to achieve scale. However, it does not enhance access to the full range of prevention and treatment services needed by recipients of care. Strategically addressing these needs for the long-term will be critical to maintaining patients' experience of quality of care and maximizing retention,17 and to ensuring both HIV viral suppression and healthy aging for PLHIV.18 This expanded focus is the essence of what we call “DSD 2.0.” WHO's 2016 HIV guidelines provide a template for DSD 2.0. They emphasize the importance of integrating ART services with the most common vertical programs that require repeated follow-up: TB prevention and treatment, FP, and chronic NCDs.4 A majority of adults with HIV will require longitudinal care for such non-HIV services. All PLHIV are eligible for a course of TB preventive therapy (TPT) and between 5% and 10% will develop TB at some point in their lifetimes.19 The unmet need for contraception among women on ART is well-documented, approaching 50% in some settings.20 Chronic NCDs such as diabetes, hypertension, and mental health disorders are also a major issue. Among adults on ART in South Africa, more than 15% have hypertension, more than 5% have diabetes,21 and, as a recent review emphasized, there is a real risk that poor quality of care for such NCDs may undermine the investments made to strengthen HIV programs.22 In most sub-Saharan African countries, PLHIV requiring care for any of these other health needs (with the intermittent exception of TB services) usually seek them in physical locations other than the HIV clinic and often on a different appointment schedule. FP programs are usually run vertically. Clinicians providing HIV services are not always trained in provision of FP nor do they routinely have the commodities available to provide FP at the point of HIV care.23 Women living with HIV are routinely referred to FP clinics, but there is often no communication between the 2 programs to align appointments or to determine best approaches to managing potential interactions between ART and contraceptives.24 The situation is worse for integration with chronic NCD programs. Some countries with strong HIV programs do not have updated national guidelines for hypertension or diabetes, let alone consistent supplies of medications outside of referral facilities. Although HIV commodities are prioritized and often paid for by external donors, NCD commodities must be borne by the country and, as a result, are often accompanied by user fees. Where NCD guidelines and medications are available, there is likely little alignment of appointment scheduling or refills with the ART program,25,26 let alone the provision of NCD screening and treatment within HIV programs. The lack of coordination between these critical services and HIV care puts an unnecessary and, to date, unquantified burden on both the patients and the health system. The burden on patients is experienced in 2 ways—once because a concurrent condition like hypertension often goes undiagnosed in any resource-poor setting and again because, once diagnosed, treatment services are only available in a parallel setting. For example, a patient with both HIV and hypertension may only need to visit an HIV clinic twice a year, but could be required to visit a different clinic monthly for hypertension care. The patient may also be required to pay out-of-pocket for the hypertension services. This fragmented care may prove to be frustrating for many patients and actually disincentivize them to remain engaged in any health services. If DSD remains narrowly focused on ART, it may make HIV treatment more convenient and efficient, but will not comprehensively address the health needs of people engaged in HIV treatment. This outcome may diminish the actual and perceived quality of care, and push patients closer to a “tipping point” where they choose to disengage from the health system altogether, leading to worse outcomes for both conditions.27 The burden on the health system results from having to maintain parallel systems to manage HIV, FP, hypertension, diabetes, and other chronic NCD programs. For example, HIV medical record systems may be robust, but few of them contain information about need for or use of other health services by PLHIV, limiting their usefulness for quality improvement or planning. Meanwhile, few countries have longitudinal record keeping for non-HIV services at all. This blind spot is critical, and reflects similar inefficiencies in supply chain, laboratory, human resources, and other key health system building blocks.28

Differentiated models of service delivery (DSD models) for HIV treatment in sub-Saharan Africa were conceived as a way to manage rapidly expanding populations of experienced patients who are clinically “stable” on antiretroviral therapy (ART). Entry requirements for most models include at least six months on treatment and a suppressed viral load. These models thus systematically exclude newly-initiated patients, who instead experience the conventional model of care, which requires frequent, multiple clinic visits that impose costs on both providers and patients. In this open letter, we argue that the conventional model of care for the first six months on ART is no longer adequate. The highest rates of treatment discontinuation are in the first six-month period after treatment initiation. Newly initiating patients are generally healthier than in the past, with higher CD4 counts, and antiretroviral medications are better tolerated, with fewer side effects and substitutions, making extra clinic visits unnecessary. Improvements in the treatment initiation process, such as same-day initiation, have not been followed by innovations in the early treatment period. Finally, the advent of COVID-19 has made it riskier to require multiple clinic visits. Research to develop differentiated models of care for the first six-month period is needed. Priorities include estimating the minimum number and type of provider interactions and ART education needed, optimizing the timing of a patient’s first viral load test, determining when lay providers can replace clinicians, ensuring that patients have sufficient but not burdensome access to support, and identifying ways to establish a habit of lifelong adherence.

ObjectiveLonger intervals between routine clinic visits and medication refills are part of patient-centred, differentiated service delivery (DSD). They have been shown to improve patient outcomes as well as optimise health services—vital as ‘universal test-and-treat’ targets increase numbers of HIV patients on antiretroviral treatment (ART). This qualitative study explored patient, healthcare worker and key informant experiences and perceptions of extending ART refills to 6 months in adherence clubs in Khayelitsha, South Africa.Design and settingIn-depth interviews were conducted in isiXhosa with purposively selected patients and in English with healthcare workers and key informants. All transcripts were audio-recorded, transcribed and translated to English, manually coded and thematically analysed. The participants had been involved in a randomised controlled trial evaluating multi-month ART dispensing in adherence clubs, comparing 6-month and 2-month refills.ParticipantsTwenty-three patients, seven healthcare workers and six key informants.ResultsPatients found that 6-month refills increased convenience and reduced unintended disclosure. Contrary to key informant concerns about patients’ responsibility to manage larger quantities of ART, patients receiving 6-month refills were highly motivated and did not face challenges transporting, storing or adhering to treatment. All participant groups suggested that strict eligibility criteria were necessary for patients to realise the benefits of extended dispensing intervals. Six-month refills were felt to increase health system efficiency, but there were concerns about whether the existing drug supply system could adapt to 6-month refills on a larger scale.ConclusionsPatients, healthcare workers and key informants found 6-month refills within adherence clubs acceptable and beneficial, but concerns were raised about the reliability of the supply chain to manage extended multi-month dispensing. Stepwise, slow expansion could avoid overstressing supply and allow time for the health system to adapt, permitting 6-month ART refills to enhance current DSD options to be more efficient and patient-centred within current health system constraints.

Purpose of review Differentiated service delivery (DSD) for HIV provides an approach to scaling services that are client-centred and aims to address client challenges whilst reducing the burden on health systems. With access to antiretroviral therapy, people living with HIV are living longer and increasingly present with comorbid conditions, such as hypertension and diabetes. This review presents the syndemic burden of HIV, hypertension and diabetes and highlights opportunities and challenges to leveraging DSD across diseases. Recent findings Prevalence of hypertension and diabetes in the eight highest HIV prevalence countries ranges between 20-24% (31.9% in those >50 years old) and 4-10%, respectively. Service delivery models addressing the concurrent syndemics focus primarily on integration of services. Two DSD examples were found where people living with HIV and other comorbidities had their care and treatment supported in healthcare worker-led facility-based adherence clubs. Summary Key enablers that have supported DSD for HIV such as simplified algorithms, optimized formulations, secure drug supply, and strengthened monitoring and evaluation systems are lacking for hypertension and diabetes and thus pose a major challenge to leveraging DSD models for people with syndemic conditions. However, the DSD approach may also catalyse opportunities to provide person-centred care for these syndemics and more implementation research in this area is warranted.

Differentiated service delivery (DSD) models for HIV often exclude children and adolescents. Given that children and adolescents have lower rates of HIV diagnosis, treatment and viral load suppression, there is a need to use DSD to meet the needs of children and adolescents living with HIV. This commentary reviews the concept of DSD, examines the application of DSD to the care of children and adolescents living with HIV, and describes national guidance on use of DSD for children and adolescents and implementation of DSD for HIV care and treatment in children and adolescents in Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)–supported programmes in seven sub-Saharan countries between 2017 and 2019. Programme descriptions include eligibility criteria, location and frequency of care delivery, healthcare cadre delivering the care, as well as the number of EGPAF-supported facilities supporting each type of DSD model. A range of DSD models were identified. While facility-based models predominate, several countries support community-based models. Despite significant uptake of various DSD models for children and adolescents, there was variable coverage within countries and variability in age criteria for each model. While the recent uptake of DSD models for children and adolescents suggests feasibility, more can be done to optimise and extend the use of DSD models for children and adolescents living with HIV. Barriers to further DSD uptake are described and solutions proposed. DSD models for children and adolescents are a critical tool that can be optimised to improve the quality of HIV care and outcomes for children and adolescents.

Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.

Differentiated care, or differentiated service delivery (DSD), is increasingly being promoted as one of the possible ways to address and improve access, quality, and efficiency of HIV prevention, care, and treatment. Family-centered care has long been promoted within the provision of HIV services, but the full benefits have not necessarily been realized. In this article, we bring together these two approaches and make the case for how family-centered DSD can offer benefits to both people affected by HIV and the health system. Family-centered DSD approaches are presented for HIV testing and antiretroviral therapy (ART) delivery, referencing policies, best practice examples, and evidence from the field. With differentiated family-centered ART delivery, the potential efficiencies gained by extending ART refills can both benefit clients by reducing the frequency and intensity of contact with the health service and lead to health system gains by not requiring multiple providers to care for one family. A family-centered DSD approach should also be leveraged along the HIV care cascade in the provision of prevention technologies and mobilizing family members to receive regular HIV testing. Furthermore, a family-centered lens should be applied wherever DSD is implemented to ensure that, for example, adolescents who are pregnant receive an adapted package of quality care.

