Understanding Barriers and Facilitators to Integrated HIV and Hypertension Care in South Africa.

Background The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. The objective of this study was to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV seeking treatment in primary care clinics in Johannesburg, South Africa. Methods Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by the Theoretical Domains Framework was used to identify and compare determinants of hypertension care across different stakeholder groups. Results Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) the patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care. Conclusions The convergence of multi-stakeholder data regarding barriers to hypertension screening, treatment, and management highlight key areas for improvement, where tailored implementation strategies may address challenges recognized by each stakeholder group.

Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial.

A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.

Point-of-Care Tenofovir Urine Testing for the Prediction of Treatment Failure and Drug Resistance During Initial Treatment for Human Immunodeficiency Virus Type 1 (HIV-1) Infection.

BACKGROUND: Viral rebound during antiretroviral treatment (ART) is most often driven by suboptimal adherence in the absence of drug resistance. We assessed the diagnostic performance of point-of-care (POC) tenofovir (TFV) detection in urine for the prediction of viral rebound and drug resistance during ART. METHODS: We performed a nested case-control study within the ADVANCE randomized clinical trial (NCT03122262) in Johannesburg, South Africa. Adults with human immunodeficiency virus (HIV) and newly initiating ART were randomized to receive either dolutegravir or efavirenz, tenofovir disoproxil fumarate or alafenamide, and emtricitabine. All participants with rebound ≥200 copies/mL between 24 and 96 weeks of follow-up were selected as cases and matched to controls with virological suppression <50 copies/mL. Rapid POC urine-TFV detection was performed retrospectively. RESULTS: We included 281 samples from 198 participants. Urine-TFV was detectable in 30.7% (70/228) of cases and in 100% (53/53) of controls. Undetectable urine-TFV predicted rebound with a sensitivity of 69% [95% confidence interval {CI}: 63-75] and specificity of 100% [93-100]. In cases with virological failure and sequencing data (n = 42), NRTI drug resistance was detected in 50% (10/20) of cases with detectable urine-TFV versus in 8.3% (2/24) of cases with undetectable urine-TFV. Detectable urine-TFV predicted NRTI resistance (odds ratio [OR] 10.4 [1.8-114.4] P = .005) with a sensitivity of 83% [52-98] and specificity of 69% [50-84]. CONCLUSIONS: POC objective adherence testing using a urine-TFV test predicted viral rebound with high specificity. In participants with rebound, urine-TFV testing predicted the selection of drug resistance. Objective adherence testing may be used to rapidly provide insight into adherence, suppression, and drug resistance during ART.

Experiences in receiving financial incentives to access HIV care in Johannesburg, South Africa.

Background: Financial incentivisation has been used to improve all steps of the HIV cascade with varying results. Most studies conducted on the matter are of a quantitative nature, not giving enough space for in-depth understanding as to why financial incentives work or do not work. Objectives: To describe experiences with, and opinions on, the use of financial incentives to promote linkage to and retention in care from the perspective of people living with HIV. Method: We performed a qualitative cross-sectional study. In-depth interviews were conducted with adult men and women with HIV accessing health services or research study visits. After codebook development, NVivo 12 software was used to code and analyse the data. Results: Through the provision of financial incentives, participants were able to cover basic needs. However, some deemed financial incentives as a form of income rather than a nudge to spark interest in changing their health behaviour. Participants communicated that a need for some type of incentive exists and recommended food vouchers as the best possible solution. Conclusion: Financial incentivisation can facilitate engagement in the HIV care continuum through providing support to people living with HIV. What this study adds: This study complements the body of research that explores the feasibility of using incentives and which of them may be most beneficial in encouraging patients with HIV to enter into and sustain HIV care.

A Retrospective Medical Record Review to Describe Health Status and Cardiovascular Disease Risk Factors of Bus Drivers in South Africa.

