HIV Clinic In South Africa Research Articles

A qualitative assessment of the perceived acceptability and feasibility of eHARTS, a mobile application for transition readiness assessment for adolescents living with HIV in South Africa.

South Africa has the highest burden of adolescents living with HIV (ALHIV) in the world. The transition from pediatric to adult centered HIV care is a vulnerable period during which many clinical outcomes of ALHIV suffer. Transition readiness assessments may help ALHIV transition from pediatric to adult care to improve their health outcomes. Here, we evaluated the perceived acceptability and feasibility of a mobile health (mHealth) application, eHARTS, to determine transition readiness for ALHIV in South Africa. We conducted in-depth interviews with adolescents (n = 15) and healthcare providers (n = 15) at three government-supported hospitals in KwaZulu-Natal, South Africa. We used a semi-structured interview guide comprising of open-ended questions based on the unified theory of acceptance and use of technology. We did a thematic analysis of the data using an iterative, team-based coding approach to develop themes that were representative of the participants' perspectives on the acceptability and feasibility of eHARTS. We found that most participants found eHARTS to be acceptable because of its simplicity and lack of stigma. Participants believed eHARTS was feasible as it could easily be administered within a hospital setting and integrated into regular clinic activity without disrupting patient care. Additionally, eHARTS was found to have great utility for adolescents and healthcare providers. Clinicians saw it as a valuable tool to engage adolescents and prepare them for transition. Despite concerns that eHARTS may give adolescents a wrong impression about immediate transition, participants suggested that eHARTS be framed in an empowering way as they prepare for transition to adult care. Our data showed that eHARTS is a simple, mobile transition assessment tool with perceived acceptability and feasibility for use in HIV clinics in South Africa for ALHIV. It is particularly useful for ALHIV and transitioning to adult care as it can help identify gaps in readiness for transition.

Undisclosed Antiretroviral Therapy Use at Primary Health Care Clinics in Rural KwaZulu Natal South Africa: A DO-ART Trial Sub-study

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.

Mental health, substance use and viral suppression in adolescents receiving ART at a paediatric HIV clinic in South Africa.

IntroductionMental health problems are prevalent in adolescents living with HIV (ALHIV), often remain untreated, and may negatively affect antiretroviral therapy (ART) adherence and viral suppression. We implemented routine mental health screening at a paediatric ART clinic to improve the identification and management of mental health problems in ALHIV. In this report, we examine screening outcomes, associated patient characteristics and the odds of unsuppressed viral load in ALHIV screening positive for mental disorders.MethodsAdolescents aged 10 to 19 years attending Rahima Moosa Hospital in Johannesburg, South Africa between February 1, 2018, and January 1, 2020, were offered mental health screening at each routine HIV care visit. The screening included four pre‐screening questions followed by full screening (conditional on positive pre‐screening) for depression (Patient Health Questionnaire‐9 [PHQ‐9]), suicide (Adolescent Innovations Project [AIP]‐handbook), anxiety (Generalized Anxiety Disorder‐7 [GAD‐7]), post‐traumatic stress disorder (PTSD) (Primary Care PTSD Screen [PC‐PTSD‐5]) and substance use (CAGE Adapted to Include Drugs [CAGE‐AID]). We assessed screening outcomes and calculated adjusted odds ratios for associations between positive screening tests at the first screen and unsuppressed viral load (>400 copies/mL) at the measurement taken closest to the date of screening, within hundred days before and one day after screening.ResultsOut of 1203 adolescents who attended the clinic, 1088 (90.4%) were pre‐screened of whom 381 (35.0%) underwent full screening, 48 (4.4%) screened positive for depression (PHQ‐9 ≥10), 29 (2.8%) for suicidal concern, 24 (2.2%) for anxiety (GAD‐7 ≥10), 38 (3.2%) for PTSD (PC‐PTSD‐5 ≥3), 18 (1.7%) for substance use (CAGE‐AID ≥2) and 97 (8.9%) for any of these conditions. Positive screening for depression (aOR 2.39, 95% CI 1.02 to 5.62), PTSD (aOR 3.18, 95% CI 1.11 to 9.07), substance use (aOR 7.13, 95% CI 1.60 to 31.86), or any condition (aOR 2.17, 95% CI 1.17 to 4.02) were strongly associated with unsuppressed viral load.ConclusionsALHIV affected by mental health problems have increased rates of unsuppressed viral load and need specific clinical attention. The integration of routine mental health screening in paediatric ART programmes is a feasible approach for identifying and referring adolescents with mental health and adherence problems to counselling and psychosocial support services and if needed to psychiatric care.

