Journal of the International AIDS Society

Because of its recent regulatory approval in southern and eastern Africa, CAB PrEP represents a scientific advancement with unknown implementation costs in most African countries. To our knowledge, this paper is the first study comparing PrEP costs in health facilities where clients had a choice between three PrEP methods. We collected and analyzed the direct service delivery costs for each method using the same costing approach and assumptions at three facilities in Lesotho and six facilities in Zimbabwe. On average, in Lesotho, the direct costs of providing CAB PrEP were $57.22 for an initiation visit and $54.20 for a refill visit (same PrEP product dose dispensed in both visit types), while the direct costs of oral PrEP were $22.47 (initiation visit with one month of PrEP dispensed) and $31.98 (refill visit dispensing a three-month dose of medication), and the direct costs of the dapivirine ring were $34.27 (initiation visit with one month of PrEP dispensed) and $50.70 (refill visit dispensing a three-month supply). In Zimbabwe, the average per-visit direct costs to provide CAB PrEP were $48.26 (initiation visit) and $47.40 (refill visit), to provide oral PrEP were $13.47 (initiation visit with one month of PrEP dispensed) and $21.78 (refill visit dispensing a three-month dose), and to provide the dapivirine ring were $42.56 (refill visit dispensing a three-month supply). Initiation visits for the dapivirine ring were not observed in Zimbabwe. At a time when national governments are creating budgets for the HIV response with decreased financial support from bilateral and multilateral partners, this paper will inform HIV prevention planning by providing critical client-level data from the healthcare provider perspective.

IntroductionDespite improvements in treatment for people living with HIV (PWH), adherence remains a challenge for many. In this study we aimed to identify preferences for daily pill or long-acting injectable (LAI) antiretroviral therapy (ART) and for possible treatment package features, among PWH enrolled in Ryan White HIV/AIDS Program Part A (RWPA) Medical Case Management (MCM) programs. MethodsParticipants were recruited from six MCM programs from across the New York RWPA eligible metropolitan area (the five boroughs of New York City and Rockland, Putman, and Westchester counties). We developed a discrete choice experiment (DCE) with four attributes: (1) Type of ART Medication (daily pills or LAI), (2) Service Location and Mode, (3) Support, and (4) Rewards. We used an alternative-specific design in which the levels for the last three attributes were dependent on levels within the first (Type of ART). Latent class multinomial logit analysis (LCA) was used for preference estimation and hypothesis-free investigation of preference heterogeneity. ResultsFrom June 2022 through January 2023, 200 New York RWPA MCM clients completed the DCE. We selected a two-group LCA solution. A majority of participants had a higher preference for LAI regimens compared to daily pills (n=114 [57%] versus n=86 [43%]). Those who preferred LAI ART were younger (median age 49 versus 58.5 years, p<0.001), less likely to identify as straight/heterosexual (69% versus 82%, p=0.03), and more likely to identify as Latino/a (54% versus 30%; p<0.001). Preferences for service locations/mode, supports, and rewards were similar across LCA groups. Participants who preferred LAI ART were more likely to have heard of LAI ART before the survey (59% versus 41%, p=0.012). Overall, only 4% of participants self-reported having tried LAI ART. ConclusionsAssessing preferences among groups under-represented in clinical trials is essential to effective and equitable real-world implementation of innovative treatment options. Our study found that there were distinct groups that differed in their preferred ART regimen type and that New York RWPA MCM clients had limited familiarity with LAI ART. To inform regimen selection, we began pilot-testing educational materials and a patient-provider decision-making tool in 2023.

BackgroundSix multi-month dispensing (6MMD) of antiretroviral therapy (ART) for HIV treatment clients has expanded rapidly in the past decade, but its effect on individual outcomes in routine (non-trial) care is still poorly documented and based on observational programmatic data. Malawi launched 6MMD in April 2019 and scaled-up implementation in 2020. We compared retention in care for clients who received 6MMD to those who did not using a target trial emulation (TTE) approach to minimize bias. MethodsWe used routine clinical data from Malawis Electronic Medical Record (EMR) system to identify ART clients eligible for 6MMD in 27 districts from 01/2020-12/2021. Eligible participants were non-pregnant adults ([&ge;]18 years), on ART for [&ge;]6 months, clinically stable as evidenced by a dispensing duration of 3 months (3MMD), and with no prior 6MMD exposure. We created four six-month trials, defined eligibility at the start of each trial period, and classified participants as either receiving 6MMD or non-6MMD (dispensing duration of 1-3 months) within the six-month interval. Follow-up started at 6MMD enrollment for the 6MMD arm or the first visit in the trial enrollment period for the non-6MMD arm. Retention at 12 and 24 months was defined as having a clinic visit within 12-24 (trial 1-4) and 24-36 (trial 1-2) months from trial enrollment. Using an intention-to-treat approach, we estimated adjusted risk differences (aRD) with 95% confidence intervals (CI) using a Poisson regression model with an identity link function and robust standard errors adjusting for age, sex, duration on ART, facility type, regional location, WHO clinical stage at ART initiation. Pooled RDs were estimated by accounting for within-subject variation in a Poisson regression model using data from all trials. ResultsOf the 159,801 unique patients eligible for this study (65% female, median age 37 years), 74% (118,910) were ever enrolled in 6MMD. Retention rates at 12 months (trials 1-4) and 24 months (trials 1-2) were consistently higher in the 6MMD group than the non-6MMD group. The pooled risk for retention was 3% higher in the 6MMD vs non-6MMD groups (aRD 3.0%; 95% CI: 2.8%-3.3%) at 12 months and 2.0% higher (aRD: 2.0%; 95% CI: 1.7%-2.4%) at 24 months. ConclusionsWe observed slightly higher retention in care rates in Malawi at 12 and 24 months among patients on 6MMD compared to those receiving shorter medication dispensing intervals. Future work to assess the impact of 6MMD on visit burden and resource use would offer a comprehensive view of the benefits to both ART clients and the health system.