Cardiovascular disease (CVD) is the leading cause of death globally. The occupational challenges of bus drivers may increase their risk of CVD, including developing obesity, hypertension, and diabetes. We evaluated the medical records of 266 bus drivers visiting an occupational medical practice between 2007 and 2017 in Johannesburg, South Africa, to determine the health status of bus drivers and investigate risk factors for CVD, and their impact on the ability to work. The participants were in majority male (99.3%) with a median age of 41.2 years (IQR 35.2); 23.7% were smokers, and 27.1% consumed alcohol. The median body mass index (BMI) was 26.8 m/kg2 (IQR 7.1), with 63.1% of participants having above normal BMI. Smoking, BMI, and hypertension findings were in line with national South African data, but diabetes prevalence was far lower. Undiagnosed hypertension was found in 9.4% of participants, uncontrolled hypertension in 5.6%, and diabetes in 3.0%. Analysis by BMI category found that obesity was significantly associated with increased odds of hypertension. Uncontrolled hypertension was the main reason for being deemed 'unfit to work' (35.3%). Our research highlights the need for more regular screening for hypertension and interventions to address high BMI.

Essential health services delivery in South Africa during COVID-19: Community and healthcare worker perspectives.

Background: Between May 2020 and February 2022, South Africa's health system bore strain as it battled mitigating the coronavirus pandemic. The country's pandemic response was scrutinized. This period also brought into focus pre-existing shortcomings in the healthcare system and its governing bodies. Contextually, there is a paucity in literature on the experiences of healthcare providers and users. This study aimed to contribute information on COVID-19, with the intention of providing guidance on preparing for future infectious disease outbreaks. Methods: Cross sectional exploratory qualitative methodology was employed using semi-structured interviews and focus group discussions with community members (CM) and healthcare workers (HCW) from two South African study sites: (a) rural Bushbuckridge (run by Agincourt Health and Socio-Demographic Surveillance Site) and (b), Regions D and F in Johannesburg Metropole. Results: After interviewing 42 CMs and 43 HCWs, it emerged that mandated process changes while minimizing COVID-19 exposure, necessitated healthcare personnel focusing on critical care treatment at the expense of less acute ones. COVID-19 isolation protocols, extensive absenteeism and HCWs with advanced skills being perceived as more adept to treat COVID-19 patients contributed to HCWs experiencing higher workloads. Fears regarding contracting and transmitting COVID-19, suffering financial losses, and not being able to provide adequate advice to patients were recurrent themes. Dissemination of relevant information among healthcare facility personnel and communities suffered due to breakdowns in communication. Conclusion: Concessions and novel strategies to avail medication to patients had to be created. Since providence was lacking, government needs to formulate health intervention strategies that embrace health literacy, alternate methods of chronic medication dispensation, improved communication across health care platforms and the use of telehealth, to circumvent the threats of possible further infectious disease outbreaks.

The influence of smoking and HIV infection on pulmonary function.

Background: Prevalence of HIV, smoking, and pulmonary infections in South Africa are high. Objectives: We investigated the role of smoking and HIV status on lung function. Methods: This is a secondary analysis of a cross-sectional study conducted in South Africa. Data included demographics, pulmonary risk factors and a spirometry test to obtain the forced expiratory volume in one second (FEV1) and the ratio of FEV1/forced vital capacity (FVC). In the initial multivariable regression analysis, the effect of smoking on pulmonary function in HIV-positive adults was assessed. The analysis was repeated, assessing the influence of HIV status on lung function in both HIV-negative and HIV-positive smokers. The models were adjusted for age, sex, body mass index (BMI), time since HIV diagnosis, antiretroviral treatment (ART) use, occupational hazards, history of tuberculosis or pneumonia, indoor smoking and the presence of an indoor fireplace during childhood. Results: This study included 524 people living with HIV (PLWH, 66.7% female, mean age 40.9 years [s.d.; 9.4]) and 79 HIV-negative smokers (77.2% male, mean age 34.4 years [s.d.: 12.1]). Of the PLWH, 118 (22.5%) were past or current smokers and 406 (77.5%) were non-smokers. Smoking was not associated with changes in the FEV1 or FEV1/FVC ratio in multivariable regression analysis. In the second analysis, HIV status was also not associated with reduced pulmonary function following adjustment for confounders. Conclusion: Neither smoking nor being HIV-positive was associated with decreased pulmonary function in this relatively young population. These findings should be confirmed in a longitudinal study, including an older population.