Prevalence of TB symptoms, diagnosis and treatment among people living with HIV (PLHIV) not on ART presenting at outpatient clinics in South Africa and Kenya: baseline results from a clinical trial

ObjectiveWe used screening data and routine clinic records for intervention arm patients in the Simplified Algorithm for Treatment Eligibility (SLATE) trials to describe the prevalence of tuberculosis (TB) symptoms, diagnosis...

Using national laboratory data to assess cumulative frequency of linkage after transfer to community-based HIV clinics in South Africa.

IntroductionChanges to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding have led to closures of non‐governmental HIV clinics with patient transfers to government‐funded clinics. We sought to determine the success of transfers in South Africa using a national data source.MethodsAll adults (≥18 years) on antiretroviral therapy (ART) who visited a single PEPFAR‐funded hospital‐based HIV clinic in Durban, South Africa from March to June 2012 were transferred to community‐based clinics. Previously, we matched patient records from the hospital‐based HIV clinic with National Health Laboratory Services (NHLS) Corporate Data Warehouse (CDW) data to estimate the proportion of patients with a CD4 count or viral load (VL) in the CDW during the year before transfer. As a proxy for retention in care, in this study we evaluated whether patients had a CD4 count or VL at another facility within approximately three years of transfer. Patients referred to a private doctor at transfer were excluded from the analysis. We assessed predictors (age, sex, CD4 count, VL status, ART duration and location of future care) of not having post‐transfer laboratory data using Cox proportional hazards models.ResultsOf the 3893 patients referred to a government facility at transfer, 41% were male and median age was 39 years (IQR 34 to 46). There was a post‐transfer CD4 count or VL from another facility for 23% of these individuals within six months, 44% within one year, 57% within two years and 61% within approximately three years. Male sex (aHR 1.20, 95% CI 1.10 to 1.31) and shorter duration on ART (<3 months, aHR 3.80, 95% CI 2.77 to 5.21; three months to one year, aHR 1.32, 95% CI 1.15 to 1.51, each compared with >1 year) were associated with not having a post‐transfer record.ConclusionsUsing data from the NHLS CDW, 61% of patients had evidence of a post‐transfer laboratory record at another facility within approximately three years after closure of a large South African HIV clinic. Males and those with shorter time on ART prior to transfer were at highest risk for lacking follow‐up laboratory data. As patients transfer care, national data sources can be used to evaluate long‐term patient care trajectories.

Prevalence, incidence, predictors, treatment, and control of hypertension among HIV-positive adults on antiretroviral treatment in public sector treatment programs in South Africa.