Background The antiretroviral therapy (ART) adherence club (AC) differentiated service delivery model, where clinically stable ART patients receive their ART refills and psychosocial support in groups has supported clinically stable patients’ retention and viral suppression. Patients and health systems could benefit further by reducing visit frequency and increasing ART refills. We designed a cluster-randomized control trial comparing standard of care (SoC) ACs and six-month ART refill (Intervention) ACs in a large primary care facility in Khayelitsha, South Africa. Methods Existing ACs were randomized to either the control (SOC ACs) or intervention (Intervention ACs) arm. SoC ACs meet five times annually, receiving two-month ART refills with a four-month ART refill over year-end. Blood is drawn at the AC visit ahead of the clinical assessment visit. Intervention ACs meet twice annually receiving six-month ART refills, with a third individual visit for routine blood collection anytime two-four weeks before the annual clinical assessment AC visit. Primary outcomes will be retention in care, annual viral load assessment completion and viral load suppression. (

BackgroundHIV and TB programs have rapidly scaled-up over the past decade in Sub-Saharan Africa and uninterrupted supplies of those medicines are critical to their success. However, estimates of stock-outs are largely unknown. This survey aimed to estimate the extent of stock-outs of antiretroviral and TB medicines in public health facilities across South Africa, which has the world's largest antiretroviral treatment (ART) program and a rising multidrug-resistant TB epidemic.MethodsWe conducted a cross-sectional telephonic survey (October-December 2015) of public health facilities. Facilities were asked about the prevalence of stock-outs on the day of the survey and in the preceding three months, their duration and impact.ResultsNationwide, of 3547 eligible health facilities, 79% (2804) could be reached telephonically. 88% (2463) participated and 4% (93) were excluded as they did not provide ART or TB treatment. Of the 2370 included facilities, 20% (485) reported a stock-out of at least 1 ARV and/or TB-related medicine on the day of contact and 36% (864) during the three months prior to contact, ranging from 74% (163/220) of health facilities in Mpumalanga to 12% (32/261) in the Western Cape province. These 864 facilities reported 1475 individual stock-outs, with one to fourteen different medicines out of stock per facility. Information on impact was provided in 98% (1449/1475) of stock-outs: 25% (366) resulted in a high impact outcome, where patients left the facility without medicine or were provided with an incomplete regimen. Of the 757 stock-outs that were resolved 70% (527) lasted longer than one month.InterpretationThere was a high prevalence of stock-outs nationwide. Large interprovincial differences in stock-out occurrence, duration, and impact suggest differences in provincial ability to prevent, mitigate and cope within the same framework. End-user monitoring of the supply chain by patients and civil society has the potential to increase transparency and complement public sector monitoring systems.

BACKGROUND The World Health Organization recommends differentiated antiretroviral therapy (ART) delivery with longer visit intervals for clinically stable patients. We examined time trends in visit frequency and associations between criteria for clinical stability and visit frequency in ART programs in Southern Africa. METHODS We included adults on ART from 4 programs with viral-load monitoring, 2 programs with CD4 monitoring, and 4 programs with clinical monitoring of ART. We classified patients as clinically stable based on virological (viral load 200 cells/µL), or clinical (no current tuberculosis) criteria. We used Poisson regression and survival models to examine associations between criteria for clinical stability and the rate of clinic visits. RESULTS We included 180,837 patients. There were trends toward fewer visits in more recent years and with longer ART duration. In all ART programs, clinically stable patients were seen less frequently than patients receiving failing ART, but the strength of the association varied. Adjusted incidence rate ratios comparing visit rates for stable patients with patients on failing ART were 0.82 (95% confidence interval: 0.73 to 0.90) for patients classified based on the virological criterion, 0.81 (0.69 to 0.93) for patients classified based on the clinical criterion, and 0.90 (0.85 to 0.96) for patients classified based on the immunological criterion for stability. CONCLUSION Differences in visit rates between stable patients and patients failing ART were variable and modest overall. Larger differences were seen in programs using virological criteria for clinical stability than in programs using immunological criteria. Greater access to routine viral-load monitoring may increase scale-up of differentiated ART delivery.

BACKGROUND Community-based models of antiretroviral therapy (ART) delivery are widely discussed as a priority in the expansion of HIV treatment services, but data on their effectiveness are limited. We examined outcomes of ART patients decentralized to community-based adherence clubs (CACs) in Cape Town, South Africa and compared these to patients managed in the community health center. METHODS The analysis included 8150 adults initiating ART from 2002 to 2012 in a public sector service followed until the end of 2013. From June 2012, stable patients (on ART >12 months, suppressed viral load) were referred to CACs. Loss to follow-up (LTFU) was compared between services using proportional hazards models with time-varying covariates and inverse probability weights of CAC participation. FINDINGS Of the 2113 CAC patients (71% female, 7% youth ages ≤ 24 years), 94% were retained on ART after 12 months. Among CAC patients, LTFU [adjusted hazard ratio (aHR): 2.17, 95% confidence interval (CI): 1.26 to 3.73 ] and viral rebound (aHR 2.24, 95% CI: 1.00 to 5.04) were twice as likely in youth (16-24 years old) compared with older patients, but no difference in the risk of LTFU or viral rebound was observed by sex (P-values 0.613 and 0.278, respectively). CAC participation was associated with a 67% reduction in the risk of LTFU (aHR: 0.33, 95% CI: 0.27 to 0.40) compared with community health centre, and this association persisted when stratified by patient demographic and clinic characteristics. INTERPRETATION CACs are associated with reduced risk of LTFU compared with facility-based care. Community-based models represent an important development to facilitate ART delivery and possibly improve patient outcomes.

