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Background: Low-cost, scalable strategies are necessary to reach the UNAIDS 2030 target of ending HIV as a public health threat. Use of treatment partners, informal caregivers selected by people living with HIV to support antiretroviral therapy adherence, is one such strategy that is included in many countries' HIV guidelines, including Botswana, a country with high HIV prevalence. Method: From June 2021 to June 2022, we pilot tested a clinic-based treatment partner intervention ("Mopati"), including standardized language for providers to guide patients on treatment partner selection and workshops to train treatment partners on providing non-directive support to patients using a non-confrontational, non-judgmental approach. Sixty unsuppressed patients (30 per clinic) and 45 treatment partners (17 intervention, 28 control) were recruited from an intervention–control clinic matched-pair in Gaborone, Botswana. Results: Mopati had medium-to-large effects on increasing patients' adherence, adherence self-efficacy, intrinsic adherence motivation, and perceived non-directive support from treatment partners, and decreasing treatment partner caregiver burden. Aggregate viral suppression rates significantly increased in the intervention (vs. control) clinic. Qualitative data from 14 clinic staff, 21 patients, and 16 treatment partners indicated that Mopati was viewed as effective. Providers said the guidance empowered them to be proactive in communicating about adherence; most reported using the guidance. Conclusion: This study shows preliminary support for the use of treatment partners in HIV care, and further evidence for interventions that leverage patients' existing support. This research can inform ways to improve adherence to HIV treatment as well as the treatment of HIV-related comorbid conditions in lower-resource settings. Trial Registration: ClinicalTrials.gov Identifier: NCT04796610. [ABSTRACT FROM AUTHOR]

We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98–1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95–1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81–0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program. [ABSTRACT FROM AUTHOR]

Characterizing spatial distribution of HIV outcomes is vital for targeting interventions to areas most at risk. We performed spatial analysis to identify geographic clusters and factors associated with mortality in KwaZulu-Natal, South Africa. We utilized Sizanani trial (NCT01188941) data, which enrolled participants August 2010-January 2013 and obtained vital status at 5.8 (IQR 5.0–6.4) years of follow-up. We mapped geocoded addresses to 2011 Census-defined small area layer (SAL) centroids, used Kulldorff's spatial scan statistic to identify mortality clusters, and compared socio-demographic factors for SALs within and outside mortality clusters. We assigned 1,143 participants living with HIV (260 [23%] of whom died during follow-up) to 677 SALs. One lower mortality cluster (n = 90, RR = 0.23, p = 0.022) was identified near a hospital outside Durban. SALs in the cluster were younger (24y vs 25y, p < 0.001); had fewer bedrooms/household (3 vs 4, p < 0.001); had more females (52% vs 51%, p = 0.013) and residents with no schooling past age 20 (4% vs 3%, p < 0.001) or no education at all (4% vs 3%, p < 0.001); had fewer residents with income >3,200 ZAR/month (5% vs 9%, p < 0.001); and had reduced access to piped water (p < 0.001), refuse disposal (p < 0.001), and toilets (p < 0.001). Targeted interventions may improve outcomes in areas with similar characteristics. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic and associated restrictions could adversely affect long-term HIV care. We evaluated the experiences of people receiving antiretroviral therapy (ART) through a decentralized delivery program in South Africa during the COVID-19 pandemic. We telephoned a random subsample of participants enrolled in a prospective cohort study in KwaZulu-Natal in April and May 2020 and administered a semi-structured telephone interview to consenting participants. We completed interviews with 303 of 638 contacted participants (47%); 66% were female, with median age 36y. The most common concerns regarding the COVID-19 pandemic were food running out (121, 40%), fear of becoming infected with COVID-19 (103, 34%), and being unable to work/losing employment or income (102, 34%). Twenty-five (8%) participants had delayed ART pick-up due to the pandemic, while 212 (70%) had new concerns about ART access going forward. Mental health scores were worse during the pandemic compared to baseline (median score 65.0 vs 80.0, p < 0.001). Decentralized ART distribution systems have the potential to support patients outside of health facilities during the COVID-19 pandemic, but economic concerns and mental health impacts related to the pandemic must also be recognized and addressed. [ABSTRACT FROM AUTHOR]

We used the Practical, Robust Implementation and Sustainability Model to evaluate implementation of South Africa's Central Chronic Medicine Dispensing and Distribution (CCMDD) program, a differentiated service delivery program which allows clinically stable HIV-positive patients to receive antiretroviral therapy refills at clinic- or community-based pick-up points. Across ten clinics, we conducted 109 semi-structured interviews with stakeholders (pick-up point staff, CCMDD service providers and administrators) and 16 focus groups with 138 patients. Participants had highly favorable attitudes and said CCMDD decreased stigma concerns. Patient-level barriers included inadequate education about CCMDD and inability to get refills on designated dates. Organizational-level barriers included challenges with communication and transportation, errors in medication packaging and tracking, rigid CCMDD rules, and inadequate infrastructure. Recommendations included: (1) provide patient education and improve communication around refills (at the patient level); (2) provide dedicated space and staff, and ongoing training (at the organizational/clinic level); and (3) allow for prescription renewal at pick-up points and less frequent refills, and provide feedback to clinics (at the CCMDD program level). [ABSTRACT FROM AUTHOR]

Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014–2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies. [ABSTRACT FROM AUTHOR]

Introduction: South Africa's government‐led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community‐ or clinic‐based pick‐up points intended to increase convenience and decongest clinics. To understand CCMDD pick‐up point use among people living with HIV, we evaluated factors associated with uptake of a community‐ versus clinic‐based pick‐up point at CCMDD enrolment. Methods: We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non‐pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu‐Natal. We identified factors associated with community‐based pick‐up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self‐perceived barriers to care, self‐efficacy, HIV‐related discrimination, and perceived benefits and challenges of CCMDD. Results and Discussion: Among 1521 participants, 67% were females, with median age 36 years (IQR 30–44). Uptake of a community‐based pick‐up point was associated with younger age (aOR 1.18 per 10‐year decrease, 95% CI 1.05–1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10–1.83) versus being unemployed, no self‐perceived barriers to care (aOR 1.42, 95% CI 1.09–1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03–2.01) or 40 (aOR 1.91, 95% CI 1.39–2.63) versus 10–35 on the self‐efficacy scale, where higher scores indicate greater self‐efficacy. Additional factors included more convenient pick‐up point location (aOR 2.32, 95% CI 1.77–3.04) or hours (aOR 5.09, 95% CI 3.71–6.98) as perceived benefits of CCMDD, and lack of in‐clinic follow‐up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30–8.31). Conclusions: Uptake of community‐based pick‐up was associated with younger age, full‐time employment, and systemic and structural factors of living with HIV (no self‐perceived barriers to care and high self‐efficacy), as well as perceptions of CCMDD (convenient pick‐up point location and hours, lack of in‐clinic follow‐up). Strategies to facilitate community‐based pick‐up point uptake should be tailored to patients' age, employment, self‐perceived barriers to care and self‐efficacy to maximize the impact of CCMDD in decongesting clinics. [ABSTRACT FROM AUTHOR]

Changes in an individual's contextual factors following HIV diagnosis may influence long-term outcomes. We evaluated how changes to contextual factors between HIV diagnosis and 9-month follow-up predict 5-year mortality among HIV-infected individuals in Durban, South Africa enrolled in the Sizanani Trial (NCT01188941). We used random survival forests to identify 9-month variables and changes from baseline predictive of time to mortality. We incorporated these into a Cox proportional hazards model including age, sex, and starting ART by 9 months a priori, 9-month social support and competing needs, and changes in mental health between baseline and 9 months. Among 1,154 participants with South African ID numbers, 900 (78%) had baseline and 9-month data available of whom 109 (12%) died after 9-month follow-up. Those who reported less social support at 9 months had a 16% higher risk of mortality. Participants who went without basic needs or healthcare at 9 months had a 2.6 times higher hazard of death compared to participants who did not. Low social support and competing needs at 9-month follow-up substantially increase long-term mortality risk. Reassessing contextual factors during follow-up and targeting interventions to increase social support and affordability of care may reduce long-term mortality for HIV-infected individuals in South Africa. [ABSTRACT FROM AUTHOR]

We evaluated COVID-19 stigma and medical mistrust among people living with HIV in South Africa. We conducted telephone interviews with participants in a prospective study of a decentralized antiretroviral therapy program. Scales assessing medical mistrust, conspiracy beliefs, anticipated and internalized stigma, and stereotypes specific to COVID-19 were adapted primarily from the HIV literature, with higher scores indicating more stigma or mistrust. Among 303 participants, the median stigma summary score was 4 [interquartile range (IQR) 0–8; possible range 0–24] and 6 (IQR 2–9) for mistrust (possible range 0–28). A substantial proportion of participants agreed or strongly agreed with at least one item assessing stigma (54%) or mistrust (43%). Higher COVID-19 stigma was associated with female gender and antecedent HIV stigma, and lower stigma with reporting television as a source of information on COVID-19. Further efforts should focus on effects of stigma and mistrust on protective health behaviors and vaccine hesitancy. [ABSTRACT FROM AUTHOR]