BackgroundOne of the key risk factors for cardiovascular disease is hypertension. Hypertension, which leads to heart attacks and strokes, already affects one billion people worldwide, making it a global public health issue. Incidence and prevalence of the condition is on the rise in low- and middle-income countries, with the biggest increase in sub-Saharan Africa and South Africa at the forefront. We examined the prevalence, incidence, predictors, treatment, and control of hypertension among HIV-positive patients on ART in a large South African observational cohort.MethodsWe conducted a prospective study of ART naïve adults initiating ART at a public sector HIV clinic in South Africa between April 2004–2017. Patients with diagnosed hypertension at ART initiation were excluded from the incidence analysis. Log-binomial regression was used to estimate predictors of hypertension at ART initiation, while competing risks regression was used to evaluate the relationship between predictors of incident hypertension, accounting for death as a competing risk.ResultsAmong 77,696 eligible patients, 22.0% had prevalent hypertension at ART initiation. Of the remaining patients with no hypertension at ART initiation, 8,125 incident hypertension cases were diagnosed over the period of follow-up, corresponding to an incident rate of 5.4 per 100 person-years (95% confidence interval (CI): 5.3–5.6). We found patients ≥40 years of age and patients with a body mass index (BMI) ≥25kg/m2 were at increased risk of both prevalent and incident hypertension. Male patients and those with pre-hypertension at ART initiation had increased hazards of hypertension over the period of follow-up. When assessing the choice of antiretroviral drug in first-line ART, patients initiated on nevirapine were at 27% increased risk of developing hypertension compared to those initiated on efavirenz, while patients who initiated on either zidovudine or stavudine had a 40% increased risk of developing hypertension compared to patients initiated on tenofovir. Patientswith poorer health status at ART initiation (i.e. WHO III/IV stage, low CD4 count, low hemoglobin levels and low BMI) had a decrease risk of prevalent hypertension. We found an inverse relationship in patients with a CD4 count <50 cells/mm3 at ART initiation who had a 25% increased risk of incident hypertension compared to those with a CD4 count ≥350 cells/mm3.ConclusionOver 20% of patients in our cohort had hypertension at ART initiation, and 13% of those with normal blood pressure at ART initiation developed hypertension while on ART. Older patients, males, those on nevirapine, zidovudine or stavudine, and those who are overweight/obese should be targeted for frequent blood pressure monitoring and the identification of other cardiovascular risk factors to encourage lifestyle modifications. Additionally, these groups should be offered pharmaceutical therapy to help prevent myocardial infarction, heart failure, stroke, and kidney disease. Further research is needed to determine the level of access and adherence to pharmaceutical treatment for hypertension in this population. Additionally, an HIV-negative comparison population is needed to assess the association of the HIV virus itself with hypertension.

Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa.

ObjectiveTo determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site.DesignRetrospective cohort analysis.SettingGovernment supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa.ParticipantsTwo hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015.InterventionAttendance in an adolescent-friendly clinic compared to a standard pediatric clinic.Outcomes measuresRetention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml.ResultsOverall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2–11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3–32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1–5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5–9.7; p = 0.005).ConclusionAdolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.

A clinical scoring system to prioritise investigation for tuberculosis among adults attending HIV clinics in South Africa.

BackgroundThe World Health Organization (WHO) recommendation for regular tuberculosis (TB) screening of HIV-positive individuals with Xpert MTB/RIF as the first diagnostic test has major resource implications.ObjectiveTo develop a diagnostic prediction model for TB, for symptomatic adults attending for routine HIV care, to prioritise TB investigation.DesignCohort study exploring a TB testing algorithm.SettingHIV clinics, South Africa.ParticipantsRepresentative sample of adult HIV clinic attendees; data from participants reporting ≥1 symptom on the WHO screening tool were split 50:50 to derive, then internally validate, a prediction model.OutcomeTB, defined as “confirmed” if Xpert MTB/RIF, line probe assay or M. tuberculosis culture were positive; and “clinical” if TB treatment started without microbiological confirmation, within six months of enrolment.ResultsOverall, 79/2602 (3.0%) participants on ART fulfilled TB case definitions, compared to 65/906 (7.2%) pre-ART. Among 1133/3508 (32.3%) participants screening positive on the WHO tool, 1048 met inclusion criteria for this analysis: 52/515 (10.1%) in the derivation and 58/533 (10.9%) in the validation dataset had TB. Our final model comprised ART status (on ART > 3 months vs. pre-ART or ART < 3 months); body mass index (continuous); CD4 (continuous); number of WHO symptoms (1 vs. >1 symptom). We converted this to a clinical score, using clinically-relevant CD4 and BMI categories. A cut-off score of ≥3 identified those with TB with sensitivity and specificity of 91.8% and 34.3% respectively. If investigation was prioritised for individuals with score of ≥3, 68% (717/1048) symptomatic individuals would be tested, among whom the prevalence of TB would be 14.1% (101/717); 32% (331/1048) of tests would be avoided, but 3% (9/331) with TB would be missed amongst those not tested.ConclusionOur clinical score may help prioritise TB investigation among symptomatic individuals.