IntroductionFor differentiated models of care (DMOCs) that support client-centred HIV treatment (ART) in South Africa, a key next step in achieving integration is aligning clinic visits and medication dispensing for HIV treatment with other health needs like family planning. We assessed alignment between ART medication and family planning supply collection visits among DMOCs in South Africa. MethodsWe analysed self-reported data collected between September-December 2024 from women living with HIV (18-49 years, on ART [&ge;]6 months) at 24 public healthcare facilities in four provinces (Gauteng, Mpumalanga, KwaZulu-Natal, and Eastern Cape). Participants were enrolled from four service delivery models: conventional care not eligible for DMOC (CN), conventional care eligible for DMOC but not enrolled (CE), facility pickup points (FAC-PuP), and external pickup points (EXT-PuP). Surveys assessed contraceptive use, visit alignment for injectable (Depo-Provera & Nur-Isterate) and oral contraceptive users, and how misaligned visits affected family planning adherence. ResultsAmong 843 eligible women, 57% (460/843) reported current contraception use, with Depo-Provera being the most common (44%). Contraceptives users were younger (median 35 vs 38 years) and had slightly less ART experience (median 7 vs 8 years) than non-users. Contraceptive use varied by DMOC: CN (52%), CE (60%), FAC-PuP (63%), and EXT-PuP (50%). Half (131/260) of women using oral contraceptives or injectables collected their contraceptive and ART products on different days, with EXT-PuP showing the lowest level of alignment. Primary reasons for non-use were personal choice and beliefs (38%), followed by pregnancy-related factors (26%). Analysis of unmet family planning need in a subsample of 299 women found 22% had unmet need. ConclusionThe findings reveal a high proportion of misalignment between ART and family planning services across models of care. Aligning ART and family-planning guidelines and services will promote ART and contraceptive adherence and reduce the burden on clients, maintaining the benefits of differentiated models and promoting integration of multi-condition service delivery.

Background: Retention to care and viral load suppression are essential components for effective HIV management, particularly among adolescents and young adults aged 15-24 years, who remain vulnerable to treatment challenges. This study aimed to assess factors associated with poor retention in care and viral load suppression among young people receiving antiretroviral therapy (ART) at Mpilo Centre of Excellence (MCoE) in Bulawayo, Zimbabwe, with the objective to guide youth-friendly interventions and improve health outcomes. Methods: A mixed methods cross-sectional study was conducted involving 110 HIV-positive youths aged 15-24 years on ART, recruited through systematic sampling and surveyed between November and December 2024. Data was collected using structured questionnaires, focus group discussions, in-depth interviews, and key informant interviews. Quantitative data were analyzed using descriptive statistics and logistic regression models to identify factors linked to viral load suppression, while qualitative data underwent thematic analysis. Results: Viral load suppression was achieved by 68.19% of participants, who met the viral suppression criterion of <50 copies/ml. Analysis identified several significant predictors via multivariable logistic regression. Younger adolescents (15-19 years) had lower odds of achieving suppression compared to older youths (20-24 years) (Adjusted Odds Ratio [AOR]: 0.81; 95% Confidence Interval [CI]: 0.67-0.97; p=0.041), while female participants demonstrated higher suppression rates than males (AOR: 0.43; 95% CI: 0.21-0.96; p=0.032). Absence of adherence challenges to ART emerged as a strong predictor of suppression (AOR: 0.12; 95% CI: 0.03-0.72; p=0.018), and perceived lack of clinical staff support was associated with a threefold higher risk of unsuppressed viral load (AOR: 3.01; 95% CI: 1.34-7.69; p=0.046). Lower treatment self-efficacy negatively impacted suppression odds (AOR: 2.65; 95% CI: 1.11-7.83; p=0.046), and lack of friend support for clinic visits reduced the likelihood of suppression (AOR: 0.31; 95% CI: 0.09-0.89; p=0.001). Qualitative findings confirmed that persistent barriers--including stigma, limited family support, economic hardship, school and work commitments--compromised both retention and adherence among adolescents and young adults. Conclusion: Younger age, male sex, ART adherence challenges, lack of clinical staff support, and lower treatment self-efficacy were significantly associated with poor viral suppression among 15-24-year-olds at Mpilo Centre of Excellence. These findings underscore the need for tailored adolescent- and youth-friendly services, enhanced adherence support, and improved treatment literacy to strengthen retention in care and viral suppression. Addressing these factors is critical for advancing progress towards UNAIDS 95-95-95 targets and reducing HIV transmission among Zimbabwