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Background: As people with HIV grow older, stable engagement in care is essential for healthy aging. We evaluate the HIV care cascade for older adults in rural South Africa at 2 time points cross-sectionally and assess movement in the cascade over time., Setting: We evaluated the cascade stage at waves 1 (2014-2015) and 2 (2018-2019) of Health and Aging in Africa: A Longitudinal Study of an INDPETH Community in South Africa, a population-based longitudinal cohort study in Mpumalanga Province, South Africa., Methods: Biomarker screening defined cascade stages [HIV+/no antiretroviral therapy (ART); ART+/unsuppressed viral load; ART+/suppressed viral load]. Between-wave probability of death, cascade progression, regression, cascade transitions, and sociodemographic predictors were assessed with Poisson regression. The impact of death was considered using the Fine and Gray competing risk model., Results: We observed a higher prevalence of antiretroviral therapy with viral suppression over time (50% in wave 1 vs. 70% in wave 2). Among those alive, the oldest age group (70+ years old) was most likely to have cascade progression [adjusted risk ratio for treatment initiation vs. 40-49 years old: 1.38 (95% confidence interval: 1.02 to 1.86)]. However, there was a significant risk of death and cascade regression. Death between waves reached 40% for 70+-year-olds who were ART+/unsuppressed. In competing risk models, older age was associated with equivalent or less cascade progression., Conclusion: Older age groups who were unsuppressed on treatment and men had poorer cascade outcomes. Improvements observed in HIV treatment coverage over time for older adults must be interpreted in the context of the high risk of death for older HIV-positive adults, especially among those failing treatment., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: HIV self-testing (HIVST) offers a promising approach to increase HIV diagnosis and advance progress towards the UNAIDS 95-95-95 targets. We aimed to understand patterns of HIVST awareness and utilization in nine sub-Saharan African (SSA) countries, with the goal of identifying populations to target in disseminating this technology., Design: A cross-sectional study., Methods: We pooled individual-level population-based data from nine Demographic and Health Surveys (DHS) in SSA conducted 2015-2019 (Burundi, Cameroon, Guinea, Malawi, Senegal, Sierra Leone, South Africa, Zambia, Zimbabwe). Primary outcomes were HIVST awareness and utilization. We used logistic regression with survey fixed effects to explore the relationship between sociodemographic characteristics and these outcomes. Models were adjusted for sex, age, rural/urban residence, education, wealth, and marital status. We accounted for complex survey design., Results: The study sample included 177 572 people (66.0% women, mean age 29 ± 10 years), of whom 86.6% [95% confidence interval (95% CI) 86.4-86.7] were unaware of HIVST, 11.7% (95% CI 11.6-11.9) were aware of but never used HIVST, and 1.7% (95% CI 1.6-1.8) had used HIVST. In adjusted models, women were less likely to be aware of HIVST [odds ratio (OR) 0.75, 95% CI 0.71-0.79], but more likely to have used HIVST (OR 1.17, 95% CI 1.03-1.32) compared with men. Rural residents, those who were least educated, and poorest were less likely to have heard of or used HIVST., Conclusion: HIVST awareness and uptake were low. Rural, less educated, and lower income populations were least likely to have heard of or used HIVST. Efforts to scale-up HIVST in these settings should aim to reach these less advantaged groups., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration., Competing Interests: The authors have declared that no competing interests exist.

