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Background: Lesotho has the second-highest HIV and AIDS prevalence globally and is the country's second leading cause of death. Despite increasing ART coverage, adolescents remain left behind and face high mortality because of delayed ART initiation. This study aimed to explore the experiences and challenges of nurses when initiating adolescents living with HIV on ART in Thaba-Tseka, Lesotho. Methods: A qualitative descriptive research design and twelve in-depth interviews were conducted among nurses from a hospital in the Thaba-Tseka district. Participants were selected purposively until data saturation was reached. Data were transcribed verbatim and analysed manually using the thematic analysis approach. The findings were presented in themes and sub-themes. Individual face-to-face interviews were conducted in English and Sesotho from May to August 2021. Results: The key findings in this study involved adolescents' attendance at the health care facility, ART initiation process, HIV stigma influencing the uptake of ART, poor ART follow-up and socio-economic factors affecting adherence to ART. Conclusion: The themes uncovered in this study provide valuable insights into the gaps in ART initiation, and highlight the challenges encountered by nurses during this process among adolescents in Lesotho. The experiences and obstacles shared by nurses during ART initiation cover a range of issues, collectively demonstrating their engagement in HIV and ART care. These findings emphasise the critical role of policymakers and health care providers in devising customised ART initiation interventions for adolescents. Addressing these challenges will be crucial for enhancing ART uptake and adherence among adolescents living with HIV in Lesotho. [ABSTRACT FROM AUTHOR]

Abstract Whether, and how, cardioprotective effects of antiretroviral treatment (ART) in adolescents with perinatal HIV infection (APHIV) vary with age at treatment initiation is unknown. We used magnetic resonance imaging to compare cardiac status between APHIV initiated on ART at

Research suggests that womens experience of intimate partner violence (IPV) is associated with poor engagement in HIV care and treatment. However, most studies have been cross-sectional and conducted in North America. We examined the association between physical IPV and HIV care outcomes in a prospective cohort study of women living with HIV (WLHIV) in Malawi, South Africa, Uganda, and Zimbabwe. At enrollment, 15% of the 351 participants self-reported physical IPV. IPV experience was not associated with time to first engagement in HIV care or the proportion virally suppressed after 6 months on ART. Women reporting physical IPV were less likely to initiate ART within 6 months of becoming eligible (adjusted RR 0.74, 95% CI 0.53-1.03). IPV screening is critical to identify survivors and link them to appropriate services. However, addressing IPV may not increase engagement in HIV care or viral load suppression among WLHIV in sub-Saharan Africa.

Supplemental Digital Content is Available in the Text. Objectives: Efforts to control the COVID-19 pandemic have potentially compromised the availability and/or quality of HIV services. We aimed to assess the pandemic's impact on antiretroviral therapy (ART) initiation and HIV viral load (VL) monitoring in 3 West African countries. Methods: We used routinely collected data from 5 clinics contributing to the International epidemiologic Database to Evaluate AIDS collaboration in Burkina Faso, Côte d'Ivoire, and Nigeria. We included ART-naïve adults living with HIV initiating ART from January 1, 2018. We conducted regression discontinuity analysis to estimate changes in the number of ART initiations and VL measures per week, before and during the pandemic period in each country. Results: In clinics in Burkina Faso and Côte d'Ivoire, ART initiations per week remained constant throughout the studied periods (−0.24 points (p) of ART initiations/week 95% CI: −5.5 to 5.9, −0.9 p, 95% CI: −8.5 to 8.6, respectively), whereas in Nigeria's clinic, they decreased significantly (−6.3 p, 95% CI: −10.8 to −1.7) after the beginning of the pandemic. The volume of VL tests performed decreased significantly in all 3 countries (−17.0 p, 95% CI: −25.3 to −8.6 in Burkina Faso, −118.4 p, 95% CI: −171.1 to −65.8 in Côte d'Ivoire and −169.1 p, 95% CI: −282.6 to −55.6 in Nigeria). Conclusions: HIV clinics in two out of three countries in West Africa demonstrated resilience as they successfully maintained access to ART for ALWH despite the challenges imposed by the pandemic. However, VL monitoring was severely disrupted and did not return to prepandemic levels approximately 1 year after the beginning of the pandemic. Continued monitoring of the HIV care continuum in the postpandemic period is essential to mitigate potential enduring effects on ALWH's virological and clinical outcomes. [ABSTRACT FROM AUTHOR]

Targeted strategies are central to increasing HIV-status awareness and progress on the care cascade among men. We implemented Village-Health-Team (VHT)-delivered HIV self-testing (HIVST) among men in a peri-urban Ugandan district and assessed linkage to confirmatory-testing, antiretroviral-therapy (ART) initiation and HIV-status disclosure following HIVST. We conducted a prospective cohort study from November 2018 to June 2019 and enrolled 1628 men from 30-villages of Mpigi district. VHTs offered each participant one HIVST-kit and a linkage-to-care information leaflet. At baseline, we collected data on demographics, testing history and risk behavior. At one-month, we measured linkage to confirmatory-testing and HIV-status disclosure, and at three months ART-initiation if tested HIV-positive. We used Poisson regression generalized estimating equations to evaluate predictors of confirmatory-testing. We found that 19.8% had never tested for HIV and 43% had not tested in the last 12-months. After receiving HIVST-kits, 98.5% self-reported HIVST-uptake in 10-days, 78.8% obtained facility-based confirmation in 30-days of HIVST with 3.9% tested HIV-positive. Of the positives, 78.8% were newly diagnosed, 88% initiated ART and 57% disclosed their HIV-status to significant others. Confirmatory testing was associated with having a higher level of education and knowing a partner's HIV-status. VHT-delivered HIVST may be effective for boosting testing, ART-initiation and HIV-status disclosure among men. [ABSTRACT FROM AUTHOR]

Background Weight gain following initiation of antiretroviral therapy (ART) is common. We assessed the impact of changes in weight in the year following ART initiation with subsequent cardiometabolic disease among AIDS Clinical Trials Group (ACTG) participants. Methods Linear regression models were fit to examine the association between change in weight/waist circumference (WC) in weeks 0–48 and change in metabolic parameters in weeks 0–48 and 48–96. Cox proportional hazard models were fit to examine the association between changes in weight/WC in weeks 0–48 and diabetes mellitus (DM), metabolic syndrome, or cardiometabolic and cardiovascular events after week 48. Results Participants (N = 2624) were primarily male (81%) and non-White (60%). Mean weight gain from 0–48 weeks was 3.6 kg (SD 7.3); 130 participants developed DM; 360 metabolic syndrome; 424 any cardiometabolic event; 28 any cardiovascular event, over 480 weeks of follow-up. In adjusted models, total cholesterol increased by 0.63 mg/dL (95% confidence interval [CI] [.38,.089]) and LDL by 0.39 mg/dL (0.19, 0.59) per 1 kg increase in weight from weeks 0 to48. Participants who experienced >10% weight gain (vs −5% to 5%) had an increased risk of DM (hazard ratio [HR] 2.01, 95% CI [1.30, 3.08]), metabolic syndrome (HR 2.24, 95% CI [1.55, 2.62]), and cardiometabolic outcomes (HR 1.54, 95% CI [1.22, 1.95]). Participants who lost more than 5% of their baseline weight had a lower risk of incident metabolic syndrome (HR 0.67, 95% CI [0.42, 1.07]). Trends for WC were similar. Conclusions Weight and body composition changes in the first year following ART initiation are associated with contemporaneous changes in metabolic parameters and subsequent cardiometabolic disease. [ABSTRACT FROM AUTHOR]

Background Aspirational targets to end AIDS by 2030 include having 95% of people with human immunodeficiency virus (HIV; PWH) diagnosed, 95% treated, and 95% with controlled viral load (VL). Our objective was to describe, using a large French prospective cohort, the median transition times through the cascade of care between 2009 and 2019. Methods We analyzed patients whose first HIV diagnosis was made between 1 January 2009 and 31 December 2019. Using the Kaplan–Meier method, we estimated the time to linkage to care (from HIV diagnosis to first biological assessment), to treatment (date of first antiretroviral therapy [ART] prescription), and to controlled VL (first value <200 copies/mL). Analyses were disaggregated by time periods and patients' characteristics. Censoring date was 31 December 2021. Results Among the 16 864 patients linked to care since 2009, the median [Q1; Q3] time from HIV diagnosis to controlled VL decreased from 254 [127–745] to 73 [48–132] days in 2009–2011 and 2018–2019, respectively. Transition times from linkage to care to first ART decreased from 67 [17; 414] in 2009–2011 to 13 [5; 26] days in 2018–2019, and from ART to controlled VL from 83 [35; 130] in 2009–2011 to 38 [28; 90] days in 2018–2019. Differences were observed depending on patients' characteristics. Conclusions We describe drastic reductions in transition time through the cascade of care, allowing reduction in the transmission period following each new infection. Delayed diagnosis remains the main obstacle to ending AIDS in the next decade. [ABSTRACT FROM AUTHOR]