Body Mass Index and Waist Circumference in Patients with HIV in South Africa and Associated Socio-demographic, Health Related and Psychosocial Factors.

A high body mass index (BMI) and high waist circumference are important health risk factors predisposing for cardiovascular and metabolic diseases and certain cancers. Historically, underweight was a diagnostic criterion of HIV-infection. In a cross-sectional study the prevalence of BMI-categories and high waist circumference and its associated factors in patients visiting three outpatient HIV clinics in South Africa were measured with anthropometric measurements and structured questionnaires regarding socio-demographic information, quality of life (QoL), AIDS-related stigma, symptoms of depression, alcohol use, HIV related information and level of adherence to ART. The median age of the 2230 included patients was 37years, 66.5% were women and 88.6% received antiretroviral therapy. The prevalences of overweight, obesity and high waist circumference were 29.2, 21.9 and 44.6% respectively in women and 12.4, 4.0 and 3.9% respectively in men. Underweight was found in 18.2% of men and 6.3% of women. In multinomial regression analysis compared to a normal BMI, both overweight and obesity were associated with female gender, with being married or cohabiting and with a higher QoL score. Underweight was associated with male gender and tobacco use and negatively associated with being married or cohabiting and the physical domain of the QoL measure. A high waist circumference in men was associated with higher age and negatively associated with tobacco use and stigma score. In women it was negatively associated with never being married. A high prevalence of overweight and obesity was observed in HIV-clinics in South Africa, mainly in women. Since overweight and obesity are important health risk factors, effective weight reduction interventions are desirable.

Citizenship status and engagement in HIV care: an observational cohort study to assess the association between reporting a national ID number and retention in public-sector HIV care in Johannesburg, South Africa

ObjectiveIn many resource-limited settings, people from rural areas migrate to urban hubs in search of work. Thus, urban public-sector HIV clinics in South Africa (SA) often cater to both local...

Treatment Outcomes and Costs of Providing Antiretroviral Therapy at a Primary Health Clinic versus a Hospital-Based HIV Clinic in South Africa.

BackgroundIn 2010 South Africa revised its HIV treatment guidelines to allow the initiation and management of patients on antiretroviral therapy (ART) by nurses, rather than solely doctors, under a program called NIMART (Nurse Initiated and Managed Antiretroviral Therapy). We compared the outcomes and costs of NIMART between the two major public sector HIV treatment delivery models in use in South Africa today, primary health clinics and hospital-based HIV clinics.Methods and findingsThe study was conducted at one hospital-based outpatient HIV clinic and one primary health clinic (PHC) in Gauteng Province. A retrospective cohort of adult patients initiated on ART at the PHC was propensity-score matched to patients initiated at the hospital outpatient clinic. Each patient was assigned a 12-month outcome of alive and in care or died/lost to follow up. Costs were estimated from the provider perspective for the 12 months after ART initiation. The proportion of patients alive and in care at 12 months did not differ between the PHC (76.5%) and the hospital-based site (74.2%). The average annual cost per patient alive and in care at 12 months after ART initiation was significantly lower at the PHC (US$238) than at the hospital outpatient clinic (US$428).ConclusionsInitiating and managing ART patients at PHCs under NIMART is producing equally good outcomes as hospital-based HIV clinic care at much lower cost. Evolution of hospital-based clinics into referral facilities that serve complicated patients, while investing most program expansion resources into PHCs, may be a preferred strategy for achieving treatment coverage targets.

