Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa

AbstractWe aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30–39.9 vs 18–29.9 years, 95% confidence intervals (CI): 1.0–2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4–3.6) and HIV testing history (aRR 1.7 for > 12 months vs < 12 months/no prior test, 95% CI: 1.0–2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4–3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2–18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2–0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2–3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.

Download Full-text

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Health Research Policy and Systems ◽

10.1186/s12961-020-00673-y ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Dorina Onoya ◽

Idah Mokhele ◽

Tembeka Sineke ◽

Bulelwa Mngoma ◽

Aneesa Moolla ◽

...

Keyword(s):

South Africa ◽

Health Care ◽

Health Providers ◽

Care Providers ◽

Hiv Diagnosis ◽

Gauteng Province ◽

Art Initiation ◽

Provider Perspectives ◽

Universal Test And Treat ◽

Professional Nurses

Abstract Background In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change. Methods We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11. Results The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling. Conclusions Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.

Download Full-text

Effect of perceived HIV risk on initiation of antiretroviral therapy during the universal test and treat era in South Africa

BMC Infectious Diseases ◽

10.1186/s12879-021-06689-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Sabina M. Govere ◽

Sean Galagan ◽

Boikhutso Tlou ◽

Tivani Mashamba-Thompson ◽

Ingrid V. Bassett ◽

...

Keyword(s):

South Africa ◽

Risk Perception ◽

Hiv Infection ◽

Hiv Testing ◽

Hiv Risk ◽

Perceived Risk ◽

Hiv Status ◽

Art Initiation ◽

Universal Test And Treat ◽

Hiv Risk Perception

Abstract Background South Africa has not achieved the 90–90–90 goals, in part due to low rates of antiretroviral therapy (ART) initiation among those aware of their HIV status. Perceived risk of HIV at the time of testing may affect likelihood of rapid ART initiation. The purpose of this study was to evaluate factors associated with perceived risk of HIV and the relationship between perceived HIV risk and rapid ART initiation during the universal test and treat era which was adapted in October 2016. Methods We conducted a prospective study of adults undergoing HIV testing from October 2016–February 2019 at Ithembalabantu Clinic in Durban. Eligible participants reported not previously being diagnosed with HIV. Before HIV testing, participants were asked to assess their perceived HIV risk on a four-level scale. We categorized “definitely not” and “probably not going to acquire HIV” as a low perceived risk, and “probably will” and “definitely will become HIV-infected” as a high perceived risk of HIV infection. Participants were followed for up to 14 months following HIV testing to assess ART initiation. Results Among 1519 people newly diagnosed with HIV, 55% were female and mean age was 33 years. Among those, 1382 (90.9%) had a high HIV risk perception and 137 (9.1%) reported low HIV risk perception. In the low risk group individuals were more likely to be female (58% vs 55%), unemployed (62% vs 59%), have a partner with unknown HIV status (61% vs 55%) compared to the high risk group. 83.2% of those with low HIV risk perception reported previously HIV testing compared 91.5% of those with high HIV risk perception. In the multivariate model, males were associated with a higher chances of initiating ART compared to females (adjusted hazard ratio (aHR): 1.187, CI 1.187 (1.060–1.329) and being unemployed (aHR 0.767 CI (0.650–0.905). Those with a low HIV risk perception were less likely to initiate ART 125 (91%) vs 1310 (95%) p = 0.022), and took longer to initiate on ART after HIV diagnosis (11 days’ vs 4 days, p = 0.042). Conclusion Factors associated with high HIV risk perception included being unemployed, single, and having a partner of unknown HIV status. People living with HIV (PLHIV) in South Africa who had a low self-perceived risk to HIV infection were less likely to initiate ART. Assessing self-perceived risk of HIV infection may help direct counselling and improve ART initiation to achieve universal 90–90–90 goal.

