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Supplemental Digital Content is Available in the Text. Background: People living with HIV require reliable access to and adequate supply of antiretroviral therapy (ART) for viral suppression. The Deliver Health Study, a randomized trial conducted during the COVID-19 pandemic, found that home-delivered ART significantly increased viral suppression compared with clinic-based care. The effect of changing COVID-19 alert levels on self-reported ART use has not been quantified. Setting: KwaZulu-Natal, South Africa. Methods: Adults living with HIV were followed in the Deliver Health Study during October 2019–December 2020. We used difference-in-differences (DiD) to estimate the effect of changing COVID-19 alert levels during 3 distinct periods on self-reported missed ART doses (missed 0 vs. ≥1 doses in past week) for participants receiving home-delivered vs. clinic-based refills. We additionally estimated the effect of changing COVID-19 alert levels on late clinic ART refill visits (late vs. on-time). We used relative risk regression for both binary outcomes. Results: Of 155 participants, 46% were women and the median age was 36 years. The mean number of missed weekly doses was 0.11, 0, and 0.12 in the home-delivery group and 0.09, 0.08, and 0.18 in the clinic group during periods 1, 2, and 3, respectively. There were no differences in relative risk of self-reported daily ART use between refill groups when comparing across periods [DiDperiod 2 vs. 1 = 1.05; 95% confidence interval: 0.97, 1.13 and DiDperiod 3 vs. 2 = 0.99; 95% confidence interval (CI): 0.91, 1.08]. In the clinic group, the risk of late refill visits was significantly higher during COVID-19 restrictions (vs. before alert level 5 implementation) and even after the COVID-19 alert level was downgraded to level 1 (RRperiod 2 vs. 1 = 1.83, 95% CI: 1.34, 2.51 and RRperiod 3 vs. 2 = 1.71; 95% CI: 1.43, 2.04). Conclusion: The COVID-19 pandemic did not differentially impact self-reported ART adherence by the method of ART refills, but the risk of late clinic refill visits was significantly higher during COVID-19 restrictions and sustained after restrictions were loosened. [ABSTRACT FROM AUTHOR]

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

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

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

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

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

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

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

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

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

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

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

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

Valid measurement of substance use is necessary to evaluate preventive and treatment interventions. Self-report is fast and inexpensive, but its accuracy can be hampered by social desirability bias and imperfect recall. We examined the agreement between self-report of recent use and rapid diagnostic tests for three substances (alcohol, cannabis, and methamphetamine) among 904 young men living in Cape Town, South Africa. Rapid diagnostic tests detected the respective substances in 32, 52, and 22% of men. Among those who tested positive, 61% (95% CI [56%, 66%]), 70% ([67%, 74%]), and 48% ([42%, 54%]) admitted use. Men were moderately more willing to admit use of cannabis than alcohol (log OR 0.42) or admit use of alcohol than methamphetamine (log OR 0.53). Our findings show that self-report has reasonable criterion validity in this population, but criterion validity can vary substantially depending on the substance. [ABSTRACT FROM AUTHOR]

Objective: Evaluate the clinical utility of patient-collected dried blood spots (DBS) in measuring HIV-1 viral load (VL) for monitoring antiretroviral therapy (ART) compared to provider-collected DBS and blood plasma., Design: In a randomized trial of community-based delivery of ART in South Africa, we assessed performance of: (1) DBS specimens compared to plasma, and (2) participant-collected versus staff-collected DBS specimens, to measure HIV-1 VL., Methods: The bioMérieux NucliSENS EasyQ HIV-1 v2.0 assay was used for VL measurement. From October 2017 to November 2019, we collected 996 pairs of plasma/DBS specimens from 760 participants and 315 pairs of staff-/participant-collected DBS cards from 261 participants. We assessed DBS test sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) using the WHO failure threshold of 1000 copies/mL. Log-transformed VL was compared using concordance correlation coefficients (CCC) and mean differences from linear mixed models., Results: In a population with 13% detectable VL, DBS VL compared with plasma VL had 91% (95% CI: 86-95) sensitivity, 99% (98-100) specificity, 94% (90-98) PPV, and 99% (98-99) NPV. We observed high agreement between staff-collected DBS VL and plasma VL (CCC: 0.94), and between participant-collected DBS VL and plasma VL (CCC: 0.92). Correlation between participant- and staff-collected DBS was very high (CCC: 0.97; mean difference for those with a detectable result: -0.10 log 10  copies/mL [-0.21-0.02])., Conclusions: VL results from participant-collected DBS are clinically comparable with those collected by clinical staff and using blood plasma. Self-collected DBS has potential for use for ART monitoring outside the clinic., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: To improve tuberculosis case-finding, rapid, non-sputum triage tests need to be developed according to the World Health Organization target product profile (TPP) (>90% sensitivity, >70% specificity). We prospectively evaluated and compared artificial intelligence-based, computer-aided detection software, CAD4TBv7, and C-reactive protein assay (CRP) as triage tests at health facilities in Lesotho and South Africa., Methods: Adults (≥18 years) presenting with ≥1 of the 4 cardinal tuberculosis symptoms were consecutively recruited between February 2021 and April 2022. After informed consent, each participant underwent a digital chest X-ray for CAD4TBv7 and a CRP test. Participants provided 1 sputum sample for Xpert MTB/RIF Ultra and Xpert MTB/RIF and 1 for liquid culture. Additionally, an expert radiologist read the chest X-rays via teleradiology. For primary analysis, a composite microbiological reference standard (ie, positive culture or Xpert Ultra) was used., Results: We enrolled 1392 participants, 48% were people with HIV and 24% had previously tuberculosis. The receiver operating characteristic curve for CAD4TBv7 and CRP showed an area under the curve of .87 (95% CI: .84-.91) and .80 (95% CI: .76-.84), respectively. At thresholds corresponding to 90% sensitivity, specificity was 68.2% (95% CI: 65.4-71.0%) and 38.2% (95% CI: 35.3-41.1%) for CAD4TBv7 and CRP, respectively. CAD4TBv7 detected tuberculosis as well as an expert radiologist. CAD4TBv7 almost met the TPP criteria for tuberculosis triage., Conclusions: CAD4TBv7 is accurate as a triage test for patients with tuberculosis symptoms from areas with a high tuberculosis and HIV burden. The role of CRP in tuberculosis triage requires further research., Clinical Trials Registration: Clinicaltrials.gov identifier: NCT04666311., Competing Interests: Potential conflicts of interest. B. v. G. reports that his group received royalties from Delft Imaging Systems and that he holds shares in Thirona. K. R., B. v. G., A. v. H., A. S., K. M., L. L., T. Z., B. K. M. J., S. B., T. M., and M. K. report support related to this work from the European and Developing Countries Clinical Trials Partnership 2 (EDCTP2). K. R. reports grants unrelated to this work from EDCTP2 and Horizon 2020, as well as unpaid participation on a data safety monitoring board or scientific advisory board for evaluation of new TB diagnostics. S. B. reports a grant unrelated to this work from the National Institutes of Health (NIH) and travel support from MSD. T. M. reports travel support from MSD. N. D. L. reports support for travel from ViiV Healthcare and Gilead Sciences Sarl as well as for attending a board meeting from ViiV Healthcare and Pharming. S. B. and T. M. report travel support from MSD. The other authors report no potential conflict of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