BackgroundAlthough community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women.MethodsWe examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods.ResultsAmong women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p

Background. The 95-95-95 strategy implementation is a positive initiative for moving the HIV tide towards elimination, with a focus on addressing the huge inequalities in existence in access to HIV services. Objectives. To establish performance towards the 90-90-90 and 95-95-95 targets and trends in HIV positivity rates since strategy implementation rollout in the City of Johannesburg (CoJ), South Africa. Methods. This was a descriptive study, part of the bigger quasi-experimental study using the monthly District Health Information System during the implementation and rollout of the 90-90-90 strategy. HIV access trends were tracked and compared with the set strategy implementation targets. In addition, the HIV positivity rate was analysed to observe trends. A time trend analysis for aggregated data was performed on all the measured indicators to determine whether the decrease or increase was statistically significant. P

Abstract Background Women who are newly diagnosed with HIV infection during pregnancy may not be ready to immediately initiate lifelong antiretroviral therapy (ART; called Option B +) as is recommended. Lack of “readiness” drives early disengagement from care and undermines prevention of HIV transmission to infants. Several studies have shown high early attrition of women initiating ART in pregnancy. Although poor ART uptake and adherence have been attributed to various factors including stigma, disclosure issues and structural issues, there is no standard way of determining which pregnant woman will face challenges and therefore need additional support. We developed and validated a novel ART readiness tool in Lusaka, Zambia. Methods The aim of this study was to develop and validate a tool that could be used to assess how ready a newly diagnosed pregnant woman living with HIV would be to initiate ART on the day of diagnosis. Using a mixed method design, we conducted this study in three public-setting health facilities in Lusaka, Zambia. Informed by qualitative research and literature review, we identified 27 candidate items. We assessed content validity using expert and target population judgment approaches. We administered the 27-item questionnaire to 454 newly diagnosed pregnant women living with HIV, who were enrolled into a randomized trial (trials number NCT02459678). We performed item reduction analysis and used Cronbach’s alpha coefficient of 0.70 as threshold for reliability. Results A total of 454 pregnant women living with HIV enrolled in the study between March 2017 and December 2017; 452 had complete data for analysis. The correlation coefficient between the 27 items on the completed ART readiness scale ranged from 0.31 to 0.70 while item discrimination index ranged from -0.01 to 2.38. Sixteen items were selected for the final scale, representing three domains, which we classified as “internalized and anticipated HIV stigma”, “partner support” and “anticipated structural barriers”. Conclusion We developed and validated a tool that could be used to assess readiness of newly diagnosed women living with HIV to initiate ART. This ART readiness tool could allow clinics to tailor limited resources to pregnant women living with HIV needing additional support to initiate and remain on ART.

Lami Bayisa,1 Diriba Bayisa,2 Ebisa Turi,3 Diriba Mulisa,1 Tadesse Tolossa,3 Adugna Olani Akuma,1 Merga Chala Bokora,2 Dawit Tesfaye Rundasa1 1Department of Nursing, School of Nursing and Midwifery, Wollega University, Nekemte, Ethiopia; 2Department of Midwifery, School of Nursing and Midwifery, Wollega University, Nekemte, Ethiopia; 3Department of Public Health, Institute of Health Sciences, Wollega University, Nekemte, EthiopiaCorrespondence: Lami Bayisa, Department of Nursing, School of Nursing and Midwifery, Wollega University, P.O.Box: 395, Nekemte, Ethiopia, Tel +251 924318135, Email lamisabayisa@gmail.comBackground: The test-and-treat approach recommends early ART initiation (same day). Early ART start has double the benefits as treatment and as prevention. However, there is limited information regarding same-day ART initiation in Ethiopia. Hence, this study aimed to assess the magnitude and factors of same-day ART initiation among people living with HIV (PLHIV) on ART at Nekemte specialized hospital, in Western Ethiopia.Methods: A cross-sectional study was conducted among 483 PLHIV from January 10 to February 15, 2021. Data were collected using an investigator-administered questionnaire. Epi Data 3.1 and STATA 14.0 were used for data entry and analysis, respectively. Variables with P-value < 0.25 from bivariable analysis were included in the multivariable analysis. AOR with 95% CI and P-value < 0.05 were used to declare statistical significance.Results: A total of 483 study subjects participated and gave a 100% response rate. Two thirds (65%) of them started ART on the same day with a 95% CI [60.2– 68.8]. Urban dwellers (AOR = 3.93 (95% 1.96– 7.87)), with no OIs (AOR = 4.02 (95% CI: 1.54– 10.47)), not screened for TB (AOR = 6.02 (95% CI: 1.71– 21.15)), tested via VCT (AOR = 2.32 (95% CI: 1.37– 3.26)), who have not used CPT (AOR = 1.88 (95% CI: 1.10– 3.23)), who have not used IPT (AOR = 2.36 (95% CI: 1.0– 5.57)), who were tested in 2019/20 (AOR = 2.37 (95% CI: 1.08– 5.518)), and with BMI ≥ 25 kg/m2 (AOR = 2.18 (95% CI: 1.05– 4.52)) were significantly associated with same-day ART initiation.Conclusion: Two thirds of study subjects initiated ART on the same day as HIV diagnosis. Voluntary testing and immediate referral to HIV care, advocating test-and-treat, and intensive counseling should be strengthened and reinforced for newly diagnosed HIV-positive people. Given that, high attention should be paid to individuals from urban residence, not screened for TB, who have not used CPT and IPT prophylaxis.Keywords: antiretroviral therapy, ART initiation, same day

Introduction Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately.Methods We conducted a qualitative study to inform interventions supporting rapid initiation in the ‘Test and Start’ era. We purposively sampled 20 adult patients living with HIV and a previous gap in care from ten health facilities in Lusaka, Zambia for interviews. We inductively analysed transcripts using a thematic, narrative approach. In their narratives, seven participants discussed delaying ART initiation.Results Drawing on messages gleaned from facility-based counselling and community information, many cited greater fear of rapid sickness or death due to imperfect adherence or treatment side effects than negative health consequences due to delayed initiation. Participants described needing time to ‘prepare’ their minds for a lifetime treatment commitment. Concerns about inadvertent HIV status disclosure during drug collection discouraged immediate initiation, as did feeling healthy, and worries about the impact of ART initiation on relationship dynamics.Conclusion Findings suggest that counselling messages should accurately communicate treatment risks, without perpetuating fear-based narratives about HIV. Identifying and managing patient-specific concerns and reasons for the ‘need for time’ may be important for supporting individuals to rapidly accept lifelong treatment.Key messagesFear-based adherence messaging in health facilities about the dangers of missing a treatment dose or changing the time when ART is taken contributes to Zambian patients’ refusals of immediate ART initiationResponsive health systems that balance a stated need for time to accept one's diagnosis and prepare to embark on a lifelong treatment plan with interventions to identify and manage patient-specific treatment related fears and concerns may support more rapid ART initiationPerceived social stigma around HIV continues to be a significant challenge for treatment initiation.

PURPOSE OF THE REVIEW: In 2015, antiretroviral therapy (ART) was recommended for all people living with HIV (PLHIV) regardless of CD4 count (Treat All). To better understand how to improve linkage to care under these new guidelines, we conducted a systematic review of studies evaluating linkage interventions in Sub-Saharan Africa under Treat All. RECENT FINDINGS: We identified 14 eligible articles and qualitatively analyzed the effectiveness of the interventions. Increases in linkage were reported by supply-side and counseling interventions. Mobile testing and economic incentives did not increase linkage. Given the lag time between adoption and implementation, only two of the studies were conducted in a Treat All setting. None of the interventions specifically focused on re-linking PLHIV who had disengaged from care. Future studies must design interventions that target not only newly diagnosed or treatment naïve PLHIV, but should explicitly focus on PLHIV who have disengaged from care.