Background: Eligibility for differentiated antiretroviral therapy (ART) delivery models has to date been limited to low-risk stable patients. Objectives: We examined the outcomes of patients who accessed their care and treatment through an ART adherence club (AC), a differentiated ART delivery model, immediately following receiving support to achieve viral suppression after experiencing elevated viral loads (VLs) at a high-burden ART clinic in Khayelitsha, South Africa. Methods: Beginning in February 2012, patients with VLs above 400 copies/mL either on first- or second-line regimens received a structured intervention developed for patients at risk of treatment failure. Patients who successfully suppressed either on the same regimen or after regimen switch were offered immediate enrolment in an AC facilitated by a lay community health worker. We conducted a retrospective cohort analysis of patients who enrolled in an AC directly after receiving suppression support. We analysed outcomes (retention in care, retention in AC care and viral rebound) using Kaplan–Meier methods with follow-up from October 2012 to June 2015. Results: A total of 165 patients were enrolled in an AC following suppression (81.8% female, median age 36.2 years). At the closure of the study, 119 patients (72.0%) were virally suppressed and 148 patients (89.0%) were retained in care. Six, 12 and 18 months after AC enrolment, retention in care was estimated at 98.0%, 95.0% and 89.0%, respectively. Viral suppression was estimated to be maintained by 90.0%, 84.0% and 75.0% of patients at 6, 12 and 18 months after AC enrolment, respectively. Conclusion: Our findings suggest that patients who struggled to achieve or maintain viral suppression in routine clinic care can have good retention and viral suppression outcomes in ACs, a differentiated ART delivery model, following suppression support.

In several studies of antiretroviral treatment (ART) programs for persons with human immunodeficiency virus infection, investigators have reported that there has been a higher rate of loss to follow-up (LTFU) among patients initiating ART in recent years than among patients who initiated ART during earlier time periods. This finding is frequently interpreted as reflecting deterioration of patient retention in the face of increasing patient loads. However, in this paper we demonstrate by simulation that transient gaps in follow-up could lead to bias when standard survival analysis techniques are applied. We created a simulated cohort of patients with different dates of ART initiation. Rates of ART interruption, ART resumption, and mortality were assumed to remain constant over time, but when we applied a standard definition of LTFU, the simulated probability of being classified LTFU at a particular ART duration was substantially higher in recently enrolled cohorts. This suggests that much of the apparent trend towards increased LTFU may be attributed to bias caused by transient interruptions in care. Alternative statistical techniques need to be used when analyzing predictors of LTFU--for example, using "prospective" definitions of LTFU in place of "retrospective" definitions. Similar considerations may apply when analyzing predictors of LTFU from treatment programs for other chronic diseases.

OBJECTIVES: Models of care utilizing task shifting and decentralization are needed to support growing ART programmes. We compared patient outcomes between a doctor-managed clinic and a nurse-managed down-referral site in Cape Town South Africa. METHODS: Analysis included all adults who initiated ART between 2002 and 2011 within a large public sector ART service. Stable patients were eligible for down-referral. Outcomes [mortality loss to follow-up (LTFU) virologic failure] were compared under different models of care using proportional hazards models with time-dependent covariates. RESULTS: Five thousand seven hundred and forty-six patients initiated ART and over 5 years 41% (n = 2341) were down-referred; the median time on ART before down-referral was 1.6 years (interquartile range 0.9-2.6). The nurse-managed down-referral site reported lower crude rates of mortality LTFU and virologic failure compared with the doctor-managed clinic. After adjustment there was no difference in the risk of mortality or virologic failure by model of care. However patients who were down-referred were more likely to be LTFU than those retained at the doctor-managed site (adjusted hazard ratio 1.36; 95% CI 1.09-1.69). Increased levels of LTFU in the nurse-managed vs. doctor-managed service were observed in subgroups of male patients those with advanced disease at initiation and those who started ART in the early years of the programme. CONCLUSION: Reorganization of ART maintenance by down-referral to nurse-managed services is associated with programme outcomes similar to those achieved using doctor-driven primary care services. Further research is necessary to identify optimal models of care to support long-term retention of patients on ART in resource-limited settings. (c) 2014 John Wiley & Sons Ltd.

Objective The ambitious “90-90-90 treatment targets require innovative models of care to support quality ART delivery. While evidence for differentiated models of ART delivery is growing there are few data on the feasibility of scale-up. We describe the implementation of the Adherence Club (AC) model across the Cape Metro health district in Cape Town South Africa between January 2011 and March 2015. Methods Using data from monthly aggregate AC monitoring reports and electronic monitoring systems for the district cohort we report on the number of facilities offering ACs and the number of patients receiving ART care in the AC model. Results Between January 2011 and March 2015 the AC programme expanded to reach 32425 patients in 1308 ACs at 55 facilities. The proportion of the total ART cohort retained in an AC increased from 7.3% at the end of 2011 to 25.2% by March 2015. The number of facilities offering ACs also increased and by the end of the study period 92.3% of patients were receiving ART at a facility that offered ACs. During this time the overall ART cohort doubled from 66616 to 128697 patients. The implementation of the AC programme offset this increase by 51%. Conclusions ACs now provide ART care to more than 30000 patients. Further expansion of the model will require additional resources and support. More research is necessary to determine the outcomes and quality of care provided in ACs and other differentiated models of ART delivery especially when implemented at scale.