Treatment outcomes in a rural HIV clinic in South Africa: Implications for health care.

ObjectiveTo assess the treatment outcomes of an HIV clinic in rural Limpopo province, South Africa.MethodsA retrospective cohort study involving medical records review of HIV-positive patients initiated on antiretroviral treatment (ART) was conducted from December 2007 to November 2008 at Letaba Hospital. Data on socio-demographic characteristics, CD4 counts, viral loads (VLs), opportunistic infections, adverse effects of treatment, hospital admissions, and patient retention at 6, 12, 24, and 36 months on ART were collected. Analysis included descriptive statistics, chi-square and t-tests.ResultsOf 124 patient records sampled, the majority of patients were female (69%), single (49%), unemployed (56%), living at least 10 km from the hospital (52.4%), and were on treatment at 36 months (69%). Approximately 84% of patients achieved viral suppression (VLs < 400 copies/mL) by 6 months of ART and the mean CD4 count increased from 128 at baseline to 470 cells/mm3 at 24 months. There was a mean weight gain of 5.9 kg over the 36 months and the proportion of patients with opportunistic infections decreased from 54.8% (n = 68) at baseline to 15.3% (n = 19) at 36 months. Although the largest improvements in CD4, VLs, and weights were recorded in the first 6 months of ART, viral rebound became evident thereafter. Of all variables, only age < 50 years and being pregnant were significantly associated with higher VLs (p = 0.03).ConclusionGood treatment outcomes are achievable in a rural South African ART clinic. However, early viral rebound and higher VLs in pregnancy highlight the need for enhanced treatment adherence support, especially for pregnant women to reduce the risk of mother to child transmission.

Treatment outcomes in a rural HIV clinic in South Africa: Implications for health care

Treatment outcomes in a rural HIV clinic in South Africa: Implications for health care

Missed Opportunities to Address Cardiovascular Disease Risk Factors amongst Adults Attending an Urban HIV Clinic in South Africa.

We assessed cardiovascular disease (CVD) risk factor prevalence and risk stratification amongst adults on antiretroviral therapy in South Africa. Of the 175 patients screened, 37.8% had high blood pressure (HBP), 15.4% were current smokers, 10.4% had elevated cholesterol, and 4.1% had diabetes, but very few (3.6%) had a 10-year CVD risk >10%. One-third of those with HBP, 40% of those with diabetes, and two-thirds of those with high cholesterol had not previously been diagnosed. Although participants were adherent with chronic HIV care, screening for and management of CVDRF were suboptimal, representing a missed opportunity to reduce non-AIDS morbidity and mortality.

High prevalence of lipoatrophy in pre-pubertal South African children on antiretroviral therapy: a cross-sectional study