Despite improved clinical outcomes of initiating antiretroviral therapy (ART) soon after diagnosis, conflicting evidence exists regarding the impact of same-day ART initiation on subsequent clinical outcomes. We aimed to characterize the associations of time to ART initiation with loss to care and viral suppression in a cohort of newly diagnosed people living with HIV (PLHIV) entering care after Rwanda implemented a national "Treat All" policy. We conducted a secondary analysis of routinely collected data of adult PLHIV enrolling in HIV care at 10 health facilities in Kigali, Rwanda. Time from enrollment to ART initiation was categorized as same day, 1–7 days, or >7 days. We examined associations between time to ART and loss to care (>120 days since last health facility visit) using Cox proportional hazards models, and between time to ART and viral suppression using logistic regression. Of 2,524 patients included in this analysis, 1,452 (57.5%) were women and the median age was 32 (interquartile range: 26–39). Loss to care was more frequent among patients who initiated ART on the same day (15.9%), compared with those initiating ART 1–7 days (12.3%) or >7 days (10.1%), p < .001. In multivariable analyses, same-day ART initiation was associated with a greater hazard of loss to care compared with initiating >7 days after enrollment (adjusted hazard ratio 1.39, 95% confidence interval: 1.04–1.85). A total of 1,698 (67.3%) had available data on viral load measured within 455 days after enrollment. Of these, 1,476 (87%) were virally suppressed. A higher proportion of patients initiating ART on the same day were virally suppressed (89%) compared with those initiating 1–7 days (84%) or >7 days (88%) after enrollment. This association was not statistically significant. Our findings suggest that ensuring adequate, early support for PLHIV initiating ART rapidly may be important to improve retention in care for newly diagnosed PLHIV in the era of Treat All. [ABSTRACT FROM AUTHOR]

Background: Women who are newly diagnosed with HIV infection during pregnancy may not be ready to immediately initiate lifelong antiretroviral therapy (ART; called Option B +) as is recommended. Lack of "readiness" drives early disengagement from care and undermines prevention of HIV transmission to infants. Several studies have shown high early attrition of women initiating ART in pregnancy. Although poor ART uptake and adherence have been attributed to various factors including stigma, disclosure issues and structural issues, there is no standard way of determining which pregnant woman will face challenges and therefore need additional support. We developed and validated a novel ART readiness tool in Lusaka, Zambia. Methods: The aim of this study was to develop and validate a tool that could be used to assess how ready a newly diagnosed pregnant woman living with HIV would be to initiate ART on the day of diagnosis. Using a mixed method design, we conducted this study in three public-setting health facilities in Lusaka, Zambia. Informed by qualitative research and literature review, we identified 27 candidate items. We assessed content validity using expert and target population judgment approaches. We administered the 27-item questionnaire to 454 newly diagnosed pregnant women living with HIV, who were enrolled into a randomized trial (trials number NCT02459678). We performed item reduction analysis and used Cronbach's alpha coefficient of 0.70 as threshold for reliability. Results: A total of 454 pregnant women living with HIV enrolled in the study between March 2017 and December 2017; 452 had complete data for analysis. The correlation coefficient between the 27 items on the completed ART readiness scale ranged from 0.31 to 0.70 while item discrimination index ranged from -0.01 to 2.38. Sixteen items were selected for the final scale, representing three domains, which we classified as "internalized and anticipated HIV stigma", "partner support" and "anticipated structural barriers". Conclusion: We developed and validated a tool that could be used to assess readiness of newly diagnosed women living with HIV to initiate ART. This ART readiness tool could allow clinics to tailor limited resources to pregnant women living with HIV needing additional support to initiate and remain on ART. [ABSTRACT FROM AUTHOR]

Research suggests that women's experience of intimate partner violence (IPV) is associated with poor engagement in HIV care and treatment. However, most studies have been cross-sectional and conducted in North America. We examined the association between physical IPV and HIV care outcomes in a prospective cohort study of women living with HIV (WLHIV) in Malawi, South Africa, Uganda, and Zimbabwe. At enrollment, 15% of the 351 participants self-reported physical IPV. IPV experience was not associated with time to first engagement in HIV care or the proportion virally suppressed after 6 months on ART. Women reporting physical IPV were less likely to initiate ART within 6 months of becoming eligible (adjusted RR 0.74, 95% CI 0.53–1.03). IPV screening is critical to identify survivors and link them to appropriate services. However, addressing IPV may not increase engagement in HIV care or viral load suppression among WLHIV in sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Abstract Introduction In 2010, the Canadian province of British Columbia (BC) initiated the Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) program to improve HIV testing, linkage to care, and treatment uptake, thereby operationalizing the HIV Treatment as Prevention (TasP) framework at the population-level. In this analysis, we evaluated self-reported HIV care experiences and therapeutic outcomes among people diagnosed with HIV prior to and after implementation of this provincial program. Methods A cross-sectional analysis was performed on the baseline data of a cohort of people living with HIV (PLWH) (19 years and older) in the province of BC sampled from July 2016 to September 2018. All participants consented to linking their survey data to the provincial HIV treatment registry. Individuals diagnosed with HIV from January 1 2000—December 31 2009 were classified as pre-intervention and those diagnosed January 1 2010—December 31 2018 as post-intervention cohorts. Bivariate analyses were run using Chi-square and Wilcoxon Rank Sum tests. Cox proportional hazards regression model demonstrates time to antiretroviral therapy (ART) initiation (from HIV baseline) and virological suppression (2 consecutive plasma viral load measurements

Abstract Background In response to the global pandemic of COVID-19, countries around the world began imposing stay-at-home orders, restrictions on transport, and closures of businesses in early 2020. South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, fear of transmission, and government responses may have led to a reduction in antiretroviral treatment (ART) initiations for HIV-infected individuals in countries like South Africa. Methods We analyzed national, public sector, facility-level data from South Africa’s District Health Information System (DHIS) from January 2019 to March 2021 to quantify changes in ART initiation rates stratified by province, setting, facility size and type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. We excluded facilities with missing data, mobile clinics, and correctional facilities. We estimated the total number of ART initiations per study month for each stratum and compared monthly totals, by year. Results At the 2471 facilities in the final data set (59% of all ART sites in the DHIS), 28% fewer initiations occurred in 2020 than in 2019. Numbers of ART initiations declined sharply in all provinces in April-June 2020, compared to the same months in 2019, and remained low for the rest of 2020, with some recovery between COVID-19 waves in October 2020 and possible improvement beginning in March 2021. Percentage reductions were largest in district hospitals, larger facilities, and urban areas. After the initial decline in April-June 2020, most provinces experienced a clear inverse relationship between COVID-19 cases and ART initiations but little relationship between ART initiations and lockdown level. Conclusions The COVID-19 pandemic and responses to it resulted in substantial declines in the number of HIV-infected individuals starting treatment in South Africa, with no recovery of numbers during 2020. These delays may lead to worse treatment outcomes for those with HIV and potentially higher HIV transmission. Exceptional effort will be needed to sustain gains in combatting HIV.

Background: Few studies have longitudinally assessed psychological distress among people with HIV (PWH) initiating ART in resource-limited settings. Method: Baseline, 6-month, and 12-month psychological distress were measured in a Nigerian cohort newly initiating therapy; the relationship between baseline factors and psychological distress at 12 months was assessed; and the association between psychological distress at 12 months and care retention or immunologic failure was determined. Results: Among 563 patients, median age was 38 years (IQR: 33–46 years), 62% were female, and 51% were married. Psychological distress increased from 3% at baseline to 34% at 12 months. Age (aOR 1.28, 95% CI 1.06–1.56), female sex (aOR 2.89, 95% CI 1.93–4.33), lack of disclosure (aOR 4.32, 95% CI 2.48–7.51), and time on ART (6 months [aOR 6.91, 95% CI 3.14–15.18] and 12 months [aOR 32.63, 95% CI 16.54–64.36]) were associated with psychological distress while being married (OR 0.42, 95% CI 0.30–0.61) was associated with reduced odds. Tweve-month psychological distress was associated with increased risk of immunologic failure (aOR 2.22, 95% CI 1.31–3.82). Conclusion: The risk of psychological distress increased 30-fold in the first year on therapy in PWH in Nigeria. [ABSTRACT FROM AUTHOR]

The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a 'hotspot' for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011–2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13–2.28), ART initiation by 3 months (aOR 2.58; 1.61–4.12) and VS by 12 months (aOR4.87; 1.69–14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagnosed HIV infection in a city with a severe HIV epidemic. [ABSTRACT FROM AUTHOR]

Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately. We conducted a qualitative study to inform interventions supporting rapid initiation in the 'Test and Start' era. We purposively sampled 20 adult patients living with HIV and a previous gap in care from ten health facilities in Lusaka, Zambia for interviews. We inductively analysed transcripts using a thematic, narrative approach. In their narratives, seven participants discussed delaying ART initiation. Drawing on messages gleaned from facility-based counselling and community information, many cited greater fear of rapid sickness or death due to imperfect adherence or treatment side effects than negative health consequences due to delayed initiation. Participants described needing time to 'prepare' their minds for a lifetime treatment commitment. Concerns about inadvertent HIV status disclosure during drug collection discouraged immediate initiation, as did feeling healthy, and worries about the impact of ART initiation on relationship dynamics. Findings suggest that counselling messages should accurately communicate treatment risks, without perpetuating fear-based narratives about HIV. Identifying and managing patient-specific concerns and reasons for the 'need for time' may be important for supporting individuals to rapidly accept lifelong treatment. Fear-based adherence messaging in health facilities about the dangers of missing a treatment dose or changing the time when ART is taken contributes to Zambian patients' refusals of immediate ART initiation Responsive health systems that balance a stated need for time to accept one's diagnosis and prepare to embark on a lifelong treatment plan with interventions to identify and manage patient-specific treatment related fears and concerns may support more rapid ART initiation Perceived social stigma around HIV continues to be a significant challenge for treatment initiation. [ABSTRACT FROM AUTHOR]

The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a 'hotspot' for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011–2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13–2.28), ART initiation by 3 months (aOR 2.58; 1.61–4.12) and VS by 12 months (aOR4.87; 1.69–14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagnosed HIV infection in a city with a severe HIV epidemic. [ABSTRACT FROM AUTHOR]

Lami Bayisa,1 Bizuneh Wakuma,2 Tesfaye Abera,1 Diriba Mulisa,1 Getu Mosisa,1 Tadesse Tolossa,3 Ebisa Turi3 1Department of Nursing, School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia; 2Department of Pediatric Nursing, School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia; 3Department of Public Health, Institute of Health Sciences, Wollega University, Nekemte, EthiopiaCorrespondence: Lami BayisaDepartment of Nursing, School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, PO Box 395, Nekemte, EthiopiaTel +251924318135Email lamisabayisa@gmail.comIntroduction: HIV clients’ mistrust in providers’ handling of their medical information can be a reason for them not to utilize services. Compromised confidentiality of HIV clients can affect the entire community, as other people may become reluctant to seek HIV testing and counseling. In Ethiopia, there are few data on perceived breaches of confidentiality among HIV/AIDS clients. Thus, this study aimed to assess perceived breaches of confidentiality and associated factors among people living with HIV (PLHIV) on anti-retroviral therapy (ART) at Nekemte Specialized Hospital, Western Ethiopia.Methods: A facility-based cross-sectional study was conducted among 423 HIV/AIDS clients at Nekemte Specialized Hospital from January 15 to February 20, 2021. Data were collected by an investigator-administered questionnaire. Collected data were entered into EpiData version 3.1, and Stata version 14.0 was used for analysis. Bivariable and multivariable logistic regression analyses were performed. Variables with a P-value of < 0.2 in the bivariable analysis were exported to the multivariable analysis. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) and P-values of < 0.05 were used to report significantly associated variables.Results: A total of 423 PLHIV were included in the study. Nearly one-fourth of the respondents (23.60%) had perceived breaches of confidentiality (95% CI 19.8– 27.9%). Delayed ART start [(AOR 1.97) 95% CI (1.05– 3.71)], being female [(AOR 4.03) 95% CI (2.14– 7.59)], being widowed [(AOR 4.11) 95% CI (1.50– 11.20)], college education and above [(AOR 10.89) 95% CI (3.93– 30.14)], normal BMI [(AOR 2.72) 95% CI (1.06– 6.99)], substance use [(AOR 1.93) 95% CI (1.04– 3.58)], not knowing other ART user(s) [(AOR 2.89) 95% CI (1.53– 5.47)], and CD4 count ≤ 200 cells/mm3 [(AOR 2.63) 95% CI (1.22– 5.68)] were significantly associated variables.Conclusion: One in four HIV/AIDS clients reported experiencing perceived breaches of confidentiality. Thus, early ART initiation, further HIV serostatus disclosure, and encouraging patients to decide on the type of care and information they want need to be strengthened in order to reduce breaches of confidentiality.Keywords: breaches of confidentiality, ART initiation, care providers, HIV/AIDS clients, PLHIV

Background: South Africa recently adopted HIV self-test technology (HIVST) to improve HIV testing and encourage earlier treatment initiation in working populations with a low uptake of conventional testing approaches. This study investigates the impact of HIVST on testing outcomes, focusing on both frequent and infrequent working-class testers. The paper also examines the spillover effect of HIVST on antiretroviral (ART) treatment initiation. To identify these effects, the author focused on South Africa and exploited the HIVST distribution data of 6259 beneficiaries of HIVST. Methods: The author used a two-stage least-squared model to quantify the impact of the HIVST on these vulnerable working populations. Results: The results show that HIVST fosters a 27.6% higher testing uptake in infrequently testing workers compared to frequently testing workers, and that the uptake of HIVST is 11.5% higher in rural regions than in urban settings, as well as 14.5% more prominent in infrequent male testers than infrequent female testers. Notably, the positive effects of HIVST are also confirmed by the presence of positive spillover effects in workers screening positive for HIV. The paper documents a 7.6% increase in ART initiation in infrequent testers. Conclusions: There is a case for adopting this technology to improve the uptake of HIV testing and ART initiation as the country seeks to attain the UNAIDS 95–95–95 targets by 2030. [ABSTRACT FROM AUTHOR]

In South Africa, where an estimated 34% of nearly 7-million HIV-positive people were not on antiretroviral therapy (ART) in 2019, innovative strategies to diagnose and link people to care are needed. HIV self-testing (HIVST) is one such strategy. However, there is concern that access to HIVST might result in re-testing among people on ART, with a risk of false negative results and disengagement from care. Between November 2017 and December 2018, HIVST kits were distributed at a private pharmacy and at HIV testing outreach events. Each participant was instructed to report their result via SMS and those who did not were followed-up telephonically 10 days later. Electronic medical records of participants were searched for evidence of HIV services 6 months before and after enrollment. Of 1482 participants, 163 (11%) were previously diagnosed HIV-positive prior to taking the test. Of these, 123 reported a result, however 87% reported a negative result. Of the 163 previously diagnosed, 84 were not in ART care prior to the test, with 15 (18%) linking to care post-test. Of 79 who were in ART care prior to the test, 76 (96%) remained in care, even though 51 (67%) had reported a negative result. Overall, 29% of participants reported their result via SMS, and 48% when telephoned. Despite efforts to dissuade them, some previously diagnosed HIV-positive utilised HIVST. For those disengaged from care this may facilitate re-engagement. Self-testing among those already in care, regardless of the reported result, did not disrupt their treatment, and their reasons for doing the test remain unclear. [ABSTRACT FROM AUTHOR]

Lami Bayisa,1 Tesfaye Abera,1 Diriba Mulisa,1 Getu Mosisa,1 Alemnesh Mosisa,1 Tadesse Tolosa,2 Ebisa Turi,2 Bizuneh Wakuma,3 Eba Abdisa,1 Diriba Bayisa4 1Department of Nursing, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia; 2Department of Public Health, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia; 3Department of Pediatric Nursing, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia; 4Department of Midwifery, Institutes of Health Sciences, Wollega University, Nekemte, EthiopiaCorrespondence: Lami BayisaDepartment of Nursing, Institutes of Health Sciences, Wollega University, P.O. Box: 395, Nekemte, EthiopiaTel +251 924318135Email lamisabayisa@gmail.comBackground: HIV continuum of care demands early ART initiation for all HIV-infected individuals. Early ART initiation reduces onward HIV transmission facilitating rapid viral suppression. Despite this, delayed ART use is a challenge among newly diagnosed HIV-positive individuals, and there is limited evidence on time to ART initiation among this group in Ethiopia. Thus, this study aimed to assess time to ART initiation and its predictors among newly diagnosed HIV-positive individuals in Nekemte town, Western Ethiopia.Methods: An institution-based retrospective follow-up study was conducted on 518 newly diagnosed HIV-positive people from September 5, 2016 to December 20, 2020 at Nekemte town, Western Ethiopia. Data were collected from ART intake forms, registration log books and patient charts. The collected data were entered into Epi Data version 3.1 and STATA version 14.0 was used for analysis. Survival probability was checked graphically by Kaplan–Meier curve and statistically by Log rank test. Both bivariable and multivariable Cox Proportional hazards regression models were conducted to identify the predictors of ART initiation. Hazard ratio with 95% CI and p-value of < 0.05 was used to declare a statistical significance.Results: By the end of the follow-up, 371 (71.6%) individuals had initiated ART with an overall incidence rate of 51.9 per 1000 [95% CI: 54.07– 66.32] person days; median time to ART initiation was 4 [IQR: 1– 9] days. Being female (AHR = 1.33, 95% CI: 1.06– 1.67), urban dwellers (AHR = 2.02, 95% CI: 1.37– 2.97), having baseline OIs (AHR = 1.62, 95% CI: 1.60– 4.30); being tested via VCT (AHR = 1.33, 95% CI: 1.02– 1.74); linked from OPD (AHR = 0.64, 95% CI: 0.47– 0.85); disclosing HIV sero-status (AHR = 2.07, 95% CI: 1.17– 3.68); and college and above education level (AHR = 1.43, 95% CI: 1.00– 2.0) were identified as significant predictors of early initiation of ART.Conclusion: The proportion and incidence of ART initiation was high; a short median time to ART initiation was revealed in this study. Strictly screening OIs, encouraging HIV sero-status disclosure and voluntary HIV testing are recommended to increase early ART initiation.Keywords: ART initiation, time to ART initiation, newly diagnosed HIV positive, Ethiopia

