Southern African journal of HIV medicine最新文献

Background: HIV prevalence among pregnant women in South Africa was very high at 25.3% of infections reported in 2022. KwaZulu-Natal province had the highest HIV prevalence of 34.2%, followed by the Eastern Cape with 32.0% infections, and the Free State with a prevalence of 28.8%.

Objectives: To determine the HIV prevalence and healthcare services provided to pregnant women with HIV at primary healthcare clinics in the Free State province.

Method: This was a retrospective evaluation of all antenatal records from 2020 to 2023 at primary healthcare facilities in the Free State province, South Africa. All pregnant women who started antenatal care and delivered at the clinic were included in the study. Maternal demographic and clinical data, including HIV status, the clinical management of HIV, and perinatal outcomes were recorded. Maternal records of unbooked mothers and those who did not deliver at the clinic were excluded.

Results: The antenatal records of 668 pregnant women during the period 2020-2023 were reviewed. The prevalence of HIV was 27.9%, of which 22.4% tested for the first time at booking. Among pregnant women living with HIV, 4.2% had a CD4-count of < 200 cells/mm³, 48.7% had no viral load recorded and 85% were on antiretroviral therapy. Only 69.6% of the HIV-negative women were retested. All infants (n = 187) born to mothers living with HIV had a negative HIV birth polymerase chain reaction test. Approximately 41% of the HIV-exposed infants had a low-birth weight. In addition, two low-birthweight infants were stillbirths.

Conclusion: HIV prevalence among pregnant women remains high, with gaps in viral load monitoring and HIV retesting and early antenatal booking. Low-birth-weight rates were higher among HIV-exposed infants, indicating ongoing vulnerability despite available services.

Background: South Africa has the largest HIV epidemic globally. Despite the scale-up of antiretroviral therapy, people living with HIV still present with CD4 ≤ 200 cells/µL because of possible treatment interruptions and/or late presentation.

Objectives: This study assessed the proportion of CD4 specimens with counts ≤ 200 cells/µL by health district, comparing 2013 to 2023.

Method: This cross-sectional study analysed laboratory data. Annual test volumes, median CD4 and the percentage of specimens with a count ≤ 200 cells/µL were reported. The difference in the median CD4 between 2013 and 2023 was calculated. No de-duplication was possible because of the absence of unique identifiers.

Results: Data are reported for 5 821 932 specimens, with a significant decline in absolute numbers, while the percentage of specimens with a count ≤ 200 cells/µL declined by 0.4%. The median CD4 increased from 396 cells/µL in 2013 to 465 cells/µL by 2023. Between 2013 and 2023, eight districts showed a decrease in the median CD4, while 44 reported an increase ranging from 2 cells/µL (Sedibeng) to 192 cells/µL (uThukela). A percentage point reduction for counts ≤ 200 cells/µL between 2013 and 2023 was reported for 23 districts (44.2%), while 29 (55.8%) showed a percentage point increase.

Conclusion: Despite an upward trend in the national specimen-level CD4 count median over time, unacceptable levels of CD4 counts ≤ 200 cells/µL persisted. The analysis provides important insight into district burden of advanced HIV disease which warrants national attention and further investigation.

Background: South Africa has a high prevalence of HIV and substance use, with 13% of the population meeting criteria for lifetime substance use disorder (SUD). Substance disorders are associated with adverse health outcomes, including poor adherence to antiretroviral therapy (ART), reduced health-seeking behaviour and increased risk-taking behaviour. Limited research has explored the perspectives of people with HIV in low- and middle-income countries when accessing substance use treatment.

Objectives: To identify barriers and facilitators influencing engagement in substance use treatment programmes among people with HIV and SUDs, drawing on perspectives from both patients and healthcare providers.

Method: This qualitative study analysed individual interviews from Project Khanya, a peer-delivered intervention promoting ART adherence among adults living with HIV with at least a moderate SUD. Using criterion sampling, 34 adults with HIV and nine healthcare providers involved in HIV or substance use care were included. Inductive thematic analysis of transcripts from audio recordings identified individual, social, and structural factors influencing treatment engagement.

Results: Participants had a mean age of 39.2 years and 48% were female; providers had a mean age of 40.8 years and were predominantly female. Five main subthemes influenced engagement in substance use treatment: social support, substance use, service-related factors, readiness to change, and financial constraints. Facilitators included strong social support, positive healthcare experiences, outreach, psychoeducation, insight, and reduced substance use, while barriers included poor support, stigma, negative healthcare interactions, financial challenges, and ongoing substance use.

Conclusion: Intersectional stigma, privacy concerns, and ongoing substance use hinder engagement in HIV and SUD treatment, whereas holistic, person-centred approaches can improve programme attendance and health outcomes.

Background: The management of HIV among adolescents and young adults (AYAs) living with HIV is often complicated by systemic barriers within healthcare services, particularly communication challenges, inadequate support systems, and other external factors. Understanding these barriers is essential for improving antiretroviral therapy (ART) adherence and overall health outcomes in this population.

Objectives: The study aimed to examine and describe the perceptions of AYAs living with HIV on treatment adherence.

Method: A qualitative approach was applied using semi-structured interviews with AYAs aged 18-24 living with HIV. Twenty AYAs living with both perinatal and horizontally acquired HIV, from four healthcare facilities in Sedibeng District in Gauteng province, with two consecutive viral load results of above 1000 copies/mL identified using the TIER.NET patient management system, were purposively selected and interviewed. Thematic analysis was conducted.

Results: The review identified five key themes characterising the challenges with ART adherence for AYAs. These themes include personal expectations regarding the possibility of HIV cure, and discomfort from side effects, intentional treatment cessation emanating from stigma and disclosure complexities, and healthcare facility challenges, including facility appointments and limited counselling.

Conclusion: The study highlights the need for early identification of barriers to adherence. This should include implementing strategies to enhance accessibility of counselling, and other services to improve adherence and overall wellbeing of AYAs living with HIV.

Background: Targeted Universal Tuberculosis Testing (TUTT) is a strategy for early tuberculosis (TB) detection among people with HIV (PWH); however, drop-offs at key cascade stages limit its effectiveness.

Objectives: This study examines determinants of drop-offs at three stages: rapid molecular diagnostic test for TB (Xpert) TB treatment initiation, and completion.

Method: We conducted a retrospective analysis of routinely collected data in fiscal year 2022 from PWH on antiretroviral therapy (ART) in rural and urban facilities in KwaZulu-Natal, South Africa. Logistic regression identified determinants of drop-offs.

Results: Among 104 859 PWH, 66.7% were not tested using Xpert. Drop-offs were higher among PWH already on ART (Adjusted Odds Ratio [aOR] = 60.65, 95% confidence interval [CI]: 55.11-66.75), and those in multi-month dispensing (MMD; aOR = 1.42, 95% CI: 1.33-1.52) and differentiated models of care (DMoC; aOR = 1.10, 95% CI: 1.03-1.18) versus standard of care. Symptomatic PWH were less likely to experience Xpert drop-offs (aOR = 0.009, 95% CI: 0.008-0.011) than those without symptoms recorded. Of 1746 PWH diagnosed with TB, 6.3% did not initiate treatment, with higher drop-offs in DMoC (aOR = 29.22, 95% CI: 13.29-64.23) and MMD (aOR = 8.65, 95% CI: 2.72-27.48), but lower among symptomatic PWH (aOR = 0.05, 95% CI: 0.03-0.11). Among 1636 who started TB treatment, 25.6% did not complete it. Drop-offs were higher among those with previous TB (aOR = 2.50, 95% CI: 1.71-3.66), and lower among symptomatic PWH (aOR = 0.21, 95% CI: 0.15-0.29).

Conclusion: Findings reveal substantial drop-offs in Xpert testing and TB treatment completion, especially among PWH already on ART. Targeted strategies to identify and retain PWH at highest risk of drop-offs are important for optimising TUTT.

Background: HIV/AIDS continues to be of concern, particularly in South Africa, where the current prevalence is 12.7%.

Objectives: This study aimed to explore sexual practices that increased HIV vulnerability among clinic users who chose to initiate pre-exposure prophylaxis (PrEP) in KwaZulu-Natal, South Africa.

Method: A quantitative approach was utilised to collect data at an urban clinic in eThekwini (n = 376). Data were analysed using SPSS v29.

Results: Participants were predominantly female (n = 331; 88%), single (n = 343; 91.5%), and heterosexual (n = 368; 98.1%). Sexual debut occurred at 18.4 ± 2.58 years. More men reported having concurrent sexual partners (n = 24; 54.5%). Transactional sex was more often reported by single women aged 18 years to 24 years. Age-disparate relationships were more common among those aged 18 years to 24 years. A significant association between early sexual debut and the number of lifetime partners was identified (P < 0.001).

Conclusion: Our findings indicate that the study population was aware of their increased HIV vulnerability and were willing to try preventive measures, such as PrEP, to protect against seroconversion. However, interventions are required to abate the cycle of transactional sex, age-disparate relationships, and early sexual debut, especially among young women aged 15 years to 24 years.

Background: Meeting the Joint United Nations Programme on HIV/AIDS targets and ending AIDS by 2030 requires global efforts, with a particular focus on older adolescents living with HIV (OALHIV) and younger adults living with HIV (YALHIV). These population groups are often associated with unsuppressed viral load compared to adults.

Objectives: This article assessed the extent of viral load suppression (VLS) and associated factors among this group in seven high-burden districts of Namibia.

Method: A cross-sectional survey was conducted to analyse data for 600 OALHIV and YALHIV, aged 15-24 years, who were already on antiretroviral treatment prior to 2020. The study employed a stratified cluster sampling across seven districts. Data were extracted from an electronic database and analysed using Statistical Package for Social Sciences (SPSS) software. However, limitations within the database restricted the availability of certain variables.

Results: Overall, the VLS (< 1000 copies/mL) was 84.8%, with female patients showing a significantly higher VLS 88.3% compared to male patients, with 78.5% (P < 0.01; odds ratio [OR] = 2.08). Although OALHIV had higher suppression (84.9%) than YALHIV (74.6%), age was not significantly associated with VLS (P = 0.9). Dolutegravir-based regimens had a suppression of 93.3% (P < 0.01; OR = 9.1), and those with a fixed home address had an 88.2% suppression (P = 0.014; OR = 1.76).