HIV-related stigma is a well-documented barrier to HIV testing in South Africa, and may be particularly likely to create reluctance to test among South African men, who have reported feeling blamed for HIV by their partners and communities. The present study presents a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention explicitly designed to reduce stigma as a barrier to testing by asking people to recruit anyone they know to testing, thus allowing them to avoid the potential for increased stigma and/or blame associated with direct risk partner recruitment, and helping to normalize openly discussing HIV among social networks. We examined baseline and 6-10-week follow-up data from a 2022-2023 randomized trial in KwaZulu-Natal, South Africa that recruited 110 individuals who had been newly diagnosed with HIV and randomly assigned them to recruit people to HIV testing either via the E-SNRHT intervention or via risk network recruitment. Participants in the E-SNRHT intervention reported significant decreases in anticipated and enacted HIV-related stigma between baseline and follow-up; and the E-SNRHT intervention was more effective at decreasing enacted HIV-related stigma than was risk network recruitment. Individuals newly diagnosed with HIV by the E-SNRHT intervention reported significant increases in social support between intervention enrollment and follow-up, and all of these individuals reported participating in positive conversations about HIV services with peers in the 6-10 weeks after intervention enrollment. These findings suggest that E-SNRHT is a potentially important strategy to reduce HIV-related stigma as a barrier to HIV testing among peer networks in KwaZulu-Natal., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To ascertain whether a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention recruits men and individuals with previously undiagnosed HIV at higher rates than risk network recruitment., Design: Initial "seed" participants were prospectively randomly assigned to the E-SNRHT intervention or to risk network recruitment. Their network members were included in the study arm of their recruiter., Setting: Three Department of Health clinics and two drug treatment centers (DTCs) in the Msunduzi municipality of KwaZulu-Natal, South Africa., Participants: Clinics and DTCs referred 110 newly HIV-diagnosed adult "seeds" to the study from June 2022 to February 2023. E-SNRHT seeds were asked to recruit network members as described below; risk network recruitment arm seeds were asked to recruit recent sex and/or injection partners. Presenting a recruitment coupon (from clinic/DTC staff or another participant) was required for eligibility., Intervention: E-SNRHT seeds were shown educational material about HIV transmission risks and then asked to recruit anyone they know (e.g., friends, family) whom they thought could benefit from HIV testing., Main Outcome Measures: Rates of recruiting men to HIV testing and locating individuals with previously undiagnosed HIV., Results: E-SNRHT recruited significantly higher proportions of men to HIV testing (70.3 vs. 40.4%; χ2  = 16.33; P  < 0.0005) and located significantly more previously undiagnosed cases of HIV per seed than risk network recruitment (rate ratio = 9.40; P  < 0.0001). E-SNRHT also recruited significantly higher proportions of women with previously undiagnosed HIV (29.0 vs. 10.7%; χ2  = 3.87; P  = 0.049)., Conclusion: E-SNRHT is an important strategy to expand the reach of HIV testing among men and undiagnosed cases of HIV in KwaZulu-Natal., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

A positive urine TB-LAM result should lead to TB treatment initiation. TB treatment uptake was low after a positive TB-LAM but negative Xpert test. A lack of trust in TB-LAM results by clinicians and false-positive results may contribute to these results. https://bit.ly/3VGHekC., Competing Interests: Conflict of interest: The authors report no conflicts of interest., (Copyright ©The authors 2024.)