Download Full-text

Factors Influencing Rapid Antiretroviral Therapy Initiation at Four eThekwini Clinics, KwaZulu-Natal, South Africa

AIDS and Behavior ◽

10.1007/s10461-021-03530-3 ◽

2021 ◽

Author(s):

Sabina M. Govere ◽

Chester Kalinda ◽

Moses J. Chimbari

Keyword(s):

South Africa ◽

Antiretroviral Therapy ◽

Cross Sectional Study ◽

Hiv Diagnosis ◽

Cross Sectional ◽

Art Initiation ◽

Factors Influencing ◽

Universal Test And Treat ◽

Kwazulu Natal ◽

Major Factors

AbstractTimely uptake of Antiretroviral therapy considerably improves the health of people living with the Human Immunodeficiency virus. We conducted a cross-sectional study of newly HIV diagnosed individuals in four clinics in eThekwini municipality, KwaZulu-Natal. Data was collected between June 2020 and December 2020. Participants completed an interviewer-administered questionnaire after HIV testing, on the day of HIV diagnosis. We evaluated factors influencing uptake of same-day ART initiation in eThekwini clinics, KwaZulu Natal, South Africa. Demographic information, health status, sexual behaviour, knowledge of universal test and treat (UTT), ART initiation uptake, and disclosure data was collected. Among the 403 participants, same-day initiation (SDI) was 69.2% (n = 279). We observed the number of sexual partners (aOR 0.35; 95% CI 0.15–0.81), HIV status of the partner (aOR 5.03; 95% CI 2.74–9.26) and knowledge of UTT (aOR 1.97; 95% CI 1.34–2.90) were identified as major factors influencing uptake of same-day ART initiation. More strategies are needed to achieve the SDI uptake within the framework of UTT.

Download Full-text

Estimates of the Time From Seroconversion to Antiretroviral Therapy Initiation Among People Newly Diagnosed With Human Immunodeficiency Virus From 2006 to 2015, New York City

Clinical Infectious Diseases ◽

10.1093/cid/ciz1178 ◽

2019 ◽

Vol 71 (8) ◽

pp. e308-e315

Author(s):

McKaylee M Robertson ◽

Sarah L Braunstein ◽

Donald R Hoover ◽

Sheng Li ◽

Denis Nash

Keyword(s):

Human Immunodeficiency Virus ◽

Antiretroviral Therapy ◽

Hiv Testing ◽

Mixed Model ◽

Linear Mixed Model ◽

Population Based ◽

Cd4 Count ◽

Hiv Diagnosis ◽

Art Initiation ◽

Immunodeficiency Virus

Abstract Background We estimated the time from human immunodeficiency virus (HIV) seroconversion to antiretroviral therapy (ART) initiation during an era of expanding HIV testing and treatment efforts. Methods Applying CD4 depletion parameters from seroconverter cohort data to our population-based sample, we related the square root of the first pretreatment CD4 count to time of seroconversion through a linear mixed model and estimated the time from seroconversion. Results Among 28 162 people diagnosed with HIV during 2006–2015, 89% initiated ART by June 2017. The median CD4 count at diagnosis increased from 326 (interquartile range [IQR], 132–504) cells/µL to 390 (IQR, 216–571) cells/µL from 2006 to 2015. The median time from estimated seroconversion to ART initiation decreased by 42% from 6.4 (IQR, 3.3–11.4) years in 2006 to 3.7 (IQR, 0.5–8.3) years in 2015. The time from estimated seroconversion to diagnosis decreased by 28%, from a median of 4.6 (IQR, 0.5–10.5) years to 3.3 (IQR, 0–8.1) years from 2006 to 2015, and the time from diagnosis to ART initiation reduced by 60%, from a median of 0.5 (IQR, 0.2–2.1) years to 0.2 (IQR, 0.1–0.3) years from 2006 to 2015. Conclusions The estimated time from seroconversion to ART initiation was reduced in tandem with expanded HIV testing and treatment efforts. While the time from diagnosis to ART initiation decreased to 0.2 years, the time from seroconversion to diagnosis was 3.3 years among people diagnosed in 2015, highlighting the need for more effective strategies for earlier HIV diagnosis.