There are few population-level insights into the use of traditional healers and other forms of alternative care for the treatment of common mental disorders in sub-Saharan Africa. We examined the extent to which alternative practitioners are consulted, and predictors of traditional healer visits. A national survey was conducted with 3651 adult South Africans between 2002 and 2004, using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate DSM-IV diagnoses for common mood, anxiety, and substance use disorders. A minority of participants with a lifetime DSM-IV diagnosis obtained treatment from Western (29%) or alternative (20%) practitioners. Traditional healers were consulted by 9% of the respondents and 11% consulted a religious or spiritual advisor. Use of traditional healers in the full sample was predicted by older age, black race, unemployment, lower education, and having an anxiety or a substance use disorder. Alternative practitioners, including traditional healers and religious advisors, appear to play a notable role in the delivery of mental health care in South Africa.

Background: The epidemiology of DSM-IV intermittent explosive disorder (IED) is not well characterized in developing country settings. In South Africa, given the high rates of violence and trauma, there is particular interest in traumatic exposures as potential risk factors for IED. Methods: We examined the prevalence and predictors of IED in a nationally representative sample of 4,351 South African adults. IED and other diagnoses based on DSM-IV criteria were assessed using the World Health Organization Composite International Diagnostic Interview (CIDI). A 28-item scale was constructed to measure exposure to traumatic events. Results: Overall, 2.0% of participants (95% CI: 0–4.9%) fulfilled criteria for the narrow definition of IED, and 9.5% (95% CI: 6.6–12.3%) fulfilled criteria for the broad definition of IED. Individuals with IED experienced high rates of comorbid anxiety, mood and substance use disorders compared to non-IED participants. In multivariate analysis, a diagnosis of IED was associated with Caucasian and mixed-race ethnicity, psychiatric comorbidity and exposure to multiple traumatic events. Conclusion: These data suggest a relatively high prevalence of IED in South Africa. By reducing violence and trauma, and by providing appropriate psychological support to trauma survivors, we may be able to reduce rates of IED.

Antiretroviral therapy (ART) initiation is now recommended irrespective of CD4 count. However data on the relationship between CD4 count at ART initiation and loss to follow-up (LTFU) are limited and conflicting.We conducted a cohort analysis including all adults initiating ART (2008-2012) at three public sector sites in South Africa. LTFU was defined as no visit in the 6 months before database closure. The Kaplan-Meier estimator and Cox's proportional hazards models examined the relationship between CD4 count at ART initiation and 24-month LTFU. Final models were adjusted for demographics, year of ART initiation, programme expansion and corrected for unascertained mortality.Among 17 038 patients, the median CD4 at initiation increased from 119 (IQR 54-180) in 2008 to 257 (IQR 175-318) in 2012. In unadjusted models, observed LTFU was associated with both CD4 counts100 cells/μL and CD4 counts ≥300 cells/μL. After adjustment, patients with CD4 counts ≥300 cells/μL were 1.35 (95% CI 1.12 to 1.63) times as likely to be LTFU after 24 months compared to those with a CD4 150-199 cells/μL. This increased risk for patients with CD4 counts ≥300 cells/μL was largest in the first 3 months on treatment. Correction for unascertained deaths attenuated the association between CD4 counts100 cells/μL and LTFU while the association between CD4 counts ≥300 cells/μL and LTFU persisted.Patients initiating ART at higher CD4 counts may be at increased risk for LTFU. With programmes initiating patients at higher CD4 counts, models of ART delivery need to be reoriented to support long-term retention.

Introduction : Increasingly, there is a need for health authority scale up of successfully piloted differentiated models of antiretroviral therapy (ART) delivery. However, there is a paucity of evidence on system-wide outcomes after scale-up. In the Cape Town health district, stable adult patients were referred to adherence clubs (ACs) – a group model of ART delivery with five visits per year. By the end of March 2015, over 32,000 ART patients were in an AC. We describe patient outcomes of a representative sample of AC patients during this scale-up. Methods : Patients enrolled in an AC at non-research supported sites between 2011 and 2014 were eligible for analysis. We sampled 10% of ACs ( n = 100) in quintets proportional to the number of ACs at each facility, linking each patient to city-wide laboratory and service access data to validate retention and virologic outcomes. We digitized registers and used competing risks regression and cross-sectional methods to estimate outcomes: mortality, transfers, loss to follow-up (LTFU) and viral load suppression (≤400 copies/mL). Predictors of LTFU and viral rebound were assessed using Cox proportional hazards models. Results : Of the 3216 adults contributing 4019 person years of follow-up (89% in an AC, median 1.1 years), 70% were women. Retention was 95.2% (95% CI, 94.0-96.4) at 12 months and 89.3% (95% CI, 87.1-91.4) at 24 months after AC enrolment. In the 13 months prior to analysis closure, 88.1% of patients had viral load assessments and of those, viral loads ≤400 copies/mL were found in 97.2% (95% CI, 96.5-97.8) of patients. Risk of LTFU was higher in younger patients and in patients accessing ART from facilities with larger ART cohorts. Risk of viral rebound was higher in younger patients, those that had been on ART for longer and patients that had never sent a buddy to collect their medication. Conclusions : This is the first analysis reporting patient outcomes after health authorities scaled-up a differentiated care model across a high burden district. The findings provide substantial reassurance that stable patients on long-term ART can safely be offered care options, which are more convenient to patients and less burdensome to services. Keywords HIV; antiretroviral therapy; models of care; adherence club; retention; program outcomes (Published: 21 July 2017) Tsondai PR et al. Journal of the International AIDS Society 2017, 20 :21649 http://www.jiasociety.org/index.php/jias/article/view/21649 | http://dx.doi.org/10.7448/IAS.20.5.21649