Background: Implementation science frameworks situate intervention implementation and sustainment within the context of the implementing organization and system. Aspects of organizational context such as leadership have been defined and measured largely within US health care settings characterized by decentralization and individual autonomy. The relevance of these constructs in other settings may be limited by differences like collectivist orientation, resource constraints, and hierarchical power structures. We aimed to adapt measures of organizational context in South African primary care clinics., Methods: We convened a panel of South African experts in social science and HIV care delivery and presented implementation domains informed by existing frameworks and prior work in South Africa. Based on panel input, we selected contextual domains and adapted candidate items. We conducted cognitive interviews with 25 providers in KwaZulu-Natal Province to refine measures. We then conducted a cross-sectional survey of 16 clinics with 5-20 providers per clinic (N = 186). We assessed reliability using Cronbach's alpha and calculated interrater agreement (a wg ) and intraclass correlation coefficient (ICC) at the clinic level. Within clinics with moderate agreement, we calculated correlation of clinic-level measures with each other and with hypothesized predictors - staff continuity and infrastructure - and a clinical outcome, patient retention on antiretroviral therapy., Results: Panelists emphasized contextual factors; we therefore focused on elements of clinic leadership, stress, cohesion, and collective problem solving (critical consciousness). Cognitive interviews confirmed salience of the domains and improved item clarity. After excluding items related to leaders' coordination abilities due to missingness and low agreement, all other scales demonstrated individual-level reliability and at least moderate interrater agreement in most facilities. ICC was low for most leadership measures and moderate for others. Measures tended to correlate within facility, and higher stress was significantly correlated with lower staff continuity. Organizational context was generally more positively rated in facilities that showed consistent agreement., Conclusions: As theorized, organizational context is important in understanding program implementation within the South African health system. Most adapted measures show good reliability at individual and clinic levels. Additional revision of existing frameworks to suit this context and further testing in high and low performing clinics is warranted., (© 2024. The Author(s).)

Psychological interventions delivered by non-specialist providers have shown mixed results for treating maternal depression. mHealth solutions hold the possibility for unobtrusive behavioural data collection to identify challenges and reinforce change in psychological interventions. We conducted a proof-of-concept study using passive sensing integrated into a depression intervention delivered by non-specialists to twenty-four adolescents and young mothers (30% 15-17 years old; 70% 18-25 years old) with infants (< 12 months old) in rural Nepal. All mothers showed a reduction in depression symptoms as measured with the Beck Depression Inventory. There were trends toward increased movement away from the house (greater distance measured through GPS data) and more time spent away from the infant (less time in proximity measured with the Bluetooth beacon) as the depression symptoms improved. There was considerable heterogeneity in these changes and other passively collected data (speech, physical activity) throughout the intervention. This proof-of-concept demonstrated that passive sensing can be feasibly used in low-resource settings and can personalize psychological interventions. Care must be taken when implementing such an approach to ensure confidentiality, data protection, and meaningful interpretation of data to enhance psychological interventions., (© 2024. The Author(s).)

Antiretroviral therapy (ART) is needed across the lifetime to maintain viral suppression for people living with HIV. In South Africa, obstacles to reliable access to ART persist and are magnified in rural areas, where HIV services are also typically costlier to deliver. A recent pilot randomized study (the Deliver Health Study) found that home-delivered ART refills, provided at a low user fee, effectively overcame logistical barriers to access and improved clinical outcomes in rural South Africa. In the present costing study using the payer perspective, we conducted retrospective activity-based micro-costing of home-delivered ART within the Deliver Health Study and when provided at-scale (in a rural setting), and compared to facility-based costs using provincial expenditure data (covering both rural and urban settings). Within the context of the pilot Deliver Health Study which had an average of three deliveries per day for three days a week, home-delivered ART cost (in 2022 USD) $794 in the first year and $714 for subsequent years per client after subtracting client fees, compared with $167 per client in provincial clinic-based care. We estimated that home-delivered ART can reasonably be scaled up to 12 home deliveries per day for five days per week in the rural setting. When delivered at scale, home-delivered ART cost $267 in the first year and $183 for subsequent years per client. Average costs of home delivery further decreased when increasing the duration of refills from three-months to six- and 12-month scripts (from $183 to $177 and $135 per client, respectively). Personnel costs were the largest cost for home-delivered refills while ART drug costs were the largest cost of clinic-based refills. When provided at scale, home-delivered ART in a rural setting not only offers clinical benefits for a hard-to-reach population but is also comparable in cost to the provincial standard of care.

