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Introduction: South Africa (SA) has the world's highest burden of HIV infection (approximately 7.2 million), yet it is estimated that 23.5% women and 31.5% of men are unaware that they are living with HIV. The 2015 national South African HIV testing guidelines mandate the universal offer of HIV testing services (HTS) in all healthcare facilities. Methods: A multi-prong approach was used from January 2017 to June 2017 to evaluate the current implementation of HTS in ten facilities in the Ekurhuleni District of SA. First, we conducted patient exit interviews to quantify engagement in HTS services. Second, we systematically mapped the flow of individual patients through the clinic. Results: We conducted a total of 2989 exit interviews and followed 568 patients for value stream mapping. Overall self-reported testing acceptance was high at 84.7% (244), but Conclusions: The poor delivery of HTS appears to be due to a failure to recommend HTS and the added time burden placed on those accepting testing. There were significant differences in both the offer and acceptance of testing by gender. Health system issues need to be addressed to improve HTS delivery. Keywords: HIV; South Africa; facility-based testing; primary care; public health; testing; implementation science, 1 | INTRODUCTION HIV infection contributes to half of the deaths in South Africa (SA), with the highest mortality among those who are severely immunocompromised and not yet receiving antiretroviral [...]

Social networks and social support are important factors in medication adherence among people living with HIV (PLWH). Social networks can provide emotional, logistic, and material support leading to increased overall engagement in care. Certain populations of PLWH may have more limited access to social support, including those reentering community settings from correctional facilities. During periods of incarceration, social connections with family and friends may be frayed, reduced, or lost. This study, conducted in South Africa, explored the role of social support during community reentry among PLWH being released from correctional facilities. We conducted in-depth interviews with 41 community reentrants living with HIV. Qualitative analysis identified the challenges with establishing social support during reentry and the greater need for social support to remain engaged in HIV care in the community compared to in the correctional facility. These findings highlight challenges during community reentry and the importance of social support for these individuals. [ABSTRACT FROM AUTHOR]

While interventions to improve HIV linkage and retention in care exist, none have demonstrated results sufficient to reach UNAIDS 90-90-90 goals. We explored values and costs of seeking clinical care through testing three strategies to improve linkage to care: Point of care CD4 testing alone (POC-CD4), POC-CD4 combined with transportation support and combined with care facilitation. We conducted in-depth interviews with participants and transcribed audio-recordings of care facilitation sessions. Participants described values and costs enhanced or addressed by the three interventions. Psychosocial support provided through the care facilitation intervention appeared salient. Participants named other values and costs of seeking care unrelated to the intervention, such as encouragement from healthcare workers and aversion to lifelong treatment. Combined with the quantitative results of this trial, these findings may point to why the care facilitation arm was successful but not the POC-CD4 only or transportation arms. It also provides guidance for future interventions. [ABSTRACT FROM AUTHOR]

Introduction: Machine learning algorithms are increasingly being used to inform HIV prevention and detection strategies. We validated and extended a previously developed machine learning model for patient retention on antiretroviral therapy in a new geographic catchment area in South Africa., Methods: We compared the ability of an adaptive boosting algorithm to predict interruption in treatment (IIT) in 2 South African cohorts from the Free State and Mpumalanga and Gauteng and North West (GA/NW) provinces. We developed a novel set of predictive features for the GA/NW cohort using a categorical boosting model. We evaluated the ability of the model to predict IIT over all visits and across different periods within a patient's treatment trajectory., Results: When predicting IIT, the GA/NW and Free State and Mpumalanga models demonstrated a sensitivity of 60% and 61%, respectively, able to correctly predict nearly two-thirds of all missed visits with a positive predictive value of 18% and 19%. Using predictive features generated from the GA/NW cohort, the categorical boosting model correctly predicted 22,119 of a total of 35,985 missed next visits, yielding a sensitivity of 62%, specificity of 67%, and positive predictive value of 20%. Model performance was highest when tested on visits within the first 6 months., Conclusions: Machine learning algorithms may be useful in informing tools to increase antiretroviral therapy patient retention and efficiency of HIV care interventions. This is particularly relevant in developing countries where health data systems are being strengthened to collect data on a scale that is large enough to apply novel analytical methods., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Provider-initiated testing and counseling remains highly underused in many South African health facilities. We implemented a systems analysis to investigate whether simple adjustments to HIV testing services (HTS) delivery can increase HTS provision., Setting: Ten primary care facilities in the Ekurhuleni District in South Africa., Methods: Following a baseline HTS assessment that showed limited offering of HTS by clinicians, clinic staff had the option to adopt several change approaches to increase HTS delivery using existing human resources. Approaches included adjusting HTS timing, strengthening HTS promotion, counsellor management, and implementing reward systems. Evaluation was conducted identically to the baseline study using patient exit interviews to quantify HTS engagement and value stream mapping to map patient flow through the clinic., Results: We conducted 2163 exit interviews and followed 352 patients for value stream mapping. After change implementation, a significantly higher proportion of patients reported being offered HTS (742/2163, 34.3% vs. 231/2206, 10.5% during the baseline period; χ2P < 0.001) and having undertaken testing (527/2163, 24.4% vs. 197/2206, 8.9% during the baseline period; χ2P < 0.001) with only a 3-percentage point decrease in HIV-positive yield (14.0% vs. 17.1% during the baseline period). The median time to HTS offer decreased from 77 minutes to 3 minutes after clinic arrival during the intervention (χ2P = 0.001)., Conclusions: A systems approach can be an effective and appropriate implementation strategy to augment HTS delivery and increase HIV diagnoses. This low-cost approach may be extended to optimize other aspects of clinic service delivery., Competing Interests: The authors have no conflict of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Poor linkage to HIV care is impeding achievement of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets. This study aims to identify risk factors for poor linkage-to-care after HIV counseling and testing, thereby informing strategies to achieve 90-90-90., Setting: The Thol'impilo trial was a large randomized controlled trial performed between 2012 and 2015 in South Africa, comparing different strategies to improve linkage-to-care among adults aged ≥18 years who tested HIV-positive at mobile clinic HIV counseling and testing., Methods: In this secondary analysis, sociodemographic factors associated with time to linkage-to-care were identified using Cox regression., Results: Of 2398 participants, 61% were female, with median age 33 years (interquartile range: 27-41) and median CD4 count 427 cells/mm (interquartile range: 287-595). One thousand one hundred one participants (46%) had clinic verified linkage-to-care within 365 days of testing HIV-positive. In adjusted analysis, younger age [≤30 vs >40 years: adjusted hazard ratio (aHR): 0.58, 95% CI: 0.50 to 0.68; 31-40 vs >40 years: aHR: 0.81, 95% CI: 0.70 to 0.94, test for trend P < 0.001], being male (aHR: 0.86, 95% CI: 0.76 to 0.98, P = 0.028), not being South African (aHR: 0.79, 95% CI: 0.66 to 0.96, P = 0.014), urban district (aHR: 0.82, 95% CI: 0.73 to 0.93, P = 0.002), being employed (aHR: 0.81, 95% CI: 0.72 to 0.92, P = 0.001), nondisclosure of HIV (aHR: 0.63, 95% CI: 0.56 to 0.72, P < 0.001), and having higher CD4 counts (test for trend P < 0.001) were all associated with decreased hazard of linkage-to-care., Conclusion: Linkage-to-care was low in this relatively large cohort. Increasing linkage-to-care requires innovative, evidence-based interventions particularly targeting individuals who are younger, male, immigrant, urban, employed, and reluctant to disclose their HIV status.