Perceptions of HIV acquisition risk and prevalence shape sexual behavior in sub-Saharan Africa (SSA). We used data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa baseline survey. Data were collected through home-based interviews of 5059 people ≥ 40 years old. We elicited information on perceived risk of HIV acquisition and HIV prevalence among adults  ≥ 15 and ≥ 50 years old. We first describe these perceptions in key subgroups and then compared them to actual estimates for this cohort. We then evaluated the relationship between sociodemographic characteristics and accurate perceptions of prevalence in regression models. Finally, we explored differences in behavioral characteristics among those who overestimated risk compared to those who underestimated or accurately estimated risk. Compared to the actual HIV acquisition risk of < 1%, respondents vastly overestimated this risk: 35% (95% CI: 32-37) and 34% (95% CI: 32-36) for men and women, respectively. Respondents overestimated HIV prevalence at 53% (95% CI: 52-53) for those ≥ 15 years old and 48% (95% CI: 48-49) for those ≥ 50 years old. True values were less than half of these estimates. There were few significant associations between demographic characteristics and accuracy. Finally, high overestimators of HIV prevalence tested themselves less for HIV compared to mild overestimators and accurate reporters. More than 30 years into the HIV epidemic, older people in a community with hyperendemic HIV in SSA vastly overestimate both HIV acquisition risk and prevalence. These misperceptions may lead to fatalism and reduced motivation for prevention efforts, possibly explaining the continued high HIV incidence in this community., (© 2021. The Author(s).)

We sought to characterize the relationship between alcohol consumption and sexual risk-taking in an aging population in rural South Africa. A cross-sectional analysis was conducted using baseline data from the Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community (HAALSI) cohort. We elicited information on sexual risk behavior and self-reported frequency of alcohol consumption among 5059 adults  ≥ 40 years old. Multivariable models showed that more frequent alcohol consumption is associated with a higher number of sexual partners (β: 1.38, p < .001) and greater odds of having sex for money (OR: 42.58, p < .001) in older adults in South Africa. Additionally, daily drinkers were more likely to have sex without a condom (OR: 2.67, p = .01). Older adults who drank more alcohol were more likely to engage in sexual risk-taking. Behavioral interventions to reduce alcohol intake should be considered to reduce STI and HIV transmission.

Background: Although sex workers are considered a key population in the HIV epidemic in sub-Saharan Africa (SSA), less consideration has been given to female bar workers (FBW), whose primary occupation is not sex work but who often engage in transactional sex. Understanding FBWs' risk profiles is central to designing targeted HIV prevention interventions for them. This systematic review describes the socio-demographic characteristics and risk factors for HIV transmission among FBWs in SSA., Methods: We searched six databases: PubMed, Google Scholar, Web of Science, Popline, Embase and additionally the World Health Organization's WHOLIS database for grey literature between July and September 2017. Inclusion criteria were reporting (1) primary socio-demographic or behavioral data; on (2) women who sold or delivered drinks to clients; (3) in establishments serving alcohol; (4) in SSA. We excluded studies not presenting separate data on FBWs. We extracted quantitative and qualitative data from the selected studies and conducted a qualitative synthesis of findings., Results: We found 4565 potentially eligible articles, including duplicates. After applying inclusion and exclusion criteria, we retained 19 articles. FBWs often migrated from rural to urban areas due to economic need or social marginalization. They began bar-based transactional sex due to low wages, peer pressure and to increase financial independence. FBWs had high HIV risk awareness but low agency to negotiate condom use, particularly with regular partners or when offered higher prices for condomless sex. FBWs were also vulnerable to violence and stigmatization., Conclusions: FBWs are a vulnerable population for HIV infection. Despite social stigmatization and elevated risk of contracting STIs, bar work remains attractive because it enables unskilled women to both, make a living and maintain some independence. FBWs face HIV-related risk factors at the individual, community and societal level and may benefit from biomedical, behavioral and structural interventions.

Information regarding HIV pre-exposure prophylaxis (PrEP) for the general population is largely lacking, because the majority of PrEP demonstration projects have focused on key populations. This qualitative study examines barriers and facilitators to PrEP uptake and adherence among the general population in Eswatini, where PrEP is offered through public-sector primary-care clinics. We analysed 106 semi-structured in-depth interviews with healthcare workers ( n  = 26), stakeholders ( n  = 30), and clients who initiated, continued, declined or discontinued PrEP ( n  = 50). Some healthcare workers and stakeholders feared that PrEP would reduce condom use and cause drug resistance, while some clients feared possible side effects and the reaction of family members when learning of PrEP use. At the same time, respondents across all groups valued that PrEP could be taken without partner knowledge or consent, and that PrEP was available via public sector clinics. Clients felt that PrEP relieved the fear of HIV infection and thus bolstered enjoyment during sex. Overall, respondents described the general population approach to PrEP delivery as enabling and life-improving, despite the above concerns. Respondents recommended to create community PrEP promotion and delivery, gain community leaders' approval and understanding of PrEP, shorten the PrEP initiation process, and target men and adolescent girls.