Objective: To present the protocol and methods for the prospective longitudinal assessments-including clinical and digital phenotyping approaches-of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo) study, which comprises Brazilian adolescents stratified at baseline by risk of developing depression or presence of depression., Method: Of 7,720 screened adolescents aged 14 to 16 years, we recruited 150 participants (75 boys, 75 girls) based on a composite risk score: 50 with low risk for developing depression (LR), 50 with high risk for developing depression (HR), and 50 with an active untreated major depressive episode (MDD). Three annual follow-up assessments were conducted, involving clinical measures (parent- and adolescent-reported questionnaires and psychiatrist assessments), active and passive data sensing via smartphones, and neurobiological measures (neuroimaging and biological material samples). Retention rates were 96% (Wave 1), 94% (Wave 2), and 88% (Wave 3), with no significant differences by sex or group ( p > .05). Participants highlighted their familiarity with the research team and assessment process as a motivator for sustained engagement., Discussion: This protocol relied on novel aspects, such as the use of a WhatsApp bot, which is particularly pertinent for low- to-middle-income countries, and the collection of information from diverse sources in a longitudinal design, encompassing clinical data, self-reports, parental reports, Global Positioning System (GPS) data, and ecological momentary assessments. The study engaged adolescents over an extensive period and demonstrated the feasibility of conducting a prospective follow-up study with a risk-enriched cohort of adolescents in a middle-income country, integrating mobile technology with traditional methodologies to enhance longitudinal data collection., (© 2023 The Authors.)

Purpose of Review: Lottery incentives are an innovative approach to encouraging HIV prevention, treatment initiation, and adherence behaviours. This paper reviews the latest research on lottery incentives' impact on HIV-related services, and their effectiveness for motivating behaviours to improve HIV service engagement and HIV health outcomes., Recent Findings: Our review of ten articles, related to lottery incentives, published between 2018 and 2023 (inclusive) shows that lottery incentives have promise for promoting HIV-related target behaviours. The review highlights that lottery incentives may be better for affecting simpler behaviours, rather than more complex ones, such as voluntary medical male circumcision. This review recommends tailoring lottery incentives, ensuring contextual-relevance, to improve the impact on HIV-related services. Lottery incentives offer tools for improving uptake of HIV-related services. The success of lottery incentives appears to be mediated by context, the value and nature of the incentives, and the complexity of the target behaviour., (© 2024. The Author(s).)

Digital mental health is becoming increasingly common. This includes use of smartphones and wearables to collect data in real time during day-to-day life (remote measurement technologies, RMT). Such data could capture changes relevant to depression for use in objective screening, symptom management and relapse prevention. This approach may be particularly accessible to young people of today as the smartphone generation. However, there is limited research on how such a complex intervention would work in the real world. We conducted a collaborative realist review of RMT for depression in young people. Here we describe how, why, for whom and in what contexts RMT appear to work or not work for depression in young people and make recommendations for future research and practice. Ethical, data protection and methodological issues need to be resolved and standardized; without this, RMT may be currently best used for self-monitoring and feedback to the healthcare professional where possible, to increase emotional self-awareness, enhance the therapeutic relationship and monitor the effectiveness of other interventions., (© 2024. The Author(s).)

Background: Couple-based interventions (CBIs), despite strong efficacy in improving numerous HIV risk behaviors, are not widely available and have not been tested to improve women's antiretroviral therapy (ART) adherence. We examined barriers and facilitators to participation in a CBI based on cognitive behavioral couple therapy for women's ART adherence in KwaZulu-Natal, South Africa., Methods: Semi-structured interviews were conducted with women with HIV (n = 15) and men of mixed HIV status (n = 15). Thematic analyses were guided by the Consolidated Framework for Implementation Research., Results: Facilitators mostly related to the couple's relationship, including having an existing healthy relationship, men's desire to support their partners, and a potential opportunity for men's HIV disclosure. Barriers included a lack of understanding of how a CBI approach would be useful for women's ART adherence, sole focus on women if male partners were also living with HIV, and men's lack of prior HIV status disclosure to female partners., Conclusion: Findings indicate that relationship context and the male partner's HIV status need to be addressed during recruitment, enrolment, and during the intervention to promote uptake., (© 2023. The Author(s).)

Introduction: Heavy alcohol use among people living with HIV in sub-Saharan Africa can hinder the success of HIV treatment programmes, impacting progress towards United Nations Programme on HIV/AIDS goals. Primary partners can provide critical forms of social support to reduce heavy drinking and could be included in motivational interviewing (MI) interventions to address heavy drinking; however, few studies have evaluated MI interventions for couples living with HIV in sub-Saharan Africa. We aim to evaluate the feasibility and acceptability of a couple-based MI intervention with mobile breathalyser technology to reduce heavy alcohol use and improve HIV treatment outcomes among HIV-affected couples in South Africa., Methods and Analysis: We will employ a three-arm randomised controlled trial to assess the efficacy of couple-based MI (MI-only arm) and in conjunction with mobile breathalysers (MI-plus arm) to address alcohol use and HIV outcomes, as compared with enhanced usual care (control arm). We will enrol heterosexual couples aged 18-49 in a primary relationship for at least 6 months who have at least one partner reporting hazardous alcohol use and on antiretroviral therapy for 6 months. Participants in both MI arms will attend three manualised counselling sessions and those in the MI-plus arm will receive real-time feedback on blood alcohol concentration levels using a mobile breathalyser. Couples randomised in the control arm will receive enhanced usual care based on the South African ART Clinical Guidelines. Feasibility and acceptability indicators will be analysed descriptively, and exploratory hypotheses will be examined through regression models considering time points and treatment arms., Ethics and Dissemination: The study was approved by the University of California, San Francisco (HRPP; protocol number 21-35034) and Human Sciences Research Council Research Ethics Committee (REC: protocol number 1/27/20/21). We will disseminate the results at local community meetings, community-level health gatherings and conferences focused on HIV and alcohol use., Trial Registration Number: NCT05756790., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Locating undiagnosed HIV infections is important for limiting transmission. However, there is limited evidence about how best to do so. In South Africa, men have been particularly challenging to reach for HIV testing due, in part, to stigma. We pilot-tested two versions of a network-based case-finding and care-linkage intervention. The first, TRIP, asked "seeds" (original participants) to recruit their sexual and/or injection partners. The second, TRIPLE, aimed to circumvent some stigma-related issues by asking seeds to recruit anyone they know who might be at risk of being HIV-positive-unaware. We recruited 11 (18% male) newly diagnosed HIV-positive (NDP) seeds from two clinics in KwaZulu-Natal, South Africa and randomly assigned them to either TRIP or TRIPLE. Network members were recruited two steps from each seed. The TRIP arm recruited 12 network members; the TRIPLE arm recruited 62. Both arms recruited NDPs at higher rates than local clinic testing, with TRIP (50.0%) outperforming ( p = 0.012) TRIPLE (14.5%). However, TRIPLE (53.2%) was far superior to clinics (27.8%) and to TRIP (25.0%) at recruiting men. Given challenges around testing and treating men for HIV in this context, these findings suggest that the TRIPLE expanded network-tracing approach should be tested formally among larger samples in multiple settings.