Download Full-text

The effectiveness of a pregnancy leaflt to promote health in Tshwane, South Africa

Health SA Gesondheid ◽

10.4102/hsag.v19i1.764 ◽

2014 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Susan C. Wright ◽

Titilayo T. Biya ◽

Majapi E. Chokwe

Keyword(s):

South Africa ◽

Healthy Lifestyle ◽

Evidence Base ◽

Young Female ◽

Self Report ◽

Chi Square ◽

Post Secondary ◽

Two Samples ◽

Post Test ◽

Self Report Data

Background: Pregnancy-related health education conveys basic information regarding healthy lifestyle choices and preventive healthcare in order to promote the health of the mother and foetus. Verbal education is supplemented frequently by means of healthpromotion leaflts. A pregnancy-related leaflt used in primary care clinics in Tshwane, South Africa titled: ‘Are you pregnant or planning to have a baby?’ was the focus of this research.Objectives: The study had two objectives, the fist of which was to explore whether the English pregnancy leaflt improved the knowledge of young female adults with regard to maintaining their health and preventing complications during pregnancy. The second objective was to explore whether the literacy level of the young adult female had an effect on the effiacy of the English pregnancy leaflet.Method: The research design used was a pre-test post-test design. Two samples of 30 participants each, namely, a post-secondary and a tertiary sample, participated in the study. Self-report data were gathered with a questionnaire based on the leaflt. The quantitative data were analysed using descriptive statistics and a Pearson’s chi-square test.Findings: The fidings indicated both samples’ prior knowledge regarding healthmaintenance, showing that prevention of complications during pregnancy was almost nonexistent and that the pregnancy leaflt did not improve their knowledge to an extent where they would be informed and knowledgeable about their health during pregnancy.Conclusion: An evidence base must be developed in order to support the development of behaviour changing material.Agtergrond: Swangerskapsverwante gesondheidsopvoeding dra basiese inligting oor aangaande gesonde leefstylkeuses en voorkomende sorg om die gesondheid van moeder en fetus tydens swangerskap te bevorder. Verbale gesondheidsonderrig word dikwels versterk deur gedrukte inligtingstukke. ’n Swangerskapsverwante inligtingstuk tans in gebruik in primêre gesondheidsorgklinieke in Tshwane met die titel: ‘Are you pregnant or planning to have a baby?’ was die fokus van die studie.Doelwitte: Die studie het twee doelwitte gehad, naamlik (1) om uit te vind of die Engelse inligtingstuk die kennis van jong volwasse vroue to so ’n mate kon verbeter dat hulle in staat was om gesond te bly tydens hul swangerskap en komplikasies te voorkom, asook (2) om te bepaal of die geletterdheidsvlak van die jong volwasse vroue ’n invloed gehad het op die vermoë van die inligtingstuk om hul kennisvlakke te verhoog.Metode: Die navorsingsontwerp was ’n voor-toets/na-toets ontwerp. Twee groepe van 30 deelnemers elk, ’n na-sekondêre onderrig en ‘n tersiêre groep, het aan die studie deelgeneem. Data is deur self-rapportering ingesamel waar die deelnemers ’n vraelys gebaseer op die pamflt voltooi het, voor en na blootstelling aan die inligtingstuk. Die data is met behulp van beskrywende statistiek en ’n Pearson’s chi-kwadraat ontleed.Resultate: Die bevindings dui daarop dat beide groepe baie min voorkennis aangaande gesondheid tydens swangerskap gehad het en dat die swangerskapsverwante inligtingstuk nie hul kennis tot so ’n mate verbeter dat hulle ingelig en in staat sou wees om gesond te bly tydens hul swangerskap nie.Gevolgtrekking: Dit is belangrik dat navorsingsbewyse gebruik word in die ontwikkeling van gedragsveranderingsmateriaal.