In sub-Saharan Africa, female bar workers (FBWs) often serve as informal sex workers. Little is known about the prevalence of HIV and HIV-related risk factors among FBWs in Dar es Salaam (DSM), Tanzania. Using an adapted Structural HIV Determinants Framework, we identified structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition. We compared the prevalence of HIV and HIV-related risk factors among a random sample of 66 FBWs from DSM to an age-standardized, representative sample of female DSM-residents from the 2016 Demographic and Health and 2011-2012 AIDS Indicator Surveys. Compared to other women in DSM, FBWs had elevated prevalence of all four groups of risk factors. Key risk factors included gender and economic inequalities (structural); sexual violence and challenges negotiating condom use (interpersonal); depression, post-traumatic stress disorder, and low social support (psychosocial); and history of unprotected sex, multiple sex partners, and high alcohol consumption (behavioral). HIV prevalence did not differ between FBWs (7.1%, 95% CI 3.7-13.3%) and survey respondents (7.7%, 95% CI: 5.3-11.1%), perhaps due to FBWs' higher - though sub-optimal - engagement with HIV prevention strategies. Elevated exposure to HIV-related risk factors but low HIV prevalence suggests economic, psychosocial, and biomedical interventions may prevent HIV among FBWs in DSM.

There is increasing interest in home based testing and treatment of HIV to expand access to treatment in sub-Saharan Africa. Such programs rely on self-reported HIV history and use of antiretroviral therapy (ART). However, the accuracy of self-reported ART use in community settings is not well described. In this study, we compared self-reported ART (SR-ART) use in a home based survey against biological exposure to ART (BE-ART), in a population study of older adults in South Africa. Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa (HAALSI) is a cohort of adults aged 40 +. The baseline home-based interview included self-reported HIV status and ART use. All participants also underwent biological testing for HIV antibodies, viral load and exposure to emtricitabine (FTC) or lamivudine (3TC), which are included in all first-line and second-line ART regimens in the public-sector South African HIV program. We calculated the performance characteristics for SR-ART compared to BE-ART and fit multivariable logistic regression models to identify correlates of invalid SR-ART responses. Of 4560 HAALSI participants with a valid HIV test result available, 1048 (23%) were HIV-positive and 734 [70% of people living with HIV (PLWH)] were biologically validated ART users (BE-ART). The sensitivity of SR-ART use was 64% (95% CI 61-68%) and the specificity was 94% (95% CI 91-96%); the positive predictive value (PPV) was 96% (95% CI 94-98%) and negative predictive value (NPV) was 52% (95% CI 48-56%). We found no sociodemographic predictors of accurate SR-ART use. Over one in three individuals with detectable ART in their blood denied current ART use during a home-based interview. These results demonstrate ongoing stigma related to HIV and its treatment, and have important implications for community health worker programs, clinical programs, and research studies planning community-based ART initiation in the region.

Objective: To understand the relationship between HIV preexposure prophylaxis (PrEP) and resilience among Emaswati women., Design: A qualitative study using semistructured in-depth interviews., Methods: We interviewed 24 women who recently initiated PrEP at one of six public-sector primary-care clinics participating in a government demonstration project for PrEP for the general population, as well as 30 PrEP stakeholders from HIV policy, implementation and donor sectors., Results: PrEP clients and stakeholders described an environment marked by high HIV risk. In this context, clients felt PrEP enhanced their resilience through feelings of protection, control over HIV acquisition, choice in relation to when to take PrEP, sexual pleasure and relief from the fear and consequences of HIV infection. Those in serodiscordant relationships described improved partner communication and a shared sense of responsibility for HIV prevention. Both PrEP clients and stakeholders asserted that PrEP marketing and communication should be Emaswati-led and community-owned., Conclusion: PrEP helps women in Eswatini envision longer, healthier and more fulfilled lives. PrEP enhances resilience through several pathways, including self-efficacy, choice, control over HIV infection and relief from the fear of HIV infection. Social marketing and information campaigns should not only focus on PrEP as an HIV-prevention method but also emphasize how PrEP has expanded choice, enhanced control and facilitated sexual enjoyment among PrEP clients.