Purpose of Review: To explore the intersection of chatbots and HIV prevention and care. Current applications of chatbots in HIV services, the challenges faced, recent advancements, and future research directions are presented and discussed., Recent Findings: Chatbots facilitate sensitive discussions about HIV thereby promoting prevention and care strategies. Trustworthiness and accuracy of information were identified as primary factors influencing user engagement with chatbots. Additionally, the integration of AI-driven models that process and generate human-like text into chatbots poses both breakthroughs and challenges in terms of privacy, bias, resources, and ethical issues. Chatbots in HIV prevention and care show potential; however, significant work remains in addressing associated ethical and practical concerns. The integration of large language models into chatbots is a promising future direction for their effective deployment in HIV services. Encouraging future research, collaboration among stakeholders, and bold innovative thinking will be pivotal in harnessing the full potential of chatbot interventions., (© 2023. The Author(s).)

Background: There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa., Objective: This study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing., Methods: An iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development., Results: A total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules ("episodes") played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement., Conclusions: The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention's feasibility, acceptability, and efficacy in reducing depressive symptoms., (©Julia R Pozuelo, Bianca D Moffett, Meghan Davis, Alan Stein, Halley Cohen, Michelle G Craske, Meriam Maritze, Princess Makhubela, Christine Nabulumba, Doreen Sikoti, Kathleen Kahn, Tholene Sodi, DoBAt & Ebikolwa Consortium, Alastair van Heerden, Heather A O’Mahen. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.11.2023.)

Background: Maternal and child health (MCH) is a global health concern, especially impacting low- and middle-income countries (LMIC). Digital health technologies are creating opportunities to address the social determinants of MCH by facilitating access to information and providing other forms of support throughout the maternity journey. Previous reviews in different disciplines have synthesized digital health intervention outcomes in LMIC. However, contributions in this space are scattered across publications in different disciplines and lack coherence in what digital MCH means across fields., Objective: This cross-disciplinary scoping review synthesized the existing published literature in 3 major disciplines on the use of digital health interventions for MCH in LMIC, with a particular focus on sub-Saharan Africa., Methods: We conducted a scoping review using the 6-stage framework by Arksey and O'Malley across 3 disciplines, including public health, social sciences applied to health, and human-computer interaction research in health care. We searched the following databases: Scopus, PubMed, Google Scholar, ACM Digital Library, IEEE Xplore, Web of Science, and PLOS. A stakeholder consultation was undertaken to inform and validate the review., Results: During the search, 284 peer-reviewed articles were identified. After removing 41 duplicates, 141 articles met our inclusion criteria: 34 from social sciences applied to health, 58 from public health, and 49 from human-computer interaction research in health care. These articles were then tagged (labeled) by 3 researchers using a custom data extraction framework to obtain the findings. First, the scope of digital MCH was found to target health education (eg, breastfeeding and child nutrition), care and follow-up of health service use (to support community health workers), maternal mental health, and nutritional and health outcomes. These interventions included mobile apps, SMS text messaging, voice messaging, web-based applications, social media, movies and videos, and wearable or sensor-based devices. Second, we highlight key challenges: little attention has been given to understanding the lived experiences of the communities; key role players (eg, fathers, grandparents, and other family members) are often excluded; and many studies are designed considering nuclear families that do not represent the family structures of the local cultures., Conclusions: Digital MCH has shown steady growth in Africa and other LMIC settings. Unfortunately, the role of the community was negligible, as these interventions often do not include communities early and inclusively enough in the design process. We highlight key opportunities and sociotechnical challenges for digital MCH in LMIC, such as more affordable mobile data; better access to smartphones and wearable technologies; and the rise of custom-developed, culturally appropriate apps that are more suited to low-literacy users. We also focus on barriers such as an overreliance on text-based communications and the difficulty of MCH research and design to inform and translate into policy., (©Sarina Till, Mirriam Mkhize, Jaydon Farao, Londiwe Deborah Shandu, Livhuwani Muthelo, Toshka Lauren Coleman, Masenyani Mbombi, Mamara Bopape, Sonja Klingberg, Alastair van Heerden, Tebogo Mothiba, Melissa Densmore, Nervo Xavier Verdezoto Dias, CoMaCH Network. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 07.04.2023.)