BackgroundDespite changes in WHO guidelines, stavudine is still used extensively for treatment of pediatric HIV in the developing world. Lipoatrophy in sub-Saharan African children can be stigmatizing and have far-reaching consequences. The severity and extent of lipoatrophy in pre-pubertal children living in sub-Saharan Africa is unknown.MethodsIn this cross-sectional study, children who were 3-12 years old, on antiretroviral therapy and pre-pubertal were recruited from a Family HIV Clinic in South Africa. Lipoatrophy was identified and graded by consensus between two HIV pediatricians using a standardized grading scale. A professional dietician performed formal dietary assessment and anthropometric measurements of trunk and limb fat. Previous antiretroviral exposures were recorded. In a Dual-Energy X-ray Absorbtiometry (DXA) substudy body composition was determined in 42 participants.ResultsAmong 100 recruits, the prevalence of visually obvious lipoatrophy was 36% (95% CI: 27%–45%). Anthropometry and DXA measurements corroborated the clinical diagnosis of lipoatrophy: Both confirmed significant, substantial extremity fat loss in children with visually obvious lipoatrophy, when adjusted for age and sex. Adjusted odds ratio for developing lipoatrophy was 1.9 (95% CI: 1.3 - 2.9) for each additional year of accumulated exposure to standard dose stavudine. Cumulative time on standard dose stavudine was significantly associated with reductions in biceps and triceps skin-fold thickness (p=0.008).ConclusionsThe prevalence of visually obvious lipoatrophy in pre-pubertal South African children on antiretroviral therapy is high. The amount of stavudine that children are exposed to needs review. Resources are needed to enable low-and-middle-income countries to provide suitable pediatric-formulated alternatives to stavudine-based pediatric regimens. The standard stavudine dose for children may need to be reduced. Diagnosis of lipoatrophy at an early stage is important to allow timeous antiretroviral switching to arrest progression and avoid stigmatization. Diagnosis using visual grading requires training and experience, and DXA and comprehensive anthropometry are not commonly available. A simple objective screening tool is needed to identify early lipoatrophy in resource-limited settings where specialized skills and equipment are not available.

Barriers to participate in support groups for people living with HIV: a qualitative study with men receiving antiretroviral treatment in a HIV clinic in Mthatha, South Africa.

Support groups are the most common and popular way of providing social support for people living with HIV and AIDS (PLWHI). Nevertheless, HIV positive men are reluctant to attend support groups, and in most mixed gender support groups, women outnumber men. The study used a sample of men accessing antiretroviral treatment (ART) from a HIV clinic in South Africa, to examine their perceptions of support groups and explore their reasons for nonparticipation in such groups. Five focus groups interviews were conducted with 50 HIV positive men. Their age ranged from 28-70 years, all had disclosed their HIV status to partners and family members and were receiving ART for more than a year. The main barriers for nonparticipation related to issues on support groups were; Unavailability of support groups in local communities including; no access, the timing of meetings and lack of transport money. Fear of unintended disclosure of HIV status due to breach of confidentiality with resulting stigma and social rejection. On a personal level, participants felt that they had adequate support at home. Participants would consider participating if men only support groups are initiated, support groups are held on weekends, and they are provided with more information on support groups. Health care providers have a critical role to play in creating awareness of and education on the role of support groups for PLWHI. Support group planners should consider men only support groups which has been shown to have positive outcomes and facilitates member participation.

Undiagnosed Tuberculosis Among HIV Clinic Attendees

Initiation of antiretroviral therapy (ART) and the 3I's are strategies to prevent HIV-associated tuberculosis (TB). We describe factors associated with undiagnosed TB among HIV-infected patients attending an HIV clinic in South Africa and discuss implications for the 3 Is. Convenience sample of HIV clinic attendees. HIV-infected participants were assessed for TB using a symptom screen, sputum-smear microscopy, sputum and blood mycobacterial culture, fine needle aspiration of enlarged lymph nodes, and chest radiography. Four hundred twenty-two participants were enrolled. The median age and CD4+ T-cell count were 37 years [interquartile range (IQR): 31-44 years] and 215 cells per microliter (IQR: 107-347 cells/μL). Forty-seven percent had been on ART for a median duration of 8 months (IQR: 3.3-22.8 months). Three hundred sixty-one participants (85.6%) reported TB symptoms. Twenty-seven participants (6.4%) met criteria for bacteriologically confirmed TB and 50 (11.6%) for any form of TB. Bacteriologically confirmed TB was associated with CD4+ T-cell counts ≤100 cells per microliter (odds ratio: 5.05, 95% confidence interval: 1.69 to 15.12) when compared with CD4+ T-cell counts >200 cells per microliter and hemoglobin {hemoglobin < 10 g/dL [odds ratio 3.12 (95% confidence interval: 1.26 to 7.72)]}. Undiagnosed TB among HIV-infected ambulatory patients was associated with low CD4+ T-cell counts regardless of ART status. TB screening algorithms which include CD4+ T-cell count and hemoglobin testing may be an effective way to identify HIV-infected clinic attendees at highest risk of undiagnosed TB. Isoniazid preventive therapy and TB infection control are essential for reducing occurrence of HIV-associated TB even after ART initiation.