Download Full-text

The Benefits of Immediate ART

Journal of the International Association of Providers of AIDS Care (JIAPAC) ◽

10.1177/2325958219831714 ◽

2019 ◽

Vol 18 ◽

pp. 232595821983171 ◽

Cited By ~ 2

Author(s):

Yan Zhao ◽

Jennifer M. McGoogan ◽

Zunyou Wu

Keyword(s):

World Health ◽

Hiv Care ◽

Hiv Diagnosis ◽

Hiv Care Cascade ◽

Art Initiation ◽

Care Cascade ◽

Nations Programme ◽

United Nations Programme ◽

Health Organization ◽

Treat All

The benefits of “early” antiretroviral therapy (ART; ie, initiation when CD4 ≥500 cells/mm3) are now well accepted as reflected in the removal of the CD4-based eligibility from new ART guidelines by the World Health Organization (WHO). However, neither the “treat-all” strategy recommendations presented in the guidelines nor the HIV care cascade goals in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets adequately address the issue of ART timing. Our recent study on “immediate” ART (ie, ≤30 days after HIV diagnosis) adds important evidence demonstrating the real and meaningful benefits of rapid ART initiation even among those who have CD4 ≥500 cells/mm3. We call on WHO and UNAIDS to consider this research and encourage a shift from the treat-all strategy to an “immediately-treat-all” strategy, and from a slow, fragmented, complicated, multistep HIV care cascade to a fast, easy, and simple cascade with effectiveness measures that incorporate the important aspect of time.

Download Full-text

Country adherence to WHO recommendations to improve the quality of HIV diagnosis: a global policy review

BMJ Global Health ◽

10.1136/bmjgh-2019-001939 ◽

2020 ◽

Vol 5 (5) ◽

pp. e001939

Author(s):

Virginia A Fonner ◽

Anita Sands ◽

Carmen Figueroa ◽

Rachel Baggaley ◽

Caitlin Quinn ◽

...

Keyword(s):

Hiv Testing ◽

Sufficient Information ◽

Testing Strategy ◽

Hiv Diagnosis ◽

Policy Review ◽

Art Initiation ◽

Testing Strategies ◽

Testing Algorithms ◽

Almost All ◽

Exposure Prophylaxis

IntroductionEnsuring a correct and timely HIV diagnosis is critical. WHO publishes guidelines on HIV testing strategies that maximise the likelihood of correctly determining one’s HIV status. A review of national HIV testing policies in 2014 found low adherence to WHO guidelines. We updated this review to determine adherence to current recommendations.MethodsWe conducted a comprehensive policy review through April 2018. We extracted data on HIV testing strategies, recommendations on HIV retesting prior to antiretroviral therapy (ART) initiation and pre-exposure prophylaxis (PrEP)-related HIV testing information. Descriptive analyses disaggregated by region were conducted to ascertain adherence to recommendations and to describe testing strategy characteristics.ResultsOf 91 policies included, 26% (n=24/91) adhered to WHO recommendations. Having a two-assay testing strategy to rule-in HIV infection as opposed to the recommended three-assay testing strategy was a major reason for non-adherence. Of 72 country policies providing sufficient information, 31% (n=22) recommended retesting for HIV prior to initiating ART. Of 25 countries and two regions reporting PrEP-related HIV testing guidelines, almost all recommended testing prior to initiating PrEP and every 3 months during PrEP use.ConclusionsGlobal adherence to WHO recommendations for HIV testing strategies have improved since 2014 but remain low. We found adherence existed on a continuum. Such a system provides insights into how countries can move towards adherence by making relatively minor changes to testing strategies. Guidance from WHO on the role of new HIV testing technologies within testing algorithms and identifying ways to simplify testing guidance is warranted.

Download Full-text

Women’s sexual scripting in the context of universal access to antiretroviral treatment—findings from the HPTN 071 (PopART) trial in South Africa

BMC Women s Health ◽

10.1186/s12905-021-01513-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Lario Viljoen ◽

Graeme Hoddinott ◽

Samantha Malunga ◽

Nosivuyile Vanqa ◽

Tembeka Mhlakwaphalwa ◽

...

Keyword(s):

South Africa ◽

Hiv Prevention ◽

Hiv Testing ◽

Universal Access ◽

Treatment Guideline ◽

Well Being ◽

Sexual Scripts ◽

Prevention Trial ◽

Treatment As Prevention ◽

Universal Test And Treat

Abstract Background HIV treatment-based prevention modalities present new opportunities for women to make decisions around sex, intimacy, and prevention. The Universal test and treat (UTT) strategy, where widespread HIV testing is implemented and all people with HIV can access treatment, has the potential to change how sex is understood and HIV prevention incorporated into sexual relationships. We use the frame of sexual scripting to explore how women attribute meaning to sex relative to UTT in an HIV prevention trial setting. Exploring women’s sexual narratives, we explored how HIV prevention feature in the sexual scripts for women who had access to UTT in South Africa (prior to treatment guideline changes) and increased HIV prevention messaging, compared to places without widespread access to HIV testing and immediate access to treatment. Methods We employed a two-phased thematic analysis to explore longitudinal qualitative data collected from 71 women (18–35 years old) between 2016 and 2018 as part of an HIV prevention trial in the Western Cape Province, South Africa. Of the participants, 58/71 (82%) were from intervention communities while 13/71 (18%) lived in control communities without access to UTT. Twenty participants self-disclosed that they were living with HIV. Results We found no narrative differences between women who had access to UTT and those who did not. HIV and HIV prevention, including treatment-based prevention modalities, were largely absent from women’s thinking about sex. In their scripts, women idealised romantic sex, positioned sex as ‘about relationships’, and described risky sex as ‘other’. When women were confronted by HIV risk (for example, when a partner disclosed his HIV-positive status) this created a point of disjuncture between this new perception of risk and their accepted relationship scripts. Conclusion These findings suggest that HIV-negative women did not include their partners’ use of antiretroviral therapy in their sexual partnership choices. For these women, the preventive benefits of UTT are experienced passively—through community-wide viral suppression—rather than through their own behaviour change explicitly related to the availability of treatment as prevention. We propose that prevention-based modalities should be made available and supported and framed as an intervention to promote relationship well-being.

Download Full-text

Self-reported motivators for HIV testing in the treat-all era among HIV positive patients in Johannesburg, South Africa

Medicine ◽

10.1097/md.0000000000025286 ◽

2021 ◽

Vol 100 (15) ◽

pp. e25286

Author(s):

Idah Mokhele ◽

Tembeka Sineke ◽

Jonas Langa ◽

Dorina Onoya

Keyword(s):

South Africa ◽

Hiv Testing ◽

Hiv Positive ◽

Treat All

Download Full-text

How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda—A qualitative study

PLoS ONE ◽

10.1371/journal.pone.0251645 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0251645

Author(s):

Jonathan Ross ◽

Charles Ingabire ◽

Francine Umwiza ◽

Josephine Gasana ◽

Athanase Munyaneza ◽

...

Keyword(s):

Treatment Guidelines ◽

Qualitative Interviews ◽

Hiv Treatment ◽

Sub Saharan Africa ◽

Hiv Care ◽

People Living With Hiv ◽

Hiv Status ◽

Hiv Diagnosis ◽

Art Initiation ◽

Treat All

Introduction HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are likely to initiate ART when they are asymptomatic, and they may view the relative benefits and risks of ART differently than those initiating at more advanced disease stages. To date, patient perspectives of initiating care under Treat All in sub-Saharan Africa have not been well described. Methods From September 2018 to March 2019, we conducted individual, semi-structured, qualitative interviews with 37 patients receiving HIV care in two health centers in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive thematic analysis approach to describe perceived barriers to, facilitators of and acceptability of initiating and adhering to ART rapidly under Treat All. Results Of 37 participants, 27 were women and the median age was 31 years. Participants described feeling traumatized and overwhelmed by their HIV diagnosis, resulting in difficulty accepting their HIV status. Most were prescribed ART soon after diagnosis, yet fear of lifelong medication and severe side effects in the immediate period after initiating ART led to challenges adhering to therapy. Moreover, because many PLWH initiated ART while healthy, taking medications and attending appointments were visible signals of HIV status and highly stigmatizing. Nonetheless, many participants expressed enthusiasm for Treat All as a program that improved health as well as health equity. Conclusion For newly-diagnosed PLWH in Rwanda, initiating ART rapidly under Treat All presents logistical and emotional challenges despite the perceived benefits. Our findings suggest that optimizing early engagement in HIV care under Treat All requires early and ongoing intervention to reduce trauma and stigma, and promote both individual and community benefits of ART.

Download Full-text