Evaluation of a community-based HIV test and start program in a conflict affected rural area of Yambio County, South Sudan

Background Antiretroviral therapy (ART) coverage in South Sudan is around 10%. Access to HIV care in settings with low ART coverage or conflict affected is still low; innovative strategies are needed to increase access and ensure continuation of ART during instability. A pilot HIV test and start project was implemented in a conflict-affected area of South Sudan. In a retrospective analysis, we determined the feasibility and outcomes of this intervention. Methods Programme data from July 2015 to June 2018 was analysed. The project involved five mobile teams offering HIV counselling and testing (HCT) and same day ART initiation at community level. Baseline and follow-up information on clinical, immunological and viral load (VL) was routinely recorded, as well as treatment outcomes. A semi-qualitative study was conducted to assess acceptability of the program among beneficiaries and community members. Results By June 2018, 14824 people received counselling and testing for HIV and 498 (3.4%) tested positive. Out of those 395 (79.3%) started ART. A total of 72 ART patients were organized in 26 Community ART Groups (CAGs) and contingency plan was activated 9 times for 101 patients. Kaplan-Meier estimated retention in care (RIC) at 12 and 18 months was 80.6% [95% CI: 75.9–84.5%] and 69.9% [95% CI: 64.4–74.8%] respectively. RIC was significantly higher at 18 months in patients under community ART groups (CAGs) (90.9% versus 63.4% p<0.001) when compared to patients on regular follow up. VL suppression at 12 months was 90.3% and overall virological suppression reached 91.2%. A total of 279 persons were interviewed about the MSF program perception and acceptance: 98% had heard about the programme and 84% found it beneficial for the community, 98% accepted to be tested and only 4% found disadvantages to the programme. Conclusions Our study shows that HCT and early ART initiation in conflict affected populations can be provided with good program outcomes. RIC and virological suppression are comparable with facility-based HIV programs and to those in stable contexts. This model could be extrapolated to other similar contexts with low access to ART and where security situation is a concern.

Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa

Background Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania. Methods Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16–24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11). Results Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites. Conclusion Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.

Registered Nurses’ Lived Experiences of HIV Counselling and Testing in Rural Primary Healthcare Clinics in Eastern Cape, South Africa

The increase in the global rates of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) has had far reaching effects on healthcare services around the world. The aim of the study was to explore and describe the lived experiences of registered nurses (RNs) involved in daily implementation of HIV counselling and testing (HCT) in rural primary healthcare (PHC) clinics in Eastern Cape, South Africa. The researcher used a qualitative, descriptive and contextual design. Purposive sampling was used to select the participants. A total of 19 semi-structured interviews were conducted with the RNs until data saturation was achieved. The findings revealed that the RNs experienced HCT to be overwhelming. They also showed signs of stress, frustration, despair and sadness because most of the tested clients had positive results and the number of clients testing positive was increasing. Thus, it is recommended that all professionals working with HCT should be made aware of the emotional outcomes of working in HCT services. Furthermore, it is recommended that a programme to support RNs to cope better with HCT should be developed through further research.

The Effects of HIV-Related Stigma on HIV Counselling and Testing in Nigeria: A Mediation Analysis

Human immunodeficiency viruses (HIV) counselling and testing (HCT) plays a major role in the continuum of HIV programmes in Nigeria. However, HIV-related stigma (STGM) poses a serious threat to its success. Consequently, a cross-sectional study was carried out to examine whether STGM mediates the relationships between the explanatory variables (HIV-related knowledge, HIV transmission misconception (MSHIV), and perceived seriousness of HIV/acquired immune deficiency syndrome (AIDS)), and the outcome variable (HCT service utilization). The mediation analysis was undertaken using data from 768 individuals collected through convenience sampling in the Local Government Areas of Alimosho, Ikorodu, and Surulere of Lagos state, and deploying partial least squares–structural equation modelling. The results show that STGM played a mediating role in the relationship between MSHIV, perceived seriousness of HIV/AIDS, and HCT utilization. These findings offer wide ramifications for the intensification and enforcement of Nigeria’s HIV/AIDS Anti-Discrimination Act 2014 to eradicate stigma, which is important to enhance uptake of HCT to achieve the United Nations’ 90-90-90 HIV targets by 2020.

Costs and Cost-Effectiveness of HIV Counselling and Testing Modalities in Southern Mozambique

Objective: Despite the high HIV associated burden, Mozambique lacks data on HIV counselling and testing (HCT) costs. To help guide national HIV/AIDS programs, we estimated the cost per test for voluntary counselling and testing (VCT) from the patient’s perspective and the costs per person tested and per HIV-positive individual linked to care to the healthcare provider for VCT, provider-initiated counselling and testing (PICT) and home-based testing (HBT). We also assessed the cost-effectiveness of these strategies for linking patients to care.Methods: Data from a cohort study conducted in the Manhiça District were used to derive costs and linkage-to-care outcomes of the three HCT strategies. A decision tree was used to model HCT costs according to the likelihood of HCT linking individuals to care and to obtain the incremental cost-effectiveness ratios (ICERs) of PICT and HBT with VCT as the comparator. Sensitivity analyses were performed to assess robustness of base-case findings. Findings: Average and median VCT costs to the patient per individual tested were US$1.34 and US$1.08, respectively. Costs per individual tested were greatest for HBT (US$11.07), followed by VCT (US$7.79), and PICT (US$7.14). The costs per HIV-positive individual linked to care followed a similar trend. PICT was not cost-effective in comparison with VCT at a willingness-to-accept threshold of US$4.53, but only marginally given a corresponding base-case ICER of US$4.15, while HBT was dominated, with higher costs and lower impact than VCT. Base-case results for the comparison between PICT and VCT presented great uncertainty, whereas findings for HBT were robust.Conclusion: PICT and VCT are likely equally cost-effective in Manhiça. We recommend that VCT be offered as the predominant HCT strategy in Mozambique, but expansion of PICT could be considered in limited-resource areas. HBT without facilitated linkage or reduced costs is unlikely to be cost-effective.