IntroductionThe Streamlined Antiretroviral Therapy Initiation Strategy (START-ART) study found that a theory-based intervention using opinion leaders to inform and coach health care providers about the risks of treatment delay, provision of point of care (POC) CD4 testing machines (PIMA) and reputational incentives, led to rapid rise in ART initiation. We used qualitative research methods to explore mechanisms of provider behaviour change.MethodsWe conducted in-depth interviews (IDIs) with 24 health care providers and nine study staff to understand perceptions, attitudes and the context of changes in ART initiation practices. Analyses were informed by the Theoretical Domains Framework.ResultsRapid dissemination of new practices was enabled in the environmental context of an existing relationship based on communication, implementation and accountability between Makerere University Joint AIDS Program (MJAP), a Ugandan University-affiliated organization that provided technical oversight for HIV service delivery at the health facilities where the intervention was implemented, and a network of health facilities operated by the Uganda Ministry of Health. Coaching carried out by field coordinators from MJAP strengthened influence and informal accountability for carrying out the intervention. Frontline health workers held a pre-existing strong sense of professional identity. They were proud of attainment of new knowledge and skills and gratified by providing what they perceived to be higher quality care. Peer counsellors, who were not explicitly targeted in the intervention design, effectively substituted some functions of health care providers; as role models for successful ART uptake, they played a crucial role in creating demand for rapid ART initiation through interactions with patients. Point of care (POC) CD4 testing enabled immediate action and relieved providers from frustrations of lost or delayed laboratory results, and led to higher patient satisfaction (due to reduced costs because of ability to initiate ART right away, requiring fewer return trips to clinic).ConclusionsQualitative data revealed that a multicomponent intervention to change provider behaviour succeeded in the context of strong institutional and individual relationships between a University-affiliated organization, government facilities, and peer health workers (who acted as a crucial link between stakeholders) and the community. Fostering stable institutional relationships between institutional actors (non-governmental organization (NGOs) and ministry-operated facilities) as well as between facilities and the community (through peer health workers) can enhance uptake of innovations targeting the HIV cascade in similar clinical settings.

Background In 2012, the US Department of Health and Human Services updated their HIV treatment guidelines to recommend antiretroviral therapy (ART) for all people with HIV (PWH) regardless of CD4 count. We investigated recent trends and disparities in early receipt of ART prescription and subsequent viral suppression (VS). Methods We examined data from ART-naïve PWH newly presenting to HIV care at 13 North American AIDS Cohort Collaboration on Research and Design clinical cohorts in the United States during 2012–2018. We calculated the cumulative incidence of early ART (within 30 days of entry into care) and early VS (within 6 months of ART initiation) using the Kaplan-Meier survival function. Discrete time-to-event models were fit to estimate unadjusted and adjusted associations of early ART and VS with sociodemographic and clinical factors. Results Among 11 853 eligible ART-naïve PWH, the cumulative incidence of early ART increased from 42% in 2012 to 82% in 2018. The cumulative incidence of early VS among the 8613 PWH who initiated ART increased from 83% in 2012 to 93% in 2018. In multivariable models, factors independently associated with delayed ART and VS included non-Hispanic/Latino Black race, residence in the South census region, being a male with injection drug use acquisition risk, and history of substance use disorder (SUD; all P ≤.05). Conclusions Early ART initiation and VS have substantially improved in the United States since the release of universal treatment guidelines. Disparities by factors related to social determinants of health and SUD demand focused attention on and services for some subpopulations. [ABSTRACT FROM AUTHOR]

Introduction: In 2010, the Canadian province of British Columbia (BC) initiated the Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) program to improve HIV testing, linkage to care, and treatment uptake, thereby operationalizing the HIV Treatment as Prevention (TasP) framework at the population-level. In this analysis, we evaluated self-reported HIV care experiences and therapeutic outcomes among people diagnosed with HIV prior to and after implementation of this provincial program.Methods: A cross-sectional analysis was performed on the baseline data of a cohort of people living with HIV (PLWH) (19 years and older) in the province of BC sampled from July 2016 to September 2018. All participants consented to linking their survey data to the provincial HIV treatment registry. Individuals diagnosed with HIV from January 1 2000-December 31 2009 were classified as pre-intervention and those diagnosed January 1 2010-December 31 2018 as post-intervention cohorts. Bivariate analyses were run using Chi-square and Wilcoxon Rank Sum tests. Cox proportional hazards regression model demonstrates time to antiretroviral therapy (ART) initiation (from HIV baseline) and virological suppression (2 consecutive plasma viral load measurements < 200 copies/ml).Results: Of the 325 participants included in this analysis, 198 (61%) were diagnosed with HIV in the pre-intervention era and 127 (39%) in the post-intervention era. A higher proportion of participants in post-intervention era were diagnosed at walk-in clinics (45% vs. 39%) and hospitals (21% vs. 11%) (vs pre-intervention) (p = 0.042). Post-intervention participants had initiated ART with less advanced HIV disease (CD4 count 410 vs. 270 cells/ul; p = 0.001) and were less likely to experience treatment interruptions at any point in the 5 years after HIV diagnosis (17% vs. 48%; p < 0.001). The post-intervention cohort had significantly more timely ART initiation (aHR: 5.97, 95%CI 4.47, 7.97) and virologic suppression (aHR: 2.03, 95%CI 1.58, 2.60) following diagnosis, after controlling for confounders.Conclusions: We found favourable treatment experiences and more timely ART initiation and virologic suppression after a targeted TasP provincial program. Our results illustrate the importance of accessible low-barrier HIV testing and treatment in tackling the HIV epidemic. [ABSTRACT FROM AUTHOR]

Current guidelines recommend starting antiretroviral therapy (ART) as soon as possible after HIV diagnosis to reduce morbidity, mortality and onward HIV transmission. We examined factors influencing ART initiation by women who seroconverted during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial. ECHO, conducted between 2015 and 2018, enrolled HIV-negative, sexually active women, aged 16–35 years, from four African countries. Follow-up was 12–18 months, with quarterly HIV testing. Women with incident HIV infection received extensive counselling by trial staff and referral to local facilities for HIV care. Of 304 women with ≥90 days follow-up time since HIV diagnosis, 186(61.2%) initiated ART within 90 days, 69(22.7%) initiated after 90 days, and 49(16.1%) had not initiated by the end of the study. There were no statistically significant differences in characteristics among women who initiated ART ≤90 days versus those who did not. Frequent reasons for delayed or non-initiation of ART included not feeling ready to start ART and being newly diagnosed. In a large clinical trial, ART initiation was modest within 90 days of HIV diagnosis and grew to 84% with longer observation. Despite extensive counselling on the importance of early ART initiation, personal barriers delayed some women from starting ART. [ABSTRACT FROM AUTHOR]

Background: In response to the global pandemic of COVID-19, countries around the world began imposing stay-at-home orders, restrictions on transport, and closures of businesses in early 2020. South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, fear of transmission, and government responses may have led to a reduction in antiretroviral treatment (ART) initiations for HIV-infected individuals in countries like South Africa. Methods: We analyzed national, public sector, facility-level data from South Africa's District Health Information System (DHIS) from January 2019 to March 2021 to quantify changes in ART initiation rates stratified by province, setting, facility size and type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. We excluded facilities with missing data, mobile clinics, and correctional facilities. We estimated the total number of ART initiations per study month for each stratum and compared monthly totals, by year. Results: At the 2471 facilities in the final data set (59% of all ART sites in the DHIS), 28% fewer initiations occurred in 2020 than in 2019. Numbers of ART initiations declined sharply in all provinces in April-June 2020, compared to the same months in 2019, and remained low for the rest of 2020, with some recovery between COVID-19 waves in October 2020 and possible improvement beginning in March 2021. Percentage reductions were largest in district hospitals, larger facilities, and urban areas. After the initial decline in April-June 2020, most provinces experienced a clear inverse relationship between COVID-19 cases and ART initiations but little relationship between ART initiations and lockdown level. Conclusions: The COVID-19 pandemic and responses to it resulted in substantial declines in the number of HIV-infected individuals starting treatment in South Africa, with no recovery of numbers during 2020. These delays may lead to worse treatment outcomes for those with HIV and potentially higher HIV transmission. Exceptional effort will be needed to sustain gains in combatting HIV. [ABSTRACT FROM AUTHOR]