This study aims to characterize associations between depression symptom severity and HIV infection, both prior to and in years after ART initiation, among older adults. The Ugandan Non-Communicable Diseases & Aging Cohort Study (UGANDAC) is a study of 154 PLWH on ART and 142 community-based, HIV-negative controls. The Hopkins Checklist (HSCL), a 15-item depression scale, was used to screen for depression. We estimate differences in depressive symptoms by HIV and ART status and use multivariable log binomial regression to quantify differences in probable depression between PLWH on ART. HIV-infected and HIV-uninfected participants had a similar age (mean 52.0 vs. 51.9, p = 0.854) and sex distribution (47.4 vs. 47.9% female, p = 0.934). PLWH on ART had lower depression symptom severity than HIV-uninfected controls (mean score: 1.50 vs. 1.60, p = 0.006) and a lower prevalence of probable depression (21.4 vs. 33.8%, p = 0.017). Among 102 PLWH with pre-ART depression screening scores available, their mean depression symptom severity was similar to HIV-uninfected participants (mean 1.56 vs. 1.60, p = 0.512). In adjusted models, PLWH on ART had a lower prevalence of probable depression than HIV-negative controls [adjusted prevalence ratio: 0.68 (95% CI 0.47-0.99)]. In an observational cohort of PLWH over 40 on long-term ART and matched, community-based HIV-uninfected controls in rural Uganda, we found a lower prevalence of self-reported depression among aging PLWH on ART.

Introduction: Participation in antiretroviral therapy (ART) programmes has been associated with greater utilization of care for hypertension and diabetes in rural South Africa. The objective of this study was to assess whether people living with HIV on ART with comorbid hypertension or diabetes also have improved chronic disease management indicators., Methods: The Health and Aging in Africa: a longitudinal study of an INDEPTH Community in South Africa (HAALSI) is a cohort of 5059 adults >40 years old. Enrollment took place between November 2014 and November 2015. The study collected population-based data on demographics, healthcare utilization, height, weight, blood pressure (BP) and blood glucose as well as HIV infection, HIV-1 RNA viral load (VL) and ART exposure. We used regression models to determine whether HIV care cascade stage (HIV-negative, HIV+ /No ART, ART/Detected HIV VL, and ART/Undetectable VL) was associated with diagnosis or treatment of hypertension or diabetes, and systolic blood pressure and glucose among those with diagnosed hypertension or diabetes. ART use was measured from drug level testing on dried blood spots., Results and Discussion: Compared to people without HIV, ART/Undetectable VL was associated with greater awareness of hypertension diagnosis (adjusted risk ratio (aRR) 1.18, 95% CI: 1.09 to 1.28) and treatment of hypertension (aRR 1.24, 95% CI: 1.10 to 1.41) among those who met hypertension diagnostic criteria. HIV care cascade stage was not significantly associated with awareness of diagnosis or treatment of diabetes. Among those with diagnosed hypertension or diabetes, ART/Undetectable VL was associated with lower mean systolic blood pressure (5.98 mm Hg, 95% CI: 9.65 to 2.32) and lower mean glucose (3.77 mmol/L, 95% CI: 6.85 to 0.69), compared to being HIV-negative., Conclusions: Participants on ART with an undetectable VL had lower systolic blood pressure and blood glucose than the HIV-negative participants. HIV treatment programmes may provide a platform for health systems strengthening for cardiometabolic disease., (© 2019 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Introduction: The real-world association between male circumcision and HIV status has important implications for policy and intervention practice. For instance, women may assume that circumcised men are safer sex partners than non-circumcised men and adjust sexual partnering and behavior according to these beliefs. Voluntary medical male circumcision (VMMC) is highly efficacious in preventing HIV acquisition in men and this biological efficacy should lead to a negative association between circumcision and HIV. However, behavioral factors such as differential selection into circumcision based on current HIV status or factors associated with future HIV status could reverse the association. Here, we examine how HIV prevalence differs by circumcision status in older adult men in a rural South African community, a non-experimental setting in a time of expanding VMMC access., Methods: We analyzed data collected from a population-based sample of 2345 men aged 40 years and older in a rural community served by the Agincourt Health and socio-Demographic Surveillance System site in Mpumalanga province, South Africa. We describe circumcision prevalence and estimate the association between circumcision and laboratory-confirmed HIV status with log-binomial regression models., Results: One quarter of older men reported circumcision, with slightly more initiation-based circumcisions (56%) than hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in HIV prevalence between circumcised and uncircumcised men; however, those who reported hospital-based circumcision were more likely to test HIV-positive [PR (95% CI): 1.28 (1.03, 1.59)] while those who reported initiation-based circumcision were less likely to test HIV-positive [PR (95% CI): 0.68 (0.51, 0.90)]. Effects were attenuated, but not reversed after adjustment for key covariates., Conclusions: Medically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns., Competing Interests: The authors have declared that no competing interests exist.