OBJECTIVE Little is known about the evolution of program outcomes associated with rapid expansion of antiretroviral therapy (ART) in resource-limited settings. We describe temporal trends and assess associations with mortality and loss to follow-up (LTFU) in HIV cohorts from 8 countries. DESIGN Multicohort study using electronic health records. METHODS Analysis included adults in 25 Medecins Sans Frontieres-supported programs initiating ART between 2001 and 2011. Kaplan-Meier methods were used to describe time to death or LTFU and proportional hazards models to assess associations with individual and program factors. RESULTS ART programs (n = 132,334, median age 35 years, 61% female) expanded rapidly. Whereas 36-month mortality decreased from 22% to 9% over 5 years (≤2003-2008), LTFU increased from 11% to 21%. Hazard ratios (HR) of early (0-12 months) and late (12-72 months) LTFU increased over time, from 1.09 [95% confidence interval (CI): 0.83 to 1.43] and 1.04 (95% CI: 0.84 to 1.28) in 2004 to 3.29 (95% CI: 2.42 to 4.46) and 6.86 (95% CI: 4.94 to 9.53) in 2011, compared with 2001-2003. Rate of program expansion was strongly associated with increased early and late LTFU, adjusted HR (aHR) = 2.31 (95% CI: 1.78 to 3.01) and HR = 2.29 (95% CI: 1.76 to 2.99), respectively, for ≥125 vs. 0-24 patients per month. Larger program size was associated with decreased early mortality (aHR = 0.49, 95% CI: 0.31 to 0.77 for ≥20,000 vs.

In this study, the effects on young adolescent sexual risk behaviour of teacher-led school HIV prevention programmes were examined in two sites in South Africa (Cape Town and Mankweng) and one site in Tanzania (Dar es Salaam). In Cape Town, Dar es Salaam and Mankweng, 26, 24 and 30 schools, respectively, were randomly allocated to intervention or comparison groups. Primary outcomes were delayed sexual debut and condom use among adolescents aged 12-14 years (grade 8 in South Africa and grades 5 and 6 in Tanzania). In total, 5352, 4197 and 2590 students participated at baseline in 2004 in Cape Town, Dar es Salaam and Mankweng, respectively, and 73% (n = 3926), 88% (n = 3693) and 83% (n = 2142) were retained 12-15 months later. At baseline, 13% (n = 224), 5% (n = 100) and 17% (n = 164) had had their sexual debut, and 44% (n = 122), 20% (n = 17) and 37% (n = 57) of these used a condom at last sex, respectively. In Dar es Salaam, students in the intervention were less likely to have their sexual debut during the study (OR 0.65, 95% CI 0.48-0.87). In Cape Town and Mankweng, the intervention had no impact. The current interventions were effective at delaying sexual debut in Dar es Salaam but not in South Africa, where they need to be supplemented with programmes to change the environment in which adolescents make decisions about sexual behaviour.

No abstract available. (Published: 1 December 2016) Citation: Grimsrud A et al. Journal of the International AIDS Society 2016, 19 :21484 http://www.jiasociety.org/index.php/jias/article/view/21484 | http://dx.doi.org/10.7448/IAS.19.1.21484

Objective To examine the impact of different definitions of loss to follow-up (LTFU) on estimates of program outcomes in cohort studies of patients on antiretroviral therapy (ART). Study Design and Setting We examined the impact of different definitions of LTFU using data from the International Epidemiological Databases to Evaluate AIDS—Southern Africa. The reference approach, Definition A, was compared with five alternative scenarios that differed in eligibility for analysis and the date assigned to the LTFU outcome. Kaplan–Meier estimates of LTFU were calculated up to 2 years after starting ART. Results Estimated cumulative LTFU were 14% and 22% at 12 and 24 months, respectively, using the reference approach. Differences in the proportion LTFU were reported in the alternative scenarios with 12-month estimates of LTFU varying by up to 39% compared with Definition A. Differences were largest when the date assigned to the LTFU outcome was 6 months after the date of last contact and when the site-specific definition of LTFU was used. Conclusion Variation in the definitions of LTFU within cohort analyses can have an appreciable impact on estimated proportions of LTFU over 2 years of follow-up. Use of a standardized definition of LTFU is needed to accurately measure program effectiveness and comparability between programs.