Importance of testing the internal consistency and construct validity of the Pittsburgh Sleep Quality Index (PSQI) in study groups of day and night shift workers: Example of a sample of long-haul truck drivers in South Africa.

Irregular work times promote inconsistent completion of the Pittsburgh Sleep Quality Index (PSQI) among shift workers. We aimed to demonstrate the importance of testing the internal consistency and construct validity of the PSQI and of the Epworth Sleepiness Scale (ESS) by presenting the methodology in a sample of long-haul truckers in South Africa. Internal consistency of the questionnaires was assessed by Cronbach's alpha (defined as raw alpha≥0.70), and construct validity by factor analysis. 302 participants (49.3%) reported at least one night shift/week. Overall, the PSQI and ESS's alpha were 0.42 and 0.85, respectively. The factors explained 19.6% of 57.0% of the variance. The PSQI's alpha was 0.46 in night shift workers and 0.38 in non-night shift workers. In this occupational group, the PSQI must be used with caution. Testing the internal consistency and construct validity among the assessed population seems necessary. Sleep questionnaires adapted to shift workers should be preferred.

Usability and Clinical Performance Characteristics of the Asante HIV1/2 Test by Trained Users in Two African Sites.

HIV self-testing (HIVST) devices are acknowledged as having the potential to enable the acceleration of HIV diagnosis and linkage to care. How efficiently professional and trained users engaged with the Asante HIV-1/2 Oral Self-Test (Asante) (Sedia Biosciences, Portland, OR, USA), and the accuracy of the device in comparison to other HIV rapid diagnostic tests (RDT), was assessed to be able to guide the development and adoption of the device in Senegal and South Africa. Using convenience sampling, potential participants were recruited from catchment areas where HIV was prevalent. Trained users performed an HIV test on participants using an Oral HIVST. The professional user's interpretation of results was then measured against the results of various other RDTs. The South African study had 1652 participants and the Senegalese, 500. Most of the participants in each study were 18-35 years old. Senegal had a higher number of females (346/500, 69.2%) compared to South Africa (699/1662, 42.1%). Asante displayed very high sensitivity and specificity when tested against other devices. In the final enzyme-linked immunosorbent assay (ELISA) comparison, in South Africa, the sensitivity: specificity was 99.1:99.9% and in Senegal, 98.4:100.0%. Senegal further identified 53/63 (84.1%) with HIV-1, 8/63 (12.7) with HIV-2 and 2/63 (3.2%) with HIV-1/2 co-infections. Professional or trained users' interpretations of Asante results correlated strongly to results when using various RDTs, the ELISA assay and Western blot tests, making it a dependable HIV testing instrument.

Changes in Perceptions and Use of Mobile Technology and Health Communication in South Africa During the COVID-19 Lockdown: Cross-sectional Survey Study.