Purpose of Review: Globally, approximately 38.4 million people who are navigating complex lives, are also living with HIV, while HIV incident cases remain high. To improve the effectiveness of HIV prevention and treatment service implementation, we need to understand what drives human behaviour and decision-making around HIV service use. This review highlights current thinking in the social sciences, emphasizing how understanding human behaviour can be leveraged to improve HIV service delivery., Recent Findings: The social sciences offer rich methodologies and theoretical frameworks for investigating how factors synergize to influence human behaviour and decision-making. Social-ecological models, such as the Behavioural Drivers Model (BDM), help us conceptualize and investigate the complexity of people's lives. Multistate and group-based trajectory modelling are useful tools for investigating the longitudinal nature of peoples HIV journeys. Successful HIV responses need to leverage social science approaches to design effective, efficient, and high-quality programmes., Summary: To improve our HIV response, implementation scientists, interventionists, and public health officials must respond to the context in which people make decisions about their health. Translating biomedical efficacy into real-world effectiveness is not simply finding a way around contextual barriers but rather engaging with the social context in which communities use HIV services., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

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

Background: Alcohol is a teratogen; its consumption during pregnancy can lead to negative birth outcomes, collectively referred to as fetal alcohol spectrum disorders. Neurodevelopmental delays in higher-order cognitive functions that affect development of executive functions are a common feature. Studies on executive function in children have focused on children diagnosed with fetal alcohol spectrum disorder, and there is a lack of information on the impact on children not diagnosed with fetal alcohol spectrum disorder but who had been exposed to alcohol., Objective: The aim of this study was to compare the development of executive function in children between 4 and 6 years of age with and without prenatal exposure to alcohol., Methods: Children both exposed and not exposed to alcohol were recruited as part of a feasibility RCT evaluating a computer-based cognitive training program for improving executive function development. The study was conducted in a low-socioeconomic status community in South Africa with a high prevalence of fetal alcohol spectrum disorder. Neurodevelopment was assessed in participating children; NEPSY-II standardized scores for executive function domains were compared using a multivariate analysis of variance with group membership as the predictor variable., Results: No significant differences in executive functions assessments (P=.39) were found between children in the alcohol-exposed group (n=76) and those in the nonexposed group (n=40). Both groups showed moderate to severe delays in domains. In all but one subtest, the average score for both groups was below the 25th percentile of expected norms., Conclusions: We expected that alcohol exposure would have a measurable impact on executive function development. The lack of differences highlights the prevalence of developmental delays in low-socioeconomic status communities in South Africa and suggests that children are exposed to various threats to cognitive development., International Registered Report Identifier (irrid): RR2-10.2196/14489., (©Jacobus Gidion Louw, Alastair van Heerden, Leana Olivier, Tersius Lambrechts, Mandi Broodryk, Liska Bunge, Martlé Vosloo, Mark Tomlinson. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.07.2021.)