Objective: Atypical sequences of drug use progression are thought to have important implications for the development of substance dependence. The extent to which this assumption holds for South African populations is unknown. This paper attempts to address this gap by examining the prevalence and correlates of atypical patterns of drug progression among South Africans. Method: Data on substance use and other mental health disorders from a nationally representative sample of 4351 South Africans were analysed. Weighted cross tabulations were used to estimate prevalence and correlates of atypical patterns of drug use progression. Results: Overall, 12.2% of the sample reported atypical patterns of drug use progression. The most common violation was the use of extra-medical drugs prior to alcohol and tobacco. Gender was significantly associated with atypical patterns of drug use with the risk pattern varying by the type of drug. None of the anxiety or mood disorders were associated with atypical patterns of use. Atypical patterns of drug use were not associated with increased risk for a lifetime substance use disorder. Conclusion: Atypical patterns of drug use initiation seem more prevalent in South Africa compared to other countries. The early use of extra-medical drugs is common, especially among young women. Drug availability and social environmental factors may influence patterns of drug use. The findings have important implications for prevention initiatives and future research.Key words: Substance use; Gateway violations; Mental disorders; South Africa

Based on a statistical analysis of 111 facilities in Africa, Asia, and Latin America, Benjamin Chi and colleagues develop a standard loss-to-follow-up (LTFU) definition that can be used by HIV antiretroviral programs worldwide., Background Although patient attrition is recognized as a threat to the long-term success of antiretroviral therapy programs worldwide, there is no universal definition for classifying patients as lost to follow-up (LTFU). We analyzed data from health facilities across Africa, Asia, and Latin America to empirically determine a standard LTFU definition. Methods and Findings At a set “status classification” date, patients were categorized as either “active” or “LTFU” according to different intervals from time of last clinic encounter. For each threshold, we looked forward 365 d to assess the performance and accuracy of this initial classification. The best-performing definition for LTFU had the lowest proportion of patients misclassified as active or LTFU. Observational data from 111 health facilities—representing 180,718 patients from 19 countries—were included in this study. In the primary analysis, for which data from all facilities were pooled, an interval of 180 d (95% confidence interval [CI]: 173–181 d) since last patient encounter resulted in the fewest misclassifications (7.7%, 95% CI: 7.6%–7.8%). A secondary analysis that gave equal weight to cohorts and to regions generated a similar result (175 d); however, an alternate approach that used inverse weighting for cohorts based on variance and equal weighting for regions produced a slightly lower summary measure (150 d). When examined at the facility level, the best-performing definition varied from 58 to 383 d (mean = 150 d), but when a standard definition of 180 d was applied to each facility, only slight increases in misclassification (mean = 1.2%, 95% CI: 1.0%–1.5%) were observed. Using this definition, the proportion of patients classified as LTFU by facility ranged from 3.1% to 45.1% (mean = 19.9%, 95% CI: 19.1%–21.7%). Conclusions Based on this evaluation, we recommend the adoption of ≥180 d since the last clinic visit as a standard LTFU definition. Such standardization is an important step to understanding the reasons that underlie patient attrition and establishing more reliable and comparable program evaluation worldwide. Please see later in the article for the Editors' Summary, Editors' Summary Background Since 1981, AIDS has killed more than 25 million people, and about 33 million people (mostly in low- and middle-income countries) are now infected with HIV, the virus that causes AIDS. Because HIV destroys immune system cells, HIV-positive individuals are very susceptible to other infections, and, early in the AIDS epidemic, most HIV-infected people died within ten years of contracting the virus. Then, in 1996, antiretroviral therapy (ART)—a cocktail of drugs that keeps HIV in check—became available. For people living in developed countries, HIV infection became a chronic condition. However, for people living in developing countries, ART was prohibitively expensive, and HIV/AIDS remained a fatal illness. In 2003, this situation was declared a global emergency, and governments, international agencies, and funding bodies began to implement plans to increase ART coverage in resource-limited countries. By the end of 2009, more than a third of people living in these countries who needed ART were receiving it. Why Was This Study Done? Because ART does not cure HIV infection, patients have to take antiretroviral drugs regularly for the rest of their lives. But in some ART programs, more than a third of patients are lost to follow-up (LTFU), that is, they stop coming for treatment, within three years of starting treatment. Patient attrition threatens the success of ART programs, but to understand why it occurs, a standardized method for classifying patients as LTFU is essential. Classification of patients as LTFU relies on an interval-based definition of LTFU. That is, a patient who fails to attend a clinic within a specified interval after a previous visit is classified as LTFU. If this interval is too short, although many patients will be accurately identified as LTFU, there will be a high false-positive rate—some patients classified as LTFU will actually return to the clinic later. Conversely, if the interval is too long, some patients who are truly LTFU will be misclassified as active (a false-negative classification). In this study, the researchers analyzed data from health facilities across Africa, Asia, and Latin America to determine a standard definition for LTFU that minimizes patient misclassification. What Did the Researchers Do and Find? Using data collected from 111 health facilities by the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration, the researchers categorized patients receiving ART at each facility at a “status classification” date (12 months before the facility's last data export to IeDEA) as active or LTFU using a range of intervals (thresholds) since their last clinic visit. For example, for a test interval of 200 days, patients who had not revisited the clinic within 200 days of their previous visit at the status classification date were classified as LTFU; patients who had revisited the clinic were classified as active. The researchers then looked forward 365 days from the status classification date to assess the performance and accuracy of these classifications. So, a “LTFU” patient who visited the clinic anytime during the year after the status classification date represented a false-positive classification, and an “active” patient who did not return within the ensuing year represented a false-negative classification. When data from all the facilities were pooled, a threshold of 180 days produced the fewest misclassifications. At the facility level, the best-performing threshold for patient classification ranged from 58 to 383 days (with an average of 150 days), but application of a 180-day threshold to individual facilities only slightly increased misclassifications. Finally, using the 180-day threshold, average LTFU at individual facilities was 19.9%. What Do These Findings Mean? Based on these findings, the researchers recommend that the standard definition for LTFU should be when it has been 180 days or more since the patient's last clinic visit. Given the wide range of best-performing definitions among facilities, however, they recognize that local, national, or regional definitions of LTFU may be more appropriate in certain contexts. Adoption of a standard definition for LTFU, the researchers note, should facilitate harmonization of monitoring and evaluation of ART programs across the world and should help to identify “best practices” associated with low LTFU rates. Importantly, it should also provide the necessary framework for research designed to improve patient retention in ART programs, thereby helping to maximize and sustain the health gains from HIV treatment programs. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001111. Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatment Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on HIV/AIDS treatment and care and on universal access to AIDS treatment (in English and Spanish) The World Health Organization provides information about universal access to AIDS treatment (in several languages) Information about the IeDEA Collaboration available Patient stories about living with HIV/AIDS are available through Avert and through the charity website Healthtalkonline