BACKGROUND: In late March 2020, South Africa implemented a 5-stage COVID-19 Risk Adjusted Strategy, which included a lockdown that required all residents to remain home to prevent the spread of COVID-19. Due to this lockdown, individuals have been forced to find and use alternatives for accomplishing tasks including shopping, socializing, working, and finding information, and many have turned to the internet and their mobile devices. OBJECTIVE: This study aimed to describe how South Africans consume and internalize information surrounding the COVID-19 outbreak in order to determine whether the COVID-19 lockdown and social isolation have influenced technology behavior, particularly in terms of health communication and information. METHODS: From June 24 to August 24, 2020, people in South Africa were invited to complete a survey through the Upinion mobile app, an online data collection resource. The survey collected information on demographics, and technology use during the lockdown, and COVID-19 knowledge. RESULTS: There were 405 participants, of which 296 (73.06%) were female. A total of 320 (79.01%) participants had a tertiary school education, 242 (59.75%) were single, and 173 (42.72%) had full-time employment. The lockdown forced 363 (89.63%) participants to use more technology, especially for work (n=140, 24.05%) and social media/communication (n=133, 22.85%). Security or privacy issues (n=46, 38.98%) and unfamiliarity with technology (n=32, 27.12%) were identified as the most common issues faced by the 127 (31.36%) participants who were unsure about using technology prior to the lockdown. Almost all participants (n=392, 96.79%) stated that they would continue using technology after the lockdown. Multimedia (n=215, 53.09%), mobile phone content (n=99, 24.44%), and health organizations and professionals (n=91, 22.47%) were the main sources of COVID-19 information. Most participants (n=282, 69.63%) felt that they had enough information. Two-thirds (n=275, 67.90%) of participants stated that they had used their mobile phones for health information before the lockdown, with web searches (n=109, 26.91%), social media (n=58, 14.32%), and government and institutional websites (n=52; 12.84%) serving as their main sources of information. Overall, the mean COVID-19 knowledge score was 8.8 (out of 10), and 335 (82.72%) had adequate knowledge (scored ≥8). Males were less likely to identify the correct transmission routes, and single participants were less likely to identify the signs and symptoms of the coronavirus. Tertiary school graduates were 4 times more likely to correctly identify the routes and 2 times more likely to identify how to stop the spread of the virus. People aged 43-56 years were 4 times more likely to identify how the coronavirus can be prevented, and participants ≥57 years were 2.6 times more likely to obtain a knowledge score of 10 when compared to those under 29 years of age. CONCLUSIONS: This study has shown that the COVID-19 lockdown has forced people to increase technology use, and people plan to continue using technology after the lockdown is lifted. Increased technology use was seen across a variety of fields; however, barriers including privacy, unfamiliarity, and data costs were identified. This population showed high COVID-19 knowledge, although the use of web searches and social media, instead of government and institutional websites, increases the potential for health misinformation to be spread.

A Lay-User Assessment of Hepatitis C Virus Self-Testing Device Usability and Interpretation in Johannesburg, South Africa.

Only 20% of people with hepatitis C virus (HCV) know their status. In low-income countries diagnosis is under 10%. Self-testing for HCV antibodies (HCVST) could expand the coverage of HCV testing services. Currently, there are no stringent regulatory authority (SRA) approved HCVSTs, therefore lay-user usability of three prototype kits was assessed. This was a cross-sectional observational study conducted with 171 (CareStart n = 60, Bioline n = 52, First Response n = 59) participants. Participants were given one of the three HCVST kits with only instructions for use (IFU) and asked to perform the test in front of a professional trained in rapid diagnostic tests (RDT). Usability indices were calculated based on the correctness of performing each step of the product-specific process followed by contrived results interpretation and a post-test interview. The usability index was 93.9% for CareStart, 90.7% for Bioline and 94.9% for First Response. Most errors were on incorrect handwashing, sample collection and transfer to the test device. An average of 93.1% of contrived results were correctly interpreted, with most errors related to interpreting invalid results. Most participants (n = 167) stated they would visit a clinic after a positive result. With negative results, nearly half (28/60 (46.7%)) stated they should condomize, while just over two-thirds of participants that used Bioline (35/52 (67.3%)) and First Response (38/59 (64.4%)) said they should re-test. Most participants (n = 162) found the devices easy to use. Participants liked that self-testing was fast, private and convenient, however there were some confusion with IFU steps and pictures, finger-pricking with the lancet, collecting blood after the finger-prick, and transferring the sample/buffer. Prototype HCVST kits exhibit high usability and result interpretation by lay-users, and should be considered for SRA approval.

Uptake of the Ithaka mobile application in Johannesburg, South Africa, for human immunodeficiency virus self-testing result reporting.