We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, 3- and 6-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by 3 months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen's h = 0.41). Among those previously on ART (off for > 6 months), 33.3% initiated ART by 3 months in the intervention vs. 14.3% in the control arm (Cohen's h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART. [ABSTRACT FROM AUTHOR]

Background: Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted interventions. Our objective was to uncover distinct CD4-based trajectories and determine baseline demographic, clinical, and contextual factors associated with trajectory membership. Methods: We used data from the Sizanani trial (NCT01188941), in which adults were enrolled prior to HIV testing in Durban, South Africa from August 2010–January 2013. We ascertained CD4 counts from the National Health Laboratory Service over 5y follow-up. We used group-based statistical modeling to identify groups with similar CD4 count trajectories and Bayesian information criteria to determine distinct CD4 trajectories. We evaluated baseline factors that predict membership in specific trajectories using multinomial logistic regression. We examined calendar year of participant enrollment, age, gender, cohabitation, TB positivity, self-identified barriers to care, and ART initiation within 3 months of diagnosis. Results: 688 participants had longitudinal data available. Group-based trajectory modeling identified four distinct trajectories: one with consistently low CD4 counts (21%), one with low CD4 counts that increased over time (22%), one with moderate CD4 counts that remained stable (41%), and one with high CD4 counts that increased over time (16%). Those with higher CD4 counts at diagnosis were younger, less likely to have TB, and less likely to identify barriers to care. Those in the least favorable trajectory (consistently low CD4 count) were least likely to start ART within 3 months. Conclusions: One-fifth of people newly-diagnosed with HIV presented with low CD4 counts that failed to rise over time. Less than 40% were in a trajectory characterized by increasing CD4 counts. Patients in more favorable trajectories were younger, less likely to have TB, and less likely to report barriers to healthcare. Better understanding barriers to early care engagement and ART initiation will be necessary to improve long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

The UNAIDS 90-90-90 treatment targets aim to dramatically increase the number of people who initiate antiretroviral therapy (ART) by 2020. Greater understanding of barriers to ART initiation in high prevalence countries like South Africa is critical. Qualitative semi-structured interviews were conducted with 30 participants in Gugulethu Township, South Africa, including 10 healthcare providers and 20 people living with HIV (PLWH) who did not initiate ART. Interviews explored barriers to ART initiation and acceptability of theory-based intervention strategies to optimize ART initiation. An inductive content analytic approach was applied to the data. Consistent with the Theory of Triadic Influence, barriers to ART initiation were identified at the individual, social, and structural levels. Results suggested high acceptability for intervention strategies involving trained HIV-positive peers among South African PLWH and healthcare providers. Research is needed to evaluate their feasibility and efficacy in high HIV prevalence countries. [ABSTRACT FROM AUTHOR]

South Africa was the largest recipient of funding from the President's Emergency Plan for AIDS Relief (PEPFAR) for antiretroviral therapy (ART) programs from 2004 to 2012. Funding decreases have led to transfers from hospital and non-governmental organization-based care to government-funded, community-based clinics. We conducted semi-structured interviews with 36 participants to assess patient experiences related to transfer of care from a PEPFAR-funded, hospital-based clinic in Durban to either primary care clinics or hospital-based clinics. Participant narratives revealed the importance of connectedness between patients and the PEPFAR-funded clinic program staff, who were described as respectful and conscientious. Participants reported that transfer clinics were largely focused on dispensing medication and on throughput, rather than holistic care. Although participants appreciated the free treatment at transfer sites, they expressed frustration with long waiting times and low perceived quality of patient–provider communication, and felt that they were treated disrespectfully. These factors eroded confidence in the quality of the care. The transfer was described by participants as hurried with an apparent lack of preparation at transfer clinics for new patient influx. Formal (e.g., counseling) and informal (e.g., family) social supports, both within and beyond the PEPFAR-funded clinic, provided a buffer to challenges faced during and after the transition in care. These data support the importance of social support, adequate preparation for transfer, and improving the quality of care in receiving clinics, in order to optimize retention in care and long-term adherence to treatment. [ABSTRACT FROM AUTHOR]

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers. [ABSTRACT FROM AUTHOR]