Nurilign Abebe Moges,1,2 Olubukola Adeponle Adesina,3,4 Micheal A Okunlola,3,4 Yemane Berhane5 1Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia; 2Pan African University, Life and Earth Sciences Including Health and Agriculture Institute (PAULESI), University of Ibadan, Ibadan, Nigeria; 3Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria; 4Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria; 5Department of Epidemiology, Addis Continental Institute of Public Health, Addis Ababa, EthiopiaCorrespondence: Nurilign Abebe MogesDebre Markos University, Debre Markos, EthiopiaTel +251910106295Email nure113@gmail.comPurpose: HIV test and treat approach is currently a strategy used as a part of the prevention and control program in Ethiopia. The strategy adopts initiating antiretroviral therapy (ART) on the same-day as HIV diagnosis or in the next visit. However, there is little evidence on barriers and facilitators of same-day (ART) initiation in Ethiopia. Therefore, this study aimed to investigate barriers and facilitators of same-day (ART) initiation in the northwest Ethiopia.Patients and Methods: A qualitative study was conducted in East Gojjam Zone in northwest Ethiopia. Purposively selected HIV patients, healthcare workers, and treatment assistants participated in the qualitative study. Data were collected through in-depth interviews and focus group discussions (FGDs). Coding was done via ATLAS.ti software thematically. The interviews and FGDs were conducted in Amharic (local language) and then transcribed verbatim and translated into English. Coding was done via ATLAS.ti software. The thematic analysis approach was employed using the constructs of the transtheoretical behavioral model (TTM) to show stages of change that newly HIV diagnosed experienced in the course of preparation for treatment initiation.Results: A total of 19 patients, 12 treatment supporters, and 9 healthcare workers participated in the qualitative study. Shocking due to the test result, having no symptoms, mistrust of the test result, and seeking spiritual healing from holy water were the major barriers to start ART in the same-day of diagnosis or within the next visit.Conclusion: During HIV diagnosis, more barriers were observed in the early stages, while treatment facilitators emerged in the later stages of TTM. The TTM model can be applied to characterize where participants were in the stages of change.Keywords: same-day, test and treat, ART initiation, transtheoretical model, Ethiopia

Abstract Background Increased coagulation biomarkers are associated with poor outcomes among people living with HIV (PLHIV). There are few data available from African cohorts demonstrating the effect of antiretroviral therapy (ART) on coagulation biomarkers. Methods From March 2014 to October 2014, ART-naïve PLHIV initiating non-nucleoside reverse transcriptase inhibitor-based ART were recruited from seven clinics in western Kenya and followed for up to 12 months. Demographics, clinical history and blood specimens were collected. Logistic regression models adjusted for intrasite clustering examined associations between HIV viral load and D-Dimer at baseline. Mixed linear effects models were used to estimate mean change from baseline to 6 months overall, and by baseline viral load, sex and TB status at enrollment. Mean change in D-dimer at 6 months is reported on the log10 scale and as percentage change from baseline. Results Among 611 PLHIV enrolled, 66% were female, median age was 34 years (interquartile range (IQR) 29–43 years), 31 (5%) participants had tuberculosis and median viral load was 113,500 copies/mL (IQR: 23,600-399,000). At baseline, 311 (50.9%) PLHIV had elevated D-dimer (> 500 ng/mL) and median D-dimer was 516.4 ng/mL (IQR: 302.7–926.6) (log baseline D-dimer: 2.7, IQR: 2.5–3.0). Higher baseline D-dimer was significantly associated with higher viral load (p 6.0 copies/mL (− 91.1, 95%CI −136.7, − 54.2; p

Abstract Background About 13 years since the introduction of antiretroviral therapy (ART) for children living with HIV (CLHIV) in Zambia, HIV/AIDS testing and treatment guidelines for children have evolved over the years with limited documentation of long-term trends in the numbers testing HIV positive and initiating ART. We examined trends in HIV testing and ART initiation in Zambia. Methods We conducted a retrospective cohort study using routinely collected patient level data from 496 health facilities across Zambia. We used Poisson regression to derive incident rate ratios and 95% confidence intervals (95% CI) for background characteristics and used a Cuzick non-parametric test for trends to test the 13-year trends. Median time from testing to ART initiation in days and incidence rates were derived using life tables in survival analysis. We used multi-level random effects Poisson regression model to determine variations in time from HIV testing to ART initiation by facility. Results Overall, the cumulative proportion of the children who tested positive and initiated antiretroviral therapy (ART for HIV) from 2004 to 2017 was 69% (n = 99 592). During the period under review proportions of ART initiation increased from 52% in 2004–2006 to 97% in 2016–2017 (P

HIV care continuum outcome disparities by health insurance status have been noted among people with HIV (PWH). We therefore examined associations between state Medicaid expansion and HIV outcomes in the United States. Adults (≥18 years) with ≥1 visit in NA-ACCORD clinical cohorts from 2012-2017 contributed person-time annually between first and final visit or death; in each calendar year, clinical retention was ≥2 completed visits > 90 days apart, antiretroviral therapy (ART) receipt was receipt of ≥3 antiretroviral agents, and viral suppression was last measured HIV-1 RNA < 200 copies/mL. CD4 at enrollment was obtained within 6 months of enrollment in cohort. Difference-in-difference (DID) models quantified associations between Medicaid expansion changes (by state of residence) and HIV outcomes. Across 50 states, 87 290 PWH contributed 325 113 person-years of follow-up. Medicaid expansion had a substantial positive effect on CD4 at enrollment (DID = 93.5, 95% CI: 52.9, 134 cells/mm 3 ), a small negative effect on proportions clinically retained (DID = -0.19, 95% CI: -0.037, -0.01), and no effects on ART receipt (DID = 0.001, 95% CI: -0.003, 0.005) or viral suppression (DID = -0.14, 95% CI: -0.34, 0.07). Medicaid expansion had a positive effect on CD4 at entry, suggesting more timely HIV testing and care linkage, but generally null effects on downstream HIV care continuum measures., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials. K.N.A. reports service on the scientific review board for TrioHealth, Inc. and consultancy with the All of Us Research Program. P.F.R. reports consulting fees for advising on HIV care continuum and cardiometabolic outcome analyses from Gilead & Janssen. All other authors report no potential COIs., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Introduction: Rapid antiretroviral treatment (ART) initiation reduces time from HIV infection to viral suppression, decreasing HIV transmission risk. Mental health symptoms may influence timing of ART initiation. This study estimated the prevalence of ART initiation at enrolment into HIV care and the relationship between mental health and ART initiation at enrolment into HIV care. Methods: We conducted interviews with 426 individuals initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the association between mental health and timing of ART initiation. Depression (Patient Health Questionnaire‐9; cut‐point 10), anxiety (Generalized Anxiety Disorder‐7; cut‐point 10), post‐traumatic stress disorder (PTSD) (PTSD Checklist for DSM‐5; cut‐point 31) and harmful alcohol use (Alcohol Use Disorders Identification Test; cut‐point 16) were dichotomized to represent those with and without each exposure at first HIV care appointment. Date of ART initiation (date ART prescribed) was ascertained from medical records. Separate multivariable log‐binomial regression models were used to estimate the association between mental health exposures and ART initiation at enrolment into care. Results and discussion: Overall, 87% initiated ART at enrolment into HIV care. Approximately 20% reported depressive symptoms, 15% reported PTSD symptoms, 12% reported anxiety symptoms and 13% reported harmful alcohol use. In multivariable analyses, individuals with moderate to severe depressive symptoms had 1.7 (95% confidence interval [CI] 1.1, 2.7) times the prevalence of not initiating ART at enrolment into HIV care compared to those with no or mild depressive symptoms. Those with symptoms of PTSD, compared to those without, had 1.9 (95% CI 1.2, 2.9) times the prevalence of not initiating ART at enrolment into HIV care. Symptoms of anxiety or harmful drinking were not associated with ART initiation at enrolment into HIV care in multivariable models. Conclusions: Symptoms of depression and PTSD were associated with lower prevalence of ART initiation at enrolment into HIV care among this sample of individuals initiating HIV care in Cameroon under a "treat all" policy. Research should examine barriers to timely ART initiation, whether incorporating mental health services into HIV care improves timely ART initiation, and whether untreated symptoms of depression and PTSD drive suboptimal HIV care outcomes. [ABSTRACT FROM AUTHOR]

Accurate reporting of antiretroviral therapy (ART) uptake is crucial for measuring the success of epidemic control. Programs without linked electronic medical records are susceptible to duplicating ART initiation events. We assessed the prevalence of undisclosed ART use at the time of treatment initiation and explored its correlates among people presenting to public ambulatory clinics in South Africa. Data were analyzed from the community-based delivery of ART (DO ART) clinical trial, which recruited people living with HIV who presented for ART initiation at two clinics in rural South Africa. We collected data on socioeconomic factors, clinical factors, and collected blood as part of study screening procedures. We estimated the proportion of individuals presenting for ART initiation with viral load suppression (< 20 copies/mL) and fitted regression models to identify social and clinical correlates of non-disclosure of ART use. We also explored clinical and national databases to identify records of ART use. Finally, to confirm surreptitious ART use, we measured tenofovir (TDF) and emtricitabine (FTC) levels in dried blood spots. A total of 193 people were screened at the two clinics. Approximately 60% (n = 114) were female, 40% (n = 78) reported a prior HIV test, 23% (n = 44) had disclosed to a partner, and 31% (n = 61) had a partner with HIV. We found that 32% (n = 62) of individuals presenting for ART initiation or re-initiation had an undetectable viral load. In multivariable regression models, female sex (AOR 2.16, 95% CI 1.08–4.30), having a prior HIV test and having disclosed their HIV status (AOR 2.48, 95% CI 1.13–5.46), and having a partner with HIV (AOR 1.94, 95% CI 0.95–3.96) were associated with having an undetectable viral load. In records we reviewed, we found evidence of ART use from either clinical or laboratory databases in 68% (42/62) and detected either TDF or FTC in 60% (37/62) of individuals with an undetectable viral load. Undisclosed ART use was present in approximately one in three individuals presenting for ART initiation or re-initiation at ambulatory HIV clinics in South Africa. These results have important implications for ART resource use and planning in the region. A better understanding of reasons for non-disclosure of ART at primary health care clinics in such settings is needed. [ABSTRACT FROM AUTHOR]

Background Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation. Methods CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression. Results Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P =.0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P <.001). Conclusions Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital. [ABSTRACT FROM AUTHOR]

Background and Objective: Over the past 15 years, there have been three major updates to the South African national guidelines for the management of human immunodeficiency virus (HIV) in children. The purpose of this study is to describe the clinical characteristics of children who were initiated on antiretroviral therapy (ART) in Bloemfontein, South Africa, following these national treatment guidelines. Methods: Clinical information during initiation of ART in children aged 0-13 years was obtained from five HIV clinics in Bloemfontein from 2004 to 2019 as part of the establishment of an antiretroviral (ARV) pediatric registry at the University of the Free State. Data were analyzed for patient demographics, clinical presentation (World Health Organization (WHO) HIV-staging, growth rate and comorbid conditions), types of investigations done, and medicines prescribed. Results: The number of children initiated on ART increased from 168 in the period 2004-2009 to 349 (107.8%) in 2010-2014, and then dropped to 162 in the period 2015-2019. The increase in 2010-2014 was mainly in the 1000 copies/ml). There was increased use of ABC/3TC/LPVr in the < 3-year age group and ABC/3TC/EFV in the > 3-year age group. There was reduced use of the stavudine and other regimens. Conclusion and Global Health Implications: More children were started on ART and safer ARV drugs. Children under 2 years were the most debilitated by HIV, and there was an increase in HIV prevalence among children > 5 years. New strategies for the prevention and management of HIV among children in these two age groups are needed. Copyright © 2021 Walubo et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Background: Timely diagnosis and early initiation of life-saving antiretroviral therapy are critical factors in preventing mortality among HIV-infected infants. However, resource-limited settings experience numerous challenges associated with centralised laboratory-based testing, including low rates of testing, complex sample referral pathways and unacceptably long turnaround times for results. Point-of-care (POC) HIV testing for HIV-exposed infants can enable same-day communication of results and early treatment initiation for HIV-infected infants. However, complex operational issues and service integration can limit utility and must be well understood prior to implementation. We explored and documented the challenges and enabling factors in implementing the POC Xpert® HIV-1 Qual test (Cepheid, Sunnyvale, CA, USA) for early infant diagnosis (EID) as part of routine services in four public hospitals in Myanmar.Methods: This sub-study was part of a randomised controlled stepped-wedge trial (Australian and New Zealand Clinical Trials Registry, number 12616000734460) designed to investigate the impact of POC testing for EID in Myanmar and Papua New Guinea. Infants recruited during the intervention phase underwent POC testing at the participating hospitals as part of routine care. Semi-structured interviews with 23 caregivers, 12 healthcare providers and 10 key informants were used to explore experiences of POC-EID testing. The research team and hospital staff documented and discussed implementation challenges throughout the study.Results: Overall, caregivers and healthcare workers were satisfied with the short turnaround time of the POC test. Occasional delays in POC testing were mostly attributable to late receipt of samples by laboratory technicians and communication constraints among healthcare staff. Hospital staff valued technical assistance from the research group and the National Health Laboratory. Despite staff shortages and infrastructure challenges such as unreliable electricity supply and cramped space, healthcare workers and caregivers found the implementation of the POC test to be feasible at pilot sites.Conclusions: As plans for national scale-up evolve, there needs to be a continual focus on staff training, communication pathways and infrastructure. Other models of care, such as allowing non-laboratory-trained personnel to perform POC testing, and cost effectiveness should also be evaluated. [ABSTRACT FROM AUTHOR]

Objectives: People living with HIV (PLWH) have increased risk of chronic disease and poor mental health. We aimed to explore HIV disease indicators, comorbidity, and risk behavior of recent antiretroviral therapy (ART) initiators to inform current needs of PLWH. Methods: Men who have sex with men (MSM) in the Multicenter AIDS Cohort Study (MACS) who initiated ART between 2010 and 2018 (recent initiators) were compared with age‐, race‐ and geographic location‐matched men who initiated ART during 2000–2009 (early initiators). Measures of HIV disease, behavior, comorbidity and mental health were collected prospectively every 6 months using standardized forms. Results: Recent initiators had higher current CD4 (median CD4 451 vs. 307 cells/μL, P < 0.0001) and nadir CD4 (451 vs. 300 cells/μL, P < 0.0001) than earlier initiators. The proportion achieving viral suppression within a year of starting ART was significantly higher in recent compared with earlier initiators (92% vs. 74%, P < 0.0001). Median [interquartile range (IQR)] time from HIV diagnosis to ART initiation was 5.4 (1.7–23.1) months in recent initiators. Comorbidity prevalence was high in recent initiators, including obesity (24%), hypertension (25%) and kidney disease (15%). Substance use continues to be common, including cigarette use (40%), daily alcohol use (88%) and marijuana use (46%). Conclusions: Improvements in getting individuals onto ART at an early stage have led to substantially higher CD4 cell counts at initiation. However, the high burden of comorbidity, substance use and poor mental health affecting MSM living with HIV in the US underscore ongoing challenges and our need to adapt and coordinate care. [ABSTRACT FROM AUTHOR]

Introduction: AIDS‐mortality remains unacceptably high in sub‐Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact‐tracing intervention (Xpatial‐TB). The aim was to assess the burden of AHD among high‐risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO‐recommended package of care to this population. Methods: All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial‐TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB‐lipoarabinomannan (TB‐LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow‐up visits carried out under routine programmatic conditions for six months. Results: A total of 2881 adults were identified in the Xpatial TB‐contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB‐contacts) consented to the study and were screened for AHD. Seventy percent of TB index‐patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum‐CrAg was positive in 4.6% (4/87) of TB‐index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six‐month mortality was 21% among TB‐index cases and zero in TB contacts. Conclusions: A TB contact‐tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO‐recommended package of care in this rural Mozambican population. Same‐day and accelerated ART initiation was feasible and safe in this population including among those with AHD. [ABSTRACT FROM AUTHOR]