BACKGROUND: Human immunodeficiency virus self-testing (HIVST) can reduce facility-based HIV testing barriers; however, no proven applications exist with widespread uptake for self-reporting or linkage to care. Mobile health (mHealth) applications (apps) have shown high usability and feasibility scores, so Ithaka was developed for South Africans to self-report HIVST results outside clinical settings. OBJECTIVES: This study investigated the use of Ithaka as a support tool for HIVST users, specifically the ability to self-report results. METHOD: This cross-sectional study was conducted from November 2018 to June 2019. At existing HIVST distribution sites, individuals were given HIVST kits and then invited to use Ithaka. Participants could test at home and report their results through the app anytime. Ithaka tracked when people logged-on, registered, received counselling and reported results. Post-study surveys on user experience were also conducted. RESULTS: Of 751 participants, 531 (70.7%) logged onto the app, 412 (54.9%) registered, 295 (39.3%) received counselling and 168 (22.4%) self-reported results. Participants strongly agreed that Ithaka was useful and that it was easy to upload results. Forty-one participants completed a post-test survey, and 39/41 (95.1%) completed the app journey. Most participants (36/41;87.8%) had no challenges, although 2/41 (4.9%) cited perceived data costs, 2/41 (4.9%) difficulty uploading results and 1/41 (2.4%) language, as challenges. CONCLUSION: Despite the small sample size, this study has shown that HIVST participants under pragmatic conditions were willing and able to self-report results via the app, whilst also identifying areas of improvement for scaling up.

International citizen project to assess early stage adherence to public health measures for COVID-19 in South Africa.

INTRODUCTION: With over 500 000 infections and nearly 12 000 deaths, South Africa (SA) is the African epicenter of the current Coronavirus (COVID-19) pandemic. SA has implemented a 5-stage Risk-Adjusted Strategy which includes a phased national lockdown, requiring social distancing, frequent hand washing and wearing face masks. Strict adherence to this strategy is crucial to reducing COVID-19 transmission, flattening the curve, and preventing resurgence. As part of the 22-country International Citizens Project COVID-19 (ICPcovid), this study aimed to describe the SA adherence to the Risk-Adjusted Strategy and identify determinants of adherence. METHOD: During 24 April-15 May 2020, people were electronically invited, through social media platforms and a text blast, to complete an online survey, accessible via www.icpcovid.com. The survey investigated COVID-19 testing and preventative adherence measures, then used logistic regression analysis to identify predictors of adherence. RESULTS: There were 951 participants, with 731(76.9%) 25 to 54 years. Most (672;70.7%) were female, and 705(74.1%) had a university degree. Since the epidemic started, 529(55.6%) and 436(45.9%) participants stated they were eating healthier and taking more vitamins, respectively. Only 82(8.6%) had been COVID-19 tested, and 1(1.2%) tested positive. In public, 905(95.2%) socially distanced, however 99(10.4%) participants had recently attended meetings with over ten people. Regular hand washing was practiced by 907(95.4%) participants, 774(81.4%) wore face masks and 854(89.8%) stayed home when they experienced flu-like symptoms. The odds of adhering to the guidelines were lower among men versus women (AOR 0.72, 95% confidence interval [CI] = 0.528, 0.971) and those who had flu-like symptoms (AOR 0.42, 95% CI = 0.277, 0.628). In contrast, increased odds were reported for those who reported increased vitamin intake (AOR 1.37, 95% CI = 1.044,1.798), and were either cohabiting or married (AOR 1.39, 95% CI = 1.042,1.847). CONCLUSION: Despite high reported adherence, face mask use and symptomatic individuals not self-isolating, were areas for improvement. However, these factors cannot solely account for SA's increasing COVID-19 cases. Larger general population studies are needed to identify other adherence predictors for a strengthened SA COVID-19 response. While the government must continue to educate the entire population on preventative measures, provide personal protective equipment and stress the importance of adherence, there also needs to be implementation of prioritised prevention strategies for men and single individuals to address their demonstrated lower adherence.

Relationship between sleep disorders, HIV status and cardiovascular risk: cross-sectional study of long-haul truck drivers from Southern Africa.