Background: The prevalence of diabetes and hypertension has increased in HIV-positive populations, but there is limited understanding of the role that antiretroviral therapy (ART) programs play in the delivery of services for these conditions. The aim of this study is to assess the relationship between ART use and utilization of health care services for diabetes and hypertension., Methods: Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa is a cohort of 5059 adults. The baseline study collects biomarker-based data on HIV, ART, diabetes, and hypertension and self-reported data on health care utilization. We calculated differences in care utilization for diabetes and hypertension by HIV and ART status and used multivariable logistic regressions to estimate the relationship between ART use and utilization of services for these conditions, controlling for age, sex, body mass index, education, and household wealth quintile., Results: Mean age, body mass index, hypertension, and diabetes prevalence were lower in the HIV-positive population (all P < 0.001). Multivariable logistic regression showed that ART use was significantly associated with greater odds of blood pressure measurement [adjusted odds ratio (aOR) 1.27, 95% confidence interval (CI): 1.04 to 1.55] and blood sugar measurement (aOR 1.26, 95% CI: 1.05 to 1.51), counseling regarding exercise (aOR 1.57, 95% CI: 1.11 to 2.22), awareness of hypertension diagnosis (aOR 1.52, 95% CI: 1.12 to 2.05), and treatment for hypertension (aOR 1.63, 95% CI: 1.21 to 2.19)., Conclusions: HIV-positive patients who use ART are more likely to have received health care services for diabetes and hypertension. This apparent ART advantage suggests that ART programs may be a vehicle for strengthening health systems for chronic care.

Background: A consequence of the widespread uptake of anti-retroviral therapy (ART) is that the older South African population will experience an increase in life expectancy, increasing their risk for cardiometabolic diseases (CMD), and its risk factors. The long-term interactions between HIV infection, treatment, and CMD remain to be elucidated in the African population. The HAALSI cohort was established to investigate the impact of these interactions on CMD morbidity and mortality among middle-aged and older adults., Methods: We recruited randomly selected adults aged 40 or older residing in the rural Agincourt sub-district in Mpumalanga Province. In-person interviews were conducted to collect baseline household and socioeconomic data, self-reported health, anthropometric measures, blood pressure, high-sensitivity C-reactive protein (hsCRP), HbA1c, HIV-status, and point-of-care glucose and lipid levels., Results: Five thousand fifty nine persons (46.4% male) were enrolled with a mean age of 61.7 ± 13.06 years. Waist-to-hip ratio was high for men and women (0.92 ± 0.08 vs. 0.89 ± 0.08), with 70% of women and 44% of men being overweight or obese. Blood pressure was similar for men and women with a combined hypertension prevalence of 58.4% and statistically significant increases were observed with increasing age. High total cholesterol prevalence in women was twice that observed for men (8.5 vs. 4.1%). The prevalence of self-reported CMD conditions was higher among women, except for myocardial infarction, and women had a statistically significantly higher prevalence of angina (10.82 vs. 6.97%) using Rose Criteria. The HIV - persons were significantly more likely to have hypertension, diabetes, or be overweight or obese than HIV + persons. Approximately 56% of the cohort had at least 2 measured or self-reported clinical co-morbidities, with HIV + persons having a consistently lower prevalence of co-morbidities compared to those without HIV. Absolute 10-year risk cardiovascular risk scores ranged from 7.7-9.7% for women and from 12.5-15.3% for men, depending on the risk score equations used., Conclusions: This cohort has high CMD risk based on both traditional risk factors and novel markers like hsCRP. Longitudinal follow-up of the cohort will allow us to determine the long-term impact of increased lifespan in a population with both high HIV infection and CMD risk.

