Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa.

OBJECTIVES: We report on outcomes after 7 years of a community-based antiretroviral therapy (ART) programme in Khayelitsha, South Africa, with death registry linkages to correct for mortality under-ascertainment. DESIGN: This is an observational cohort study. METHODS: Since inception, patient-level clinical data have been prospectively captured on-site into an electronic patient information system. Patients with available civil identification numbers who were lost to follow-up were matched with the national death registry to ascertain their vital status. Corrected mortality estimates weighted these patients to represent all patients lost to follow-up. CD4 cell count outcomes were reported conditioned on continuous virological suppression. RESULTS: Seven thousand, three hundred and twenty-three treatment-naive adults (68% women) started ART between 2001 and 2007, with annual enrolment increasing from 80 in 2001 to 2087 in 2006. Of 9.8% of patients lost to follow-up for at least 6 months, 32.8% had died. Corrected mortality was 20.9% at 5 years (95% confidence interval 17.9-24.3). Mortality fell over time as patients accessed care earlier (median CD4 cell count at enrolment increased from 43 cells/microl in 2001 to 131 cells/microl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/microl per 6 months). By 5 years, 14.0% of patients had failed virologically and 12.2% had been switched to second-line therapy. CONCLUSION: At a time of considerable debate about future global funding of ART programmes in resource-poor settings, this study has demonstrated substantial and durable clinical benefits for those able to access ART throughout this period, in spite of increasing loss to follow-up

The evolution of HIV self-testing and the introduction of digital interventions to improve HIV self-testing

HIV self-testing (HIVST) complements traditional HIV testing programmes by removing barriers and increasing access to testing for key populations, and digital interventions have been developed for HIVST to improve the testing and linkage to care experience for users. The first HIVST kit was proposed in 1986, but it took 10 years for the home sample collection (HSC) HIVST to become available and another 16 years for rapid diagnostic test HIVST to be approved by the Federal Drug Administration. Since then, studies have shown high usability and performance of HIVST, which led the World Health Organization formally recommending HIVST in 2016, and currently almost 100 countries have incorporated HIVST into their national testing strategy. Despite the popularity, HIVST present challenges around pre-and post-test counselling, as well as the ability to report results and link users to care, and digital interventions for HIVST have been introduced to address these challenges. The first digital intervention for HIVST was introduced in 2014 and showed that digital interventions could be used to distribute HIVST kits, report results and link users to care. Since then, dozens of studies have been conducted, which have validated and expanded on these early findings, but many were pilot studies with small sample sizes and lacked the standardization of indicators required to aggregate data across platforms to prove impact at scale. For digital interventions for HIVST to be championed for scale-up, they must continue to show measurable impact at larger scales, while still maintaining and standardizing data security and integrity

Feasibility and Usability of Mobile Technology to Assist HIV Self-Testing in Youth in Zimbabwe: A Mixed-Methods Study

PURPOSE: Mobile technology is increasingly being used to widen access to and support the delivery of public health interventions. Human immunodeficiency viruses (HIV) self-testing (HIVST) enables individuals to have autonomy. We evaluated the feasibility of a novel application called ITHAKA to support HIVST among youth aged 16-24 years in Zimbabwe. METHODS: This study was nested within a trial of community-based delivery of integrated HIV and sexual and reproductive health services called CHIEDZA. Youth accessing CHIEDZA were offered provider-delivered HIV testing or HIVST supported by ITHAKA, either on a tablet on-site at a community centre or on their mobile phone off-site. ITHAKA incorporated pre and post-test counselling, and instructions for conducting the test and the appropriate actions to take depending on test result, including reporting HIV test results to health providers. The outcome was completion of the testing journey. Semistructured interviews with CHIEDZA providers explored the perceptions of and experiences with the application. RESULTS: Between April and September 2019, of the 2,181 youth who accepted HIV testing in CHIEDZA, 128 (5.8%) initiated HIVST (the remainder opting for provider-delivered testing) using ITHAKA. Nearly all who performed HIVST on-site (108/109 (99.1%)) compared to only 9/19 (47.4%) who tested off-site completed their testing journey. Low digital literacy, lack of agency, erratic network coverage, lack of dedicated phone ownership, the limited functionality of smartphones challenged implementation of ITHAKA. DISCUSSION: Digitally supported HIVST had low uptake among youth. The feasibility and usability of digital interventions should be carefully assessed before implementation, paying careful attention to digital literacy, network availability, and access to devices

Correcting for Mortality Among Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A Cohort Analysis

Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system

Cumulative probability of LTF before and after correction for mortality.

<p>Kaplan-Meier estimates of cumulative probability of loss to follow-up (LTF) before and after correction for mortality by ascertainment of vital status of patients lost to follow-up through the national vital registration system. Routine monitoring overestimated LTF by 4% at 5 years on ART (23.9 vs. 19.7%).</p

Smoothed hazard of loss to follow-up before and after ascertainment of vital status.

<p>Smoothed hazard estimates for loss to follow-up (LTF) before (A) and after (B) correction for mortality. Before ascertainment of vital status the hazard of LTF decreased over time on ART; after correcting LTF for mortality, the hazard of true LTF increased with time on ART.</p

Cox proportional hazards models of factors associated with loss to follow-up before and after correction for mortality.

<p>ART, antiretroviral treatment; WHO, World Health Organization; HR, hazard ratio; CI, confidence interval; PMTCT, prevention of mother to child transmission; TB, tuberculosis; AZT, zidovudine; 3TC, lamivudine; NVP, nevirapine; D4T, stavudine; EFV, efavirenz. P-values for CD4 count, WHO stage, year of initiation on ART and antiretroviral regimen are from Wald test for linear hypothesis after estimation. After correction for mortality, loss to follow-up was not associated with male gender or weight anymore, while new associations emerged with higher baseline CD4 counts and pregnancy at initiation of ART.</p

Patient characteristics at initiation of ART.

<p>ART, antiretroviral treatment; LTF, Lost to follow-up; IQR, interquartile range; PMTCT, prevention of mother to child transmission; TB, tuberculosis; AZT, zidovudine; 3TC, lamivudine; NVP, nevirapine; D4T, stavudine; EFV, efavirenz. </p><p>* All patients not lost to follow-up, including deaths occurring within 3 months after loss to follow-up;</p><p>** Patients lost to follow-up with available civil identification number who were alive 3 months after being lost.</p