OBJECTIVES: Long-haul truck drivers (TDs) may have lifestyles that promote cardiovascular disease (CVD), including diet, sleep and activity issues. Most studies conducted among truckers investigated the relationship between poor sleep and cardiometabolic health, but none assessed whether suspected obstructive sleep apnoea (OSA) and shortened sleep were associated with markers of cardiometabolic risk. We determined whether sleep disorders and circadian misalignment were associated with chronic inflammation and CVD risk in TDs from Southern Africa. METHODS: Participants were recruited at roadside wellness centres in Gauteng and Free State Provinces, South Africa. OSA risk was assessed using the Berlin Questionnaire, while sleep duration and sleep quality were assessed using items from the Pittsburgh Sleep Quality Index. Clinical information, neck circumference (NC), metabolic profile, elevated BP, HIV status and C-reactive protein (CRP) were collected. CVD risk was assessed using the Framingham Risk Score (FRS). RESULTS: Out of 575 participants aged on average 37.7 years, 17.2% were at OSA risk, 72.0% had elevated BP, 9.4% had HIV and 28.0% were obese. Mean sleep duration was 7.4±1.8 hours, and 49.6% reported working night shift at least once a week. Shortened sleep, OSA risk, age, body mass index, NC and years as full-time TD were associated with greater FRS independently of HIV status and night shift. Working night shift was associated with higher CRP levels in HIV+ compared with HIV- participants. CONCLUSIONS: Circadian misalignment in HIV, and OSA and short sleep duration in all truckers were associated with increased CVD risk. Truckers should be given careful attention in terms of health management and sleep education.

Working nights and lower leisure-time physical activity associate with chronic pain in Southern African long-distance truck drivers: A cross-sectional study.

BACKGROUND: In South Africa, the trucking industry employs over 70,000 people and the prevalence of chronic pain in this occupational group was reported at 10%. We investigated factors associated with chronic pain in truck drivers including mental health, physical activity, and sleep, as no study has done so. METHODS: Southern African male, long-distance truck drivers were recruited at truck stops in Gauteng and Free State Provinces, South Africa (n = 614). Chronic pain was defined as pain present for at least the last three months. Depressive symptoms were assessed with the Patient Health Questionnaire-9, post-traumatic stress disorder with the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), exposure to traumatic events with the Life Events Checklist-5 (LEC-5) and daytime sleepiness with the Epworth Sleepiness Scale. Sleep quality was measured on a four-point Likert scale. Leisure-time physical activity was measured using the Godin-Shephard leisure-time physical activity questionnaire. Associations between these factors, demographic factors and chronic pain were investigated. RESULTS: Multivariate analysis showed that working ≥ 2 nights/week (OR = 2.68, 95% CI = 1.55-4.68) was associated with chronic pain and physical activity was protective (OR = 0.97, 95% CI 0.95-0.98). In an exploratory analysis, greater depressive symptoms (p = 0.004), daytime sleepiness (p = 0.01) and worse sleep quality (p = 0.001) was associated with working ≥ 2 nights/week. Lower leisure-time physical activity was associated with worse sleep quality (p = 0.006), but not daytime sleepiness or depressive symptoms (p>0.05). CONCLUSIONS: There is a clear relationship between working nights and activity levels, and chronic pain, sleep quality, and depression in truck drivers.

Understanding adherence in virally suppressed and unsuppressed human immunodeficiency virus-positive urban patients on second-line antiretroviral treatment.