Objective: Determine the effectiveness of strategies to increase linkage to care after testing HIV positive at mobile HIV testing in South Africa., Design: Unmasked randomized controlled trial., Methods: Recruitment of adults testing HIV positive and not currently in HIV care occurred at 7 mobile HIV counseling and testing units in urban, periurban, and rural South Africa with those consenting randomized 1:1:1:1 into 1 of 4 arms. Three strategies were compared with standard of care (SOC): point-of-care CD4 count testing (POC CD4), POC CD4 plus longitudinal strengths-based counseling (care facilitation; CF), and POC CD4 plus transport reimbursement (transport). Participants were followed up telephonically and through clinic records and analyzed with an intention-to-treat analysis., Results: From March 2013 to October 2014, 2558 participants were enrolled, of whom 160 were excluded postrandomization. Compared with the SOC arm where 298 (50%) reported having entered care, linkage to care was 319 (52%) for POC CD4, hazard ratio (HR) 1.0 [95% confidence interval (CI): 0.89 to 1.2, P = 0.6]; 331 (55%) for CF, HR: 1.1 (95% CI: 0.84 to 1.3, P = 0.2); and 291 (49%) for transport, HR 0.97 (95% CI: 0.83 to 1.1, P = 0.7). Linkage to care verified with clinical records that occurred for 172 (29%) in the SOC arm; 187 (31%) in the POC CD4 arm, HR: 1.0 (95% CI: 0.86 to 1.3, P = 0.6); 225 (38%) in the CF arm, HR: 1.4 (95% CI: 1.1 to 1.7, P = 0.001); and 180 (31%) in the transport arm, HR: 1.1 (95% CI: 0.88 to 1.3, P = 0.5)., Conclusions: CF improved verified linkage to care from 29% to 38%.

Background: Early in the global response to HIV, health communication was focused toward HIV prevention. More recently, the role of health communication along the entire HIV care continuum has been highlighted. We sought to describe how a strategy of interpersonal communication allows for precision health communication to influence behavior regarding care engagement., Methods: We analyzed 1 to 5 transcripts from clients participating in longitudinal counseling sessions from a communication strategy arm of a randomized trial to accelerate entry into care in South Africa. The counseling arm was selected because it increased verified entry into care by 40% compared with the standard of care. We used thematic analysis to identify key aspects of communication directed specifically toward a client's goals or concerns., Results: Of the participants, 18 of 28 were female and 21 entered HIV care within 90 days of diagnosis. Initiating a communication around client-perceived consequences of HIV was at times effective. However, counselors also probed around general topics of life disruption-such as potential for child bearing-as a technique to direct the conversation toward the participant's needs. Once individual concerns and needs were identified, counselors tried to introduce clinical care seeking and collaboratively discuss potential barriers and approaches to overcome to accessing that care., Conclusions: Through the use of interpersonal communication messages were focused on immediate needs and concerns of the client. When effectively delivered, it may be an important communication approach to improve care engagement., Competing Interests: The authors have no conflicts of interest to disclose.