Background: During the era of the Millennium Development Goals (MDG), children were shown to have less access to human immunodeficiency virus (HIV) services than their adult counterparts; hence the call to prioritise children in the implementation of the Sustainable Development Goals (SDGs). However, South African (SA) national data in 2019 indicated that almost 3 years into the implementation of the 90-90-90 strategy, only 59% of children living with HIV had been tested for HIV compared to 90% of adults. Objectives: To evaluate the access of children to HIV services and record the viral load (VL) suppression rates during the implementation of the 90-90-90 strategy in the City of Johannesburg (COJ), South Africa. Methods: This study applied a quasi-experimental interrupted time-series (ITS) design using the monthly District Health Information System (DHIS) and National Health Laboratory Services (NHLS) databases spanning the period from 2015 to 2020, that is, before and after the implementation and roll-out of the 90-90-90 strategy. Data were extracted from these databases into MS Excel 2010 spreadsheets and analysed with Stata 15 software from Stata Corp using a two-tailed t-test at a 5% level of significance. Results: Overall, a significant increase was observed in the number of individuals tested for HIV, n = 757, p = 0.0086, and retained in care n = 2523, p = 0.001 over the whole period of analysis beginning in April 2015. Adult HIV testing, antiretroviral treatment (ART) initiation and retention in care had been decreasing in absolute numbers over a 10-month period before the intervention. An increase in these three data elements was observed following the implementation of the 90-90-90 program. On the other hand, children aged 0–15 years had demonstrated a significant increase in absolute numbers tested for HIV, n = 171, p = 0.001, but an insignificant increase in number of ART initiations, n = 14.33, p = 0.252, before implementation but a decrease after this. The overall VL suppression rates for children were lower than those of adults. Conclusion: Although the COJ has recorded progress in adult HIV testing, ART initiation and retention, children living with HIV aged 0–15 years continue to experience less access to HIV services and lower VL suppression than youths and adults of ≥ 15 years. Therefore, to ensure that the 90-90-90 targets are achieved across different age groups, children must be prioritised so that they can equally access these services with adults.

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]

Introduction: Point‐of‐care (POC) early infant diagnosis (EID) testing has been shown to dramatically decrease turnaround times from sample collection to caregiver result receipt and time to ART initiation for HIV‐positive infants compared to centralized laboratory testing. As governments in sub‐Saharan Africa implement POC EID technologies, we report on the feasibility and effectiveness of POC EID testing and the impact of same‐day result delivery on rapid ART initiation within national programmes across six countries. Methods: This pre‐/post‐evaluation compared centralized laboratory‐based (pre) with POC (post) EID testing in 52 facilities across Cameroon, Democratic Republic of Congo, Ethiopia, Kenya, Senegal and Zimbabwe between April 2017 and October 2019 (country‐dependent). Data were collected retrospectively from routine records at health facilities for all infants tested under two years of age. Hazard ratios and 95% confidence intervals were calculated to compare time‐to‐event outcomes, visualized with Kaplan–Meier curves, and the Somers' D test was used to compare continuous outcomes. Results: Data were collected for 2892 EID tests conducted on centralized laboratory‐based platforms and 4610 EID tests on POC devices with 127 (4%) and 192 (4%) HIV‐positive infants identified, respectively. POC EID significantly reduced the time from sample collection to caregiver result receipt (POC median: 0 days, IQR: 0 to 0 vs. centralized: 35 days, IQR: 26 to 56) and time from sample collection to ART initiation for HIV‐positive infants (POC median: 1 day, IQR: 0 to 7 vs. centralized: 39 days, IQR: 26 to 57). With POC testing, 72% of infants received results on the same day as sample collection; HIV‐positive infants with a same‐day diagnosis had six times the rate of ART initiation compared to those diagnosed one or more days after sample collection (HR: 6.39; 95% CI: 3.44 to 11.85). Conclusions: Same‐day diagnosis and treatment initiation for infants is possible with POC EID within routine government‐led and ‐supported public sector healthcare facilities in resource‐limited settings. Given that POC EID allows for rapid ART initiation, aligning to the World Health Organization's recommendation of ART initiation within seven days, its use in public sector programmes has the potential to reduce overall mortality for infants with HIV through early treatment initiation. [ABSTRACT FROM AUTHOR]

Background: The HPTN 071 (PopART) trial implemented universal test and treat (UTT) in three clinics in the Western Cape, South Africa at a time when antiretroviral treatment (ART) was only offered by CD4 threshold and World Health Organization clinical staging. This required a concomitant shift in the way health workers communicated ART initiation messages. We provide insight into front-line ART initiation communication pre-national policy shift. Method: The design of this study was exploratory with a case descriptive analysis of ART initiation in three clinics. To characterise their demographic profiles, we reviewed 134 randomly selected patient clinical folders of people who initiated ART at CD4 counts greater than the recommended standard. Further, we conducted 12 key informant interviews with health workers at these facilities and thematically analysed health workers' responses. Results: The median age of patients initiating ART regardless of CD4 count (above the threshold level) was 33 years and most were women (73.9%), married (76.1%), and unemployed (48.5%). The median CD4 count of patients initiating outside guidelines was 566.5 cells/µl. Contrary to expectations, key informants indicated no radical shift in messaging to explain ART initiation regardless of CD4 count. Rather, they encouraged people living with HIV (PLHIV) to initiate ART while they still "feel well". The reduced risk of onward HIV transmission did not factor significantly in how health workers motivated clients. Conclusion: Motivating PLHIV to initiate ART regardless of CD4 count in high burden settings is possible. However, there are still opportunities to improve messaging about immediate ART initiation or at high CD4 counts for the prevention of onward transmission. [ABSTRACT FROM AUTHOR]

Background: Community-based antiretroviral therapy initiation (CB-ARTi) has the potential to reduce attrition by increasing access to care, reducing patient costs, decongesting clinics and ensuring improved uptake of ART. There is a paucity of research that identifies successful implementation of CB-ARTi in sub-Saharan Africa (SSA). Objectives: The aim of the study was to review and describe the evidence on the effectiveness of CB-ARTi programmes that start ART in communities in comparison with the current standards of care in SSA. Methods: A rapid review of grey and published peer-reviewed literature between January 2009 and July 2019, by using PubMed, PDQ-Evidence, Google Scholar, clinical trial databases and major HIV (human immunodeficiency virus) conference websites, was conducted. Search terms used included ‘community-based’, ‘home initiation community models’, ‘antiretroviral therapy’, ‘clinical outcomes’, ‘viral suppression’, ‘retention in care’, ‘loss to follow-up’, ‘HIV’ and ‘sub-Saharan Africa’. Results: The search yielded 90 articles and reports following the removal of duplicates. After initial screening and full-text screening, six articles remained and were included in the qualitative narrative synthesis. This included four randomised control trials and two cohort studies of specific interventions comparing CB-ARTi with the standard of care in SSA. There is evidence that CB-ARTi can increase access to HIV-testing services, linkage to ART, retention in care and viral suppression rates and is possibly not inferior to facility-based healthcare. Conclusion: CB-ARTi has the potential to increase access to HIV services to people living with HIV in SSA. The results mentioned previously suggest that CB-ARTi models could prove to be equal and possibly not inferior to facility-based ones and warrant further investigation.

Background: Despite past and present global interventions, the human immunodeficiency virus (HIV) pandemic remains a public health problem in low- and middle-income countries (LMICs). The World Health Organization (WHO) has assisted these countries by providing antiretroviral therapy (ART) policies for adoption and adaptation to local needs. Objectives: This article describes the response of countries in sub-Saharan Africa (SSA), to the WHO’s changing CD4-threshold ART-initiation recommendations of the past two decades. Methods: Relevant articles published in international peer-reviewed journals were accessed via the following search engines: PubMed, Google Scholar, Cochrane, Embase and EBSCOhost. The study’s inclusion criteria were articles published in the English language between 2000 and 2019 that highlighted changes to the CD4 ART-initiation threshold and that focused on the WHO’s ‘commencement of ART’ policy guidelines. Sixteen studies (n = 16) from SSA were identified and included in this review: four are cross-sectional, four deal with cost-effectiveness, four are retrospective, one is a randomised trial and three are observational studies. Only studies conducted in SSA were assessed. Results: Four themes emerged: (1) adoption of the WHO CD4-ART-initiation policy by SSA countries, (2) timely implementation of the changing guideline initiation policy in the region, (3) barriers and facilitators encountered in the implementation of the changing guidelines and (4) description of similarities in policy implementation at country level from 2002 to 2019. Regional studies – cross-sectional, observational, retrospective, cost-effectiveness and randomised have described greater access to ART in SSA. However, barriers remain. The most common barriers to the timely implementation of ‘new’ ART-initiation guidelines were economic constraints, drug stock-outs, delays in obtaining baseline blood-test results and staff shortages. Conclusion: Although countries in SSA have adopted the WHO-ART-CD4 initiation-threshold policy guidelines, implementation has seldom occurred in a timely manner. Barriers have been identified. Whilst a small number of countries have implemented recommendations promptly, for many, the barriers still require to be overcome.