BACKGROUND: Understanding antiretroviral therapy (ART) adherence may assist in designing effective support interventions. OBJECTIVES: This study elicited perspectives on how to promote treatment adherence from virologically suppressed and unsuppressed patients receiving second-line ART. METHODS: This was a cross-sectional study conducted with randomly selected patients active on second-line ART, from five public health facilities in the Johannesburg inner city. Data were collected on demographics, clinical information, participant's experiences and ART knowledge. Virological failure was defined as exceeding 1000 copies/mL. RESULTS: The study sample comprised 149 participants; of which 47.7% (n = 71) were virally unsuppressed and 69.1% (n = 103) were women; the median age of the participants was 42 years (interquartile range [IQR] 36-47 years). Experiencing medication-related difficulties in taking second-line ART (p = 0.003), finding second-line regimen more difficult to take than a first-line regimen (p = 0.001) and experiencing side effects (p < 0.001) were all subjective predictors of virological failure. Participants' recommendations for improving adherence included the introduction of a single tablet regimen (31.6%, n = 55), reducing the dosage to once daily (26.4%, n = 46) and reducing the pill size for second-line regimen (4.0%, n = 7). CONCLUSION: The results of this study highlight the importance of improving patients' knowledge about adherence and motivation to continue ART use despite the persistence of side effects and difficulties with taking medication.

Evaluation of a mobile application to support HIV self-testing in Johannesburg, South Africa.

BACKGROUND: Human immunodeficiency virus self-testing (HIVST) reduces barriers associated with facility-based testing; however, no formal mechanism exists for users to self-report results or link to care. The AspectTM HIVST mobile application (app) was developed for use in South Africa. OBJECTIVES: This study evaluated the acceptability and feasibility of the AspectTM HIVST app for individuals from the inner city of Johannesburg. METHOD: This cross-sectional pilot, with a convenience sample of 300 adults, was conducted in July 2018. Participants were provided an OraQuick HIVST kit and a smartphone preloaded with the app, then asked to follow the in-app instructions for use (IFU) to complete the HIVST and upload results. Trained healthcare workers (HCWs) observed and recorded any deviations from the IFU, and conducted a post-test survey to assess acceptability. Feasibility was evaluated by the number of participants who agreed to participate, completed the self-test, and uploaded all information onto the app correctly. RESULTS: Most participants (98.7%) found the app easy to use. To reduce difficulties related to the IFU (26; 8.7%), participants suggested multimedia supplements (4; 1.3%), additional languages (4; 1.3%) and simplified instructions (5; 1.7%). All individuals approached, agreed to participate, 267 (89.0%) correctly completed all steps and 210 (78.7%) successfully captured all information on the app. Most errors (26; 8.7%) were testing errors and 1 (0.3%) was from the app sequence. Twelve (4.5%) errors were with test strip imaging and 72 (27.0%) discordances were with demographic information. CONCLUSION: Despite some challenges with IFU interpretation and data capture via the app, this pilot showed that the AspectTM HIVST app is an acceptable way to upload mobile HIVST results and demographic information to a central database.

Usability assessment of seven HIV self-test devices conducted with lay-users in Johannesburg, South Africa.

INTRODUCTION: The first 90 of the 90-90-90 initiative introduced by the World Health Organization(WHO) in 2015 requires 90% of people with HIV be aware of their status by 2020. In South Africa, conventional facility-based testing had reached 84.9% in 2018; innovative new methods, like HIV self-testing(HIVST) may close the testing gap. This study aimed to determine the usability of seven HIVST kits among untrained South Africans. METHODS: This cross-sectional study of 1400 adults in Johannesburg evaluated the usability of five blood fingerstick and two oral fluid HIVSTs, using WHO prequalification criteria, from June 2016 to June 2018. Participants were handed one kit, with no further information about the device or test procedure, and asked to perform the test in front of an observer. The observer used product-specific semi-structured questionnaires organized into a composite usability index(UI) using a HIVST process checklist, a contrived results interpretation and a post-test interview that expanded on participant experiences with the device and instructions-of-use(IFU). Participants were not tested themselves, but provided with contrived results to interpret. RESULTS: The average UI was 92.8%(84.2%-97.6%); the major difficulty was obtaining and transferring the specimen. Participants correctly interpreted 96.1% of the non-reactive/negative, 97.0% of the reactive/positive, 98.0% of the invalid and 79.9% of the weak positive results. Almost all participants(97.0%) stated they would visit a clinic or seek treatment for positive results; with negative results, half(50.6%) stated they should re-test in the next three months while one-third(36.1%) said they should condomize. Nearly all found the devices easy to use(96.6%), the IFUSs easy to understand(97.9%) and felt confident using the test unassisted(95.9%) but suggested improvements to packaging/IFUs to further increase usability; 19.9% preferred clinic-based testing to HIVST. CONCLUSION: The UI and interpretation of results was high and in-line with previous usability studies, suggesting that these kits are appropriate for use in the general, untrained and unsupervised public.