The epidemiology and clinical correlates of HIV‐1 co‐receptor tropism in non‐subtype B infections from India, Uganda and South Africa

BackgroundThe introduction of C-C chemokine receptor type-5 (CCR5) antagonists as antiretroviral therapy has led to the need to study HIV co-receptor tropism in different HIV-1 subtypes and geographical locations. This study was undertaken to evaluate HIV-1 co-receptor tropism in the developing world where non-B subtypes predominate, in order to assess the therapeutic and prophylactic potential of CCR5 antagonists in these regions.MethodsHIV-1-infected patients were recruited into this prospective, cross-sectional, epidemiologic study from HIV clinics in South Africa, Uganda and India. Patients were infected with subtypes C (South Africa, India) or A or D (Uganda). HIV-1 subtype and co-receptor tropism were determined and analyzed with disease characteristics, including viral load and CD4+ and CD8+ T cell counts.ResultsCCR5-tropic (R5) HIV-1 was detected in 96% of treatment-naïve (TN) and treatment-experienced (TE) patients in India, 71% of TE South African patients, and 86% (subtype A/A1) and 71% (subtype D) of TN and TE Ugandan patients. Dual/mixed-tropic HIV-1 was found in 4% of Indian, 25% of South African and 13% (subtype A/A1) and 29% (subtype D) of Ugandan patients. Prior antiretroviral treatment was associated with decreased R5 tropism; however, this decrease was less in subtype C from India (TE: 94%, TN: 97%) than in subtypes A (TE: 59%; TN: 91%) and D (TE: 30%; TN: 79%). R5 virus infection in all three subtypes correlated with higher CD4+ count.ConclusionsR5 HIV-1 was predominant in TN individuals with HIV-1 subtypes C, A, and D and TE individuals with subtypes C and A. Higher CD4+ count correlated with R5 prevalence, while treatment experience was associated with increased non-R5 infection in all subtypes.

Disclosing HIV to Infected Children in South Africa in the Era of HAART: A Grounded Theory Study on the Process, Reasons and Outcomes of Disclosure

South Africa has seen an increasing population of children and adolescents accessing antiretroviral treatment (ART) in the past seven years. Many of these children are at the age when they should know their HIV diagnosis. We used grounded theory to explore the process, reasons and outcomes of HIV disclosure to children accessing ART from a paediatric HIV clinic in South Africa. Twenty seven caregivers of children aged 6 - 13 years who were receiving ART participated in four focus group interviews. Four main themes, disclosure occurring as a process, asking HIV related questions, the right age to tell, and the child's reaction to the diagnosis emerged. Biological caregivers approached disclosure as a process; they planned and prepared for the disclosure event for a long time. Full disclosure occurred when the caregivers had dealt with their own personal fears over the child's diagnosis, resulting in disclosure being delayed to older age and adolescence. Non-biological caregivers disclosed impulsively to children and employed partial disclosure. Caregivers disclosed because of the child's refusal to continue taking medication or the child repeatedly questioned the reasons for taking medication. Caregivers also disclosed because it was the right time to disclose, and the right time was often when the child reaches adolescence. After learning about their HIV diagnosis children became more adherent to medication, they also ensured that their HIV infected biological caregivers were adherent too. Children kept their diagnosis secret from people outside their immediate families. The increased survival of children on ART in South Africa calls for concerted efforts from researchers and health care providers to develop disclosure guidelines to assist caregivers to disclose to children in a manner that promotes the wellbeing of the child.

Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics.

In light of increasing access to HAART in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics. Prospective observational cohort. We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors. Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78-0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34-0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29), respectively]. Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.