Background: High BMI and blood pressure are leading chronic disease risk factors in South Africa. Longterm effects of HIV and ART on adiposity and blood pressure are poorly understood, and direct comparisons of risk factor trajectories in HIV- versus HIV+ populations are rare., Methods: In 2003 and 2010, height, weight, and blood pressure were recorded in a study population (n = 505) in KwaZulu-Natal, South Africa (30% adult HIV prevalence). We modeled change in BMI and BP longitudinally in HIV- individuals (n = 315), seroconverters (n = 32), HIV+ patients not on ART (HIV+ART-; n = 52), HIV+ patients on ART for 0-<2 years as of 2010 (HIV+ART0-<2 yrs; n = 18), patients on ART for 2-5 years (HIV+ART2-5yrs; n = 44), and a subgroup with unknown HIV status (n = 44). Difference-in-differences were assessed in reference to the HIV- population., Results: Between 2003 and 2010, BMI increased significantly in the HIV- group, by 0.874 (95% CI 0.339, 1.41; p = 0.001), to 30.4. BMI drop was significantly greater in HIV+ART0-<2yrs than in HIV+ART2-5yrs (p = 0.005). DID in BMI in HIV+ART0-<2yrs versus the reference was -5.21 (95% CI -7.53, -2.90; p = 0.001), and DID in HIV+ART2-5yrs versus reference was -1.35 (95% CI -2.89, 0.189; p = 0.086). DID in SBP in HIV+ART-vs HIV- DID was -7.55 mmHg (95% CI -13.2 to -1.90; p = 0.009)., Conclusion: Short-term ART (0-<2 years) was associated with larger weight loss than either no ART or long-term ART. Once on ART for 2+ years, individuals 'caught up' on weight gain with the HIV- population. Our results showcase the importance of health system readiness to address the burgeoning double burden of disease in South Africa., Competing Interests: The authors have declared that no competing interests exist.

CD4 count testing is perceived to be an affordable strategy to diagnose treatment failure on first-line antiretroviral therapy. We hypothesize that the superior accuracy of viral load (VL) testing will result in less patients being incorrectly switched to more expensive and toxic second-line regimens. Using data from a drug resistance cohort, we show that CD4 testing is approximately double the cost to make 1 correct regimen switch under certain diagnostic thresholds (CD4 = US $499 vs. VL = US $186 or CD4 = US $3031 vs. VL = US $1828). In line with World Health Organization guidelines, our findings show that VL testing can be both an accurate and cost-effective treatment monitoring strategy.