Sub-Saharan Africa has been heavily impacted by the HIV/AIDS epidemic. Social data (e.g., social media, internet search, wearable device, etc) show great promise assisting in public health and HIV surveillance. However, research on this topic has primarily focused in higher resource settings, such as the United States. It is especially important to study the prevalence and potential use of these data sources and tools in low- and middle-income countries (LMIC), such as Sub-Saharan Africa, which have been heavily impacted by the HIV epidemic, to determine the feasibility of using these technologies as surveillance and intervention tools. Accordingly, we 1) described the prevalence and characteristics of various social technologies within South Africa, 2) using Twitter, Instagram, and YouTube as a case study, analyzed the prevalence and patterns of social media use related to HIV risk in South Africa, and 3) mapped and statistically tested differences in HIV-related social media posts within regions of South Africa. Geocoded data were collected over a three-week period in 2018 (654,373 tweets, 90,410 Instagram posts and 14,133 YouTube videos with 1,121 comments). Of all tweets, 4,524 (0.7%) were found to related to HIV and AIDS. The percentage was similar for Instagram 95 (0.7%) but significantly lower for YouTube 18 (0.1%). We found regional differences in prevalence and use of social media related to HIV. We discuss the implication of data from these technologies in surveillance and interventions within South Africa and other LMICs., Competing Interests: The authors have read the journal’s policy and have the following competing interests: SY received gift funding from Facebook and Intel, which was broadly used to support the Institute for Prediction Technology, of which SY is the director. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Background: Community-based delivery of antiretroviral therapy (ART) for HIV, including ART initiation, clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral suppression, reducing the gap in access to care for individuals who have detectable HIV viral load, including men who are less likely than women to be virally suppressed. We aimed to test the effect of community-based ART delivery on viral suppression among people living with HIV not on ART., Methods: We did a household-randomised, unblinded trial (DO ART) of delivery of ART in the community compared with the clinic in rural and peri-urban settings in KwaZulu-Natal, South Africa and the Sheema District, Uganda. After community-based HIV testing, people living with HIV were randomly assigned (1:1:1) with mobile phone software to community-based ART initiation with quarterly monitoring and ART refills through mobile vans; ART initiation at the clinic followed by mobile van monitoring and refills (hybrid approach); or standard clinic ART initiation and refills. The primary outcome was HIV viral suppression at 12 months. If the difference in viral suppression was not superior between study groups, an a-priori test for non-inferiority was done to test for a relative risk (RR) of more than 0·95. The cost per person virally suppressed was a co-primary outcome of the study. This study is registered with ClinicalTrials.gov, NCT02929992., Findings: Between May 26, 2016, and March 28, 2019, of 2479 assessed for eligibility, 1315 people living with HIV and not on ART with detectable viral load at baseline were randomly assigned; 666 (51%) were men. Retention at the month 12 visit was 95% (n=1253). At 12 months, community-based ART increased viral suppression compared with the clinic group (306 [74%] vs 269 [63%], RR 1·18, 95% CI 1·07-1·29; p superiority =0·0005) and the hybrid approach was non-inferior (282 [68%] vs 269 [63%], RR 1·08, 0·98-1·19; p non-inferiority =0·0049). Community-based ART increased viral suppression among men (73%, RR 1·34, 95% CI 1·16-1·55; p superiority <0·0001) as did the hybrid approach (66%, RR 1·19, 1·02-1·40; p superiority =0·026), compared with clinic-based ART (54%). Viral suppression was similar for men (n=156 [73%]) and women (n=150 [75%]) in the community-based ART group. With efficient scale-up, community-based ART could cost US$275-452 per person reaching viral suppression. Community-based ART was considered safe, with few adverse events., Interpretation: In high and medium HIV prevalence settings in South Africa and Uganda, community-based delivery of ART significantly increased viral suppression compared with clinic-based ART, particularly among men, eliminating disparities in viral suppression by gender. Community-based ART should be implemented and evaluated in different contexts for people with detectable viral load., Funding: The Bill & Melinda Gates Foundation; the University of Washington and Fred Hutch Center for AIDS Research; the Wellcome Trust; the University of Washington Royalty Research Fund; and the University of Washington King K Holmes Endowed Professorship in STDs and AIDS., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Among people living with HIV in South Africa, viral suppression is lower among men than women. The study aim was to test the impact of lottery incentives, which reward positive health choice (e.g. antiretroviral therapy (ART) linkage) with a chance to win a prize, on strengthening the HIV care continuum including ART initiation and viral suppression for men., Methods: We conducted a randomized, prospective trial of lottery incentives in the context of HIV testing and linkage to ART in rural KwaZulu-Natal, South Africa. Men living with HIV were randomly allocated to: lottery incentives and motivational text messages or motivational text messages only. Lottery prize eligibility was conditional on clinic registration, ART initiation, or viral suppression by one, three and six months respectively. After completing each continuum step, participants in the lottery group were notified whether they had won and were encouraged to continue in care. Lottery prizes were either a mobile phone, data or a gift card (valued at R1000/$100). Kaplan-Meier curves were plotted to determine time to ART initiation by study group. The primary outcome was viral suppression at six months., Results: Between November 2017 and December 2018, we tested 740 men for HIV and enrolled 131 HIV-positive men who reported not being on ART. At baseline, 100 (76%) participants were 30 years and older, 95 (73%) were unemployed and the median CD4 count was 472 cells/μL. At study exit, 84% (110/131) of participants had visited a clinic and 62% (81/131) were virally suppressed. Compared to motivational text messages, lottery incentives decreased the median time to ART initiation from 126 to 66 days (p = 0.0043, age-adjusted Cox regression) among all participants, and, from 134 days to 20 days (p = 0.0077) among participants who were not virally suppressed at baseline. Lottery incentives had an inconclusive effect on clinic registration (RR = 1.21, 95% CI: 0.83 to 1.76) and on viral suppression at six months (RR = 1.13, 95% CI: 0.73 to 1.75) compared to motivational text messages., Conclusions: Conditional lottery incentives shortened the time to ART initiation among South African men. Behavioural economics strategies strengthen linkage to ART, but the study power was limited to see an impact on viral suppression., Clinical Trial Number: NCT03808194., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Introduction: In South Africa, HIV-infected men are less likely than women to test and know their status (the first UNAIDS "90-90-90" target), and men have worse outcomes across the HIV care cascade. HIV self-testing (HIVST) may address this testing disparity but questions remain over the most effective distribution strategy and linkage following a positive test result. We implemented a men-focused HIVST distribution programme to evaluate components contributing to participation and retention., Methods: We conducted an implementation study of multi-venue HIVST kit distribution in rural and peri-urban KwaZulu-Natal (KZN), South Africa. We distributed HIVST kits at community points, workplaces and social venues for on site or take-home use. Clients could choose blood-based or oral-fluid-based HIVST kits and elect to watch an in-person or video demonstration. We provided a USD2 incentive to facilitate reporting test results by phone or SMS. Persons with reactive HIVST results were provided immediate confirmatory tests (if used HIVST on site) or were referred for confirmatory testing (if took HIVST off site) and linkage to care for ART initiation. We describe the testing and linkage cascade in this sample and describe predictors of reactive HIVST results and linkage., Results: Between July and November 2018, we distributed 4496 HIVST kits in two regions of KZN (96% to men, median age 28 (IQR 23 to 35). Most participants (58%) chose blood-based HIVST and 42% chose oral-swab kits. 11% of men were testing for the first time. A total of 3902 (83%) of testers reported their test result to the study team, with 314 (8%) screening positive for HIV. Among 274 men with reactive HIVST results, 68% linked to ART; no significant predictors of linkage were identified. 10% of kit users reported they would prefer a different type (oral vs. blood) of kit for repeat testing than the type they used., Conclusions: HIVST is acceptable to men and rapid distribution with optional testing support is feasible in rural and peri-urban settings. HIVST kits successfully reached younger men and identified undetected infections. Both oral and blood-based HIVST were selected. Scaling up HIVST distribution and guidance may increase the number of first-time testers among men and help achieve the first UNAIDS "90" for men in South Africa., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