Little is known about the temporal impact of the rapid scale-up of large antiretroviral therapy (ART) services on programme outcomes. We describe patient outcomes [mortality, loss-to-follow-up (LTFU) and retention] over time in a network of South African ART cohorts.Cohort analysis utilizing routinely collected patient data.Analysis included adults initiating ART in eight public sector programmes across South Africa, 2002-2007. Follow-up was censored at the end of 2008. Kaplan-Meier methods were used to estimate time to outcomes, and proportional hazards models to examine independent predictors of outcomes.Enrolment (n = 44 177, mean age 35 years; 68% women) increased 12-fold over 5 years, with 63% of patients enrolled in the past 2 years. Twelve-month mortality decreased from 9% to 6% over 5 years. Twelve-month LTFU increased annually from 1% (2002/2003) to 13% (2006). Cumulative LTFU increased with follow-up from 14% at 12 months to 29% at 36 months. With each additional year on ART, failure to retain participants was increasingly attributable to LTFU compared with recorded mortality. At 12 and 36 months, respectively, 80 and 64% of patients were retained.Numbers on ART have increased rapidly in South Africa, but the programme has experienced deteriorating patient retention over time, particularly due to apparent LTFU. This may represent true loss to care, but may also reflect administrative error and lack of capacity to monitor movements in and out of care. New strategies are needed for South Africa and other low-income and middle-income countries to improve monitoring of outcomes and maximize retention in care with increasing programme size.

Introduction : Community-based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource-limited settings. However, the evidence base for community-based models of care is limited. We describe the implementation of community-based adherence clubs (CACs) at a large, public-sector facility in peri-urban Cape Town, South Africa. Methods : Starting in May 2012, stable ART patients were down-referred from the primary care community health centre (CHC) to CACs. Eligibility was based on self-reported adherence, >12 months on ART and viral suppression. CACs were facilitated by four community health workers and met every eight weeks for group counselling, a brief symptom screen and distribution of pre-packed ART. The CACs met in community venues for all visits including annual blood collection and clinical consultations. CAC patients could send a patient-nominated treatment supporter (“buddy”) to collect their ART at alternate CAC visits. Patient outcomes [mortality, loss to follow-up and viral rebound (>1000 copies/ml)] during the first 18 months of the programme are described using Kaplan–Meier methods. Results and Discussion : From June 2012 to December 2013, 74 CACs were established, each with 25–30 patients, providing ART to 2133 patients. CAC patients were predominantly female (71%) and lived within 3 km of the facility (70%). During the analysis period, 9 patients in a CAC died (

This letter to the editor discusses a study on the outcomes of 44177 adults in South Africa approximately 10% of all those starting public sector antiretroviral therapy (ART). The study provides insight into the effectiveness of a large national ART program and has implications for other low-income and middle-income countries working toward universal ART access.

Objective: Growing evidence suggests high levels of comorbidity between hypertension and mental illness but there are few data from low- and middle-income countries. We examined the association between hypertension and depression and anxiety in South Africa. METHODS: Data come from a nationally-representative survey of adults (n = 4351). The Composite International Diagnostic Interview was used to measure DSM-IV mental disorders during the previous 12-months. The relationships between self-reported hypertension and anxiety disorders, depressive disorders and comorbid anxiety-depression were assessed after adjustment for participant characteristics including experience of trauma and other chronic physical conditions. RESULTS: Overall 16.7% reported a previous medical diagnosis of hypertension, and 8.1% and 4.9% were found to have a 12-month anxiety or depressive disorder, respectively. In adjusted analyses, hypertension diagnosis was associated with 12-month anxiety disorders [Odds ratio (OR) = 1.55, 95% Confidence interval (CI) = 1.10-2.18] but not 12-month depressive disorders or 12-month comorbid anxiety-depression. Hypertension in the absence of other chronic physical conditions was not associated with any of the 12-month mental health outcomes (p-values all