Background: Mother-to-child transmission of HIV remains an important public health problem in sub-Saharan Africa. As HIV testing and linkage to PMTCT occurs in antenatal care (ANC), major challenges for any PMTCT option in developing countries, including Tanzania, are delays in the first ANC visit and a low overall number of visits. Community health workers (CHWs) have been effective in various settings in increasing the uptake of clinical services and improving treatment retention and adherence. At the beginning of this trial in January 2013, the World Health Organization recommended either of two medication regimens, Option A or B, for prevention of mother-to-child transmission of HIV (PMTCT). It is still largely unclear which option is more effective when implemented in a public healthcare system. This study aims to determine the effectiveness, cost-effectiveness, acceptability, and feasibility of: (1) a community health worker (CWH) intervention and (2) PMTCT Option B in improving ANC and PMTCT outcomes., Methods/design: This study is a cluster-randomized controlled health systems implementation trial with a two-by-two factorial design. All 60 administrative wards in the Kinondoni and Ilala districts in Dar es Salaam were first randomly allocated to either receiving the CHW intervention or not, and then to receiving either Option B or A. Under the standard of care, facility-based health workers follow up on patients who have missed scheduled appointments for PMTCT, first through a telephone call and then with a home visit. In the wards receiving the CHW intervention, the CHWs: (1) identify pregnant women through home visits and refer them to antenatal care; (2) provide education to pregnant women on antenatal care, PMTCT, birth, and postnatal care; (3) routinely follow up on all pregnant women to ascertain whether they have attended ANC; and (4) follow up on women who have missed ANC or PMTCT appointments., Trial Registration: ClinicalTrials.gov: EJF22802. Registration date: 14 May 2013.

Objectives: Data from generalized epidemic settings have consistently found that patients on antiretroviral therapy (ART) reduce sexual risk behaviours, but how sexual behaviour changes in the general population in response to ART availability, including amongst HIV-uninfected and undiagnosed adults, has not been characterized in these settings., Design: General population open cohort., Methods: We report trends in sexual behaviour indicators for men aged 17-54 years and women aged 17-49 years in rural KwaZulu-Natal province, based on annual sexual behaviour surveys during ART scale-up from 2005 to 2011. Estimates are adjusted for survey nonparticipation and nonresponse to individual survey items using inverse probability weighting and multiple imputation. Trends are presented by HIV status, knowledge of status, age and marital status., Results: Reports of condom use at last sex with a regular partner increased by 2.6% points per year [95% confidence interval (CI) 1.5%, 3.7%] for men and 4.1% per year (3.0%, 5.3%) for women. Condom use at last sex with a casual partner was high and did not change significantly over the period for both sexes. There were statistically significant declines in the percentage reporting multiple partnerships in the last year and the point prevalence of concurrency. Trends within subgroups were generally consistent with overall estimates., Conclusion: We find no evidence of increased sexual risk-taking following ART availability and protective changes in some behaviours, suggesting that general trends in sexual behaviour are not counter-acting preventive effects of HIV treatment. Continued monitoring of population-level sexual behaviour indicators will be essential to interpret the success of combination-prevention programmes., (© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins)

Background: KwaZulu-Natal is the South African province worst affected by HIV and the focus of early modeling studies investigating strategies of antiretroviral treatment (ART) delivery. The reality of antiretroviral roll-out through primary care has differed from that anticipated and real world data are needed to inform the planning of further scaling up of services. We investigated the factors associated with uptake of antiretroviral treatment through a primary healthcare system in rural South Africa., Methods: Detailed demographic, HIV surveillance and geographic information system (GIS) data were used to estimate the proportion of HIV positive adults accessing antiretroviral treatment within northern KwaZulu-Natal, South Africa in the period from initiation of antiretroviral roll-out until the end of 2008. Demographic, spatial and socioeconomic factors influencing the likelihood of individuals accessing antiretroviral treatment were explored using multivariable analysis., Results: Mean uptake of ART among HIV positive resident adults was 21.0% (95%CI 20.1-21.9). Uptake among HIV positive men (19.2%) was slightly lower than women (21.8%, P = 0.011). An individual's likelihood of accessing ART was not associated with level of education, household assets or urban/rural locale. ART uptake was strongly negatively associated with distance from the nearest primary healthcare facility (aOR = 0.728 per square-root transformed km, 95%CI 0.658-0.963, P = 0.002)., Conclusions: Despite concerns about the equitable nature of antiretroviral treatment rollout, we find very few differences in ART uptake across a range of socio-demographic variables in a rural South African population. However, even when socio-demographic factors were taken into account, individuals living further away from primary healthcare clinics were still significantly less likely to be accessing ART.