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

Background: Early childhood is a critical phase of development. In low resource settings, monitoring this stage of development and providing appropriate and timely feedback is a challenge. Community-based service providers play a key role in promoting early childhood development in areas where government services are weak. These community-based service providers are also tasked with the collection of monitoring and evaluation data for donors and local government. Usually, collection of these data aims to provide accountability, learning, and correction leading to improvement. However, such data is rarely used beyond the accountability stage., Objective: The purpose of this study was to test the feasibility and acceptability of the Information for Action (IFA) mobile phone app. The IFA app was designed for use by community health volunteers (CHVs), and repackages routinely collected data about children into useful, offline decision support for caregivers and program managers., Methods: The IFA app was tested with a convenience sample of 10 CHVs in West Katweng'a, a sublocation of Rarieda subcounty in western Kenya. CHVs used the IFA app for 5 months as part of their regular home visits to households containing children aged 0 to 5 years, after which a qualitative assessment of the app was conducted. A total of 16 caregivers who received services from the CHVs were randomly selected to participate in 1 of 2 focus group discussions about their experience., Results: The app was reported to help facilitate interactive dialog between CHVs and caregivers, leading to improved quality of home visits. Caregivers described the app as shifting the relationship from feeling harassed by CHVs to experiencing genuine interest from CHVs. CHVs reported feasibility challenges primarily related to infrastructure. The limited battery life of mobile phones combined with the lack of readily available electricity made it difficult to keep the phones charged. CHVs reported initial anxiety as first-time mobile phones users, including concerns about using the IFA app. With time, increased levels of confidence were seen., Conclusions: Acceptability was high with both CHVs and caregivers, who reported an improvement in their client-provider relationship. A number of feasibility challenges were experienced., (©Alastair van Heerden, Debjeet Sen, Chris Desmond, Julia Louw, Linda Richter. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 05.12.2017.)

mHealth has been proposed to address inefficiencies in the current South African healthcare system, including home-based HIV testing and counseling (HTC) programs. Yet wide-scale adoption of mHealth has not occurred. Even as infrastructure barriers decrease, a need to better understand perceived adoption barriers by stakeholders remains. We conducted focus group discussions (FGD) in South Africa in 2016 with 10 home-based HTC field staff, 12 community health workers (CHWs) and 10 persons living with HIV (PLH). Key informant (KI) interviews were conducted with five health officials. Perceptions about current home-based HTC practices, future mHealth systems and the use of biometrics for patient identification were discussed, recorded and transcribed for qualitative analysis. Themes were based on a conceptual model for perceived mHealth service quality. Stakeholders brought up a lack of communication in sharing patient health information between clinics, between clinics and CHWs, and between clinics and patients as major barriers to care that mHealth can address. CHWs need better patient information from clinics in terms of physical location and health status to plan visitation routes and address patient needs. CHWs perceive that communication barriers create distrust towards them by clinic staff. PLH want automated appointment and medication reminders. KI see mHealth as a way to improve health information transfer to government officials to better allocate healthcare resources. Stakeholders are also optimistic about the ability for biometrics to improve patient identification but disagreed as to which biometrics would be acceptable, especially in older patients. All stakeholders provided useful information towards the development of mHealth systems. Hospitals are adopting patient-centered approaches that solicit feedback from patients and incorporate them into decision-making processes. A similar approach is needed in the development of mHealth systems. Further, such systems are critical to the successful extension of the health system from health facilities into people's homes., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: In South Africa where HIV prevalence is high, mentor mother programmes have been used to promote the health and wellbeing of women enrolled in government programmes preventing vertical transmission. The Masihambisane Project trained mentors to be educators and facilitators as "expert patients" in self-help groups. While this and other similar interventions demonstrate positive outcomes for mothers and their children, the long-term repercussions for mentors delivering the intervention are seldom considered. This article explores the personal impact of being a mentor, the potentially traumatizing effects of repeatedly sharing their experiences of living with HIV and the coping strategies they adopt., Results: Towards the end of the Masihambisane intervention, 10 semi-structured qualitative interviews were conducted with locally recruited mentors living with HIV and were thematically analysed. Mentors found the repeated telling of their stories a painful reminder of adverse personal experiences. In some cases, retelling caused a physical reaction. Mentors relied on coping strategies like taking breaks, writing their experiences down and debriefing sessions. Despite the difficulties associated with their role, some mentors found being advisors and the group sessions therapeutic and empowering., Conclusions: These findings indicate that the inclusion of peer mentors comes with certain responsibilities. While the mentors were resilient and some found the experience therapeutic and empowering found creative ways to cope with secondary trauma, the negative implications cannot be ignored. To effectively deliver a mentor-driven intervention to mothers enrolled in a programme to prevent vertical transmission, the possibilities of secondary trauma should be considered and mentors provided with ongoing counselling, training on coping skills and regular debriefing sessions.