We collected qualitative data (semi-structured interviews with 11 healthcare providers and 10 patients; 8 focus groups with 41 patients) to identify barriers to linkage to care among people living with HIV in South Africa who were not yet taking antiretroviral treatment. Patients and providers identified HIV stigma as a sizable barrier. Patients felt that stigma-related issues were largely beyond their control, fearing discrimination if they disclosed to employers or were seen visiting clinics in their community. Providers believed that patients should take responsibility for overcoming internal stigma and disclosing serostatus. Patients had considerable concerns about inconvenient clinic hours, long queues, difficulty in appointment scheduling, and disrespect from staff. Providers seemed to minimize the effects of such barriers and not recognize the extent of patient dissatisfaction. Better communication and understanding between patients and providers are needed to facilitate greater patient satisfaction and retention in HIV care. [ABSTRACT FROM AUTHOR]

Background: After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults. Methods: We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count <100 cells/mm³. We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing ("competing needs to healthcare") on presentation with late-stage HIV disease. Results: Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived ≥5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% Cl 1.7-4.7], reported competing needs to healthcare (AOR 1.7, 95% Cl 1.2-2.4), were male (AOR 1.7, 95% Cl 1.2-2.3), worked outside the home (AOR 1.5, 95% Cl 1.1-2.1), perceived health service delivery barriers (AOR 1.5, 95% Cl 1.1-2.1), and/or had poor emotional health (AOR 1.4, 95% Cl 1.0-1.9) had higher odds of late-stage HIV disease presentation. Conclusions: Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease. [ABSTRACT FROM AUTHOR]

In South Africa, approximately 20% of 15-49-year-olds are infected with HIV. Among black South Africans, high levels of HIV/AIDS misconceptions (e.g. HIV is manufactured by whites to reduce the black African population; AIDS is caused by supernatural forces or witchcraft) may be barriers to HIV prevention. We conducted a cross-sectional study of 150 young black adults (aged 18-26; 56% males) visiting a public clinic for sexually transmitted infections, to investigate whether HIV/AIDS misconceptions were related to low condom use in main partner relationships. We assessed agreement with HIV/AIDS misconceptions relating to the supernatural (e.g. witchcraft as a cause of HIV) and to genocide (e.g. the withholding of a cure). In multivariate models, agreement that 'Witchcraft plays a role in HIV transmission' was significantly related to less positive attitudes about condoms, less belief in condom effectiveness for HIV prevention, and lower intentions to use condoms among men. The belief that 'Vitamins and fresh fruits and vegetables can cure AIDS' was associated with lower intentions among men to use condoms. Women who endorsed the belief linking HIV to witchcraft had a higher likelihood of unprotected sex with a main partner, whereas women who endorsed the belief that a cure for AIDS was being withheld had a lower likelihood of having had unprotected sex. Knowledge about distinct types of HIV/AIDS misconceptions and their correlates can help in the design of culturally appropriate HIV-prevention messages that address such beliefs. [ABSTRACT FROM AUTHOR]

Introduction: Cross‐sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV‐1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations. Methods: Longitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self‐report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and HIV‐1 RNA at nine months were extracted from the South Africa National Health Laboratory Service database. Two path analyses were estimated, one testing associations between internalized stigma, avoidant coping and ART initiation, and the other testing associations between internalized stigma, avoidant coping and HIV‐1 RNA suppression. Results: Participants were 36 years old, on average, and 63% identified as female, 18% as Zulu and 65% as Xhosa. The two path models fit the data well (ART initiation outcome: X2(7) = 8.14, p = 0.32; root mean square error of approximation (RMSEA) = 0.02; comparative fit index (CFI) = 0.92; HIV‐1 RNA suppression outcome: X2(7)  = 6.58, p = 0.47; RMSEA = 0.00; CFI = 1.00). In both models, internalized stigma one week after diagnosis was associated with avoidant coping at three months, controlling for avoidant coping at one week. In turn, avoidant coping at three months was associated with lower likelihood of ART initiation at six months in the first model and lower likelihood of HIV‐1 RNA suppression at nine months in the second model. Significant indirect effects were observed between internalized stigma with ART non‐initiation and unsuppressed HIV‐1 RNA via the mediator of avoidant coping. Conclusions: Internalized stigma experienced soon after HIV diagnosis predicted lower likelihood of ART initiation and HIV‐1 RNA suppression over the first year following HIV diagnosis. Avoidant coping played a role in these associations, suggesting that PLWH who internalize stigma engage in greater avoidant coping, which in turn worsens medication‐ and health‐related outcomes. Interventions are needed to address internalized stigma and avoidant coping soon after HIV diagnosis to enhance treatment efforts during the first year after HIV diagnosis. [ABSTRACT FROM AUTHOR]