Hypertension in a rural community in South Africa: what they know, what they think they know and what they recommend.

BACKGROUND: Hypertension is one of the most important risk factors for cardiovascular disease and has a high prevalence in South Africa and other low- and middle-income countries. However, awareness of hypertension has been reported to be low. Health programmes can increase awareness of hypertension and its causes, but hinge on the knowledge and perception of the targeted community. Therefore, this study investigated knowledge on and perceptions about hypertension of community members in a rural area in Limpopo, South Africa with the aim to increase awareness of hypertension and cardiovascular disease in the local population. METHODS: Using a mixed methods study approach, 451 participants of the Ndlovu Cohort Study, attending a follow-up visit between August 2017 and January 2018, completed a questionnaire on cardiovascular risk perception. A knowledge score was calculated for all participants. Sixty participants were invited to participate in six focus group discussions, of which 56 participated. Audio recordings were transcribed verbatim, transcripts coded, and thematic analysis of the data undertaken to obtain an understanding of knowledge and perception of hypertension in the community. RESULTS: Most members of the community seemed to have intermediate (74.3%) or good (14.0%) knowledge of hypertension based on the knowledge score, and only 11.8% of the population had poor knowledge. The risk factors of hypertension seemed to be well known in the community. Poverty was identified as a major vulnerability in this community limiting choices for healthy lifestyles such as nutritious foods, recreational physical activity and accessing health care timely. Participants proposed community-based activities as an effective way to reach out to community members for prevention and management of hypertension. CONCLUSION: This study highlights the need for improved health promotion efforts to increase knowledge of hypertension in rural communities, and to address poverty as a major obstacle to healthy life-style choices.

Lipid levels, insulin resistance and cardiovascular risk over 96 weeks of antiretroviral therapy: a randomised controlled trial comparing low-dose stavudine and tenofovir.

BACKGROUND: HIV infection and antiretroviral treatment are associated with changes in lipid levels, insulin resistance and risk of cardiovascular disease (CVD). We investigated these changes in the first 96 weeks of treatment with low-dose stavudine or tenofovir regimens. METHODS: This is a secondary analysis of a double blind, randomised controlled trial performed in South-Africa, Uganda and India comparing low-dose stavudine (20 mg twice daily) with tenofovir in combination with efavirenz and lamivudine in antiretroviral-naïve adults (n = 1067) (Clinicaltrials.gov, NCT02670772). Over 96 weeks, data were collected on fasting lipids, glucose and insulin. Insulin resistance was assessed with the HOMA-IR index and 10-year CVD risk with the Framingham risk score (FRS). A generalized linear mixed model was used to estimate trends over time. RESULTS: Participants were on average 35.3 years old, 57.6% female and 91.8% Black African. All lipid levels increased following treatment initiation, with the sharpest increase in the first 24 weeks of treatment. The increase in all lipid subcomponents over 96 weeks was higher among those in the stavudine than the tenofovir group. Insulin resistance increased steadily with no difference detected between study groups. FRS rose from 1.90% (1.84-1.98%) at baseline to 2.06 (1.98-2.15%) at week 96 for the total group, with no difference between treatment arms (p = 0.144). Lipid changes were more marked in Indian than African participants. CONCLUSION: Lipid levels increased in both groups, with low-dose stavudine resulting in a worse lipid profile compared to tenofovir. Insulin resistance increased, with no difference between regimens. CVD risk increased over time and tended to increase more in the group on stavudine. The low CVD risk across both arms argues against routine lipid and glucose monitoring in the absence of other CVD risk factors. In high risk patients, monitoring may only be appropriate at least a year after treatment initiation.