Conclusion: The VLS of 84.8% remains below the Joint United Nations Programme on HIV/AIDS target of 95%. There is a need for improvements in antiretroviral treatment programmes, particularly in scaling up dolutegravir-based regimens, enhancing adherence and peer support to end AIDS by 2030.

Background: The WHO emphasises contact investigation of people with HIV for case finding. However, satisfactory implementation of index contact testing remains challenging in Johannesburg.

Objectives: This study draws from the Consolidated Framework for Implementation Research to explore healthcare workers' (HCWs) insights on barriers and enablers of index contact testing implementation.

Method: Data were collected through semi-structured interviews, at four healthcare facilities and four non-profit organisations (NPOs) in Johannesburg, from October 2023 to November 2023, and analysed thematically, guided by the Consolidated Framework for Implementation Research framework.

Results: Twenty-three HCWs participated: 18 counsellors (78.3%) and 5 nurses (21.7%). Most participants were aged 20-40 years (56.5%). Participants were drawn from facilities (65.0%) and NPOs (35.0%). Counsellors demonstrated a more nuanced understanding of index contact testing. Major barriers were identified in the innovation, outer setting, and inner setting domains, and key enablers in the innovation and process domains. Innovation domain barriers included perceived complexity of guidelines and their time-consuming nature. Key enablers were adaptations to educate clients about pre-exposure prophylaxis (PrEP), incorporating index contact testing into pre-test counselling, and offering home-based testing for contacts. Outer setting barriers included fears of intimate partner violence (IPV), stigma, and geographic dispersion of contacts. Inner setting barriers were limited training, insufficient knowledge, and inadequate HCW skills, compounded by a lack of resources.

Conclusion: This study highlights critical barriers that need to be addressed, through simplified guidelines, targeted training, resource allocation, stigma reduction, and IPV-reduction strategies. Leveraging enablers like PrEP education and home-based testing can enhance implementation and engagement.

Background: In the HIV/tuberculosis endemic Western Cape public care setting, diagnostic consideration of patients with persistent lymphadenopathy focuses on extra-pulmonary tuberculosis (EPTB), delaying diagnosis of other infectious or malignant causes of lymphadenopathy.

Objectives: To evaluate the diagnostic pathways of patients investigated for lymphadenopathy at Groote Schuur Hospital.

Method: A retrospective review of patients undergoing lymph node excision biopsy was conducted to correlate test selection and results prior to biopsy with final patient diagnosis and assess the impact of pre-biopsy pathways on diagnostic delay.

Results: Of 86 patients undergoing excision biopsy, 61 (71%) had no previous diagnosis to explain the lymphadenopathy. Extra-pulmonary tuberculosis was the commonest diagnosis (24.6%, 15/61), followed by lymphoma (21.3%, 13/61), and metastatic cancer (14.8%, 9/61). Median time from presentation with lymphadenopathy to first excision biopsy was 55 days (interquartile range [IQR] 22-106). Fine needle aspiration (FNA) cytology of lymphadenopathy was performed in 30 out of 61 (49%) of the patients and repeated in a third of these, while smear for acid-fast bacilli and culture for Mycobacterium tuberculosis were infrequently performed, and the GeneXpert MTB/RIF assay on FNA was never performed. FNA cytology was non-diagnostic in all seven patients with lymphoma in whom it was performed.

Conclusion: In patients with lymphadenopathy, we demonstrate how poorly structured diagnostic pathways contribute to unnecessary healthcare utilisation and diagnostic delay in treatable conditions. Providing early access to biopsy after appropriate workup ensures accurate diagnosis of unexplained lymphadenopathy.

Background: Retention of people who inject drugs (PWID) on antiretroviral therapy (ART) is critical for viral suppression. However, PWID, a key population, traditionally have poor retention in care (RiC).

Objectives: To determine the prevalence of and factors associated with RiC at 6 months, following ART initiation in three South African districts.

Method: Data of 333 PWID (adults 18+ years), who commenced ART between July 2022 and March 2023, were retrieved from TIER.Net electronic database.

Results: RiC after 6 months on ART was 40% (n = 132). Bivariate analysis showed higher retention among those on Opioid Substitution Therapy (OST) with treatment support compared to those without support (95% vs 39%; P < 0.001); and lower RiC among those with unstable housing compared to those with stable housing (12% vs 75%; P < 0.001). In the survival analysis, PWID with unstable housing had a 5-fold increased risk of poor RiC (adjusted hazard ratio [AHR] = 4.94; 95% confidence interval [95% CI]: 2.35-10.35), while those in OST had a 75% decreased risk of poor RiC (AHR = 0.25; 95% CI: 0.10-0.60).

Conclusion: PWID face significant challenges in remaining engaged in ART care, particularly those experiencing unstable housing. OST uptake can facilitate improved RiC and health outcomes, highlighting the need for expanded harm reduction strategies. Addressing unstable housing remains urgent to strengthen HIV treatment outcomes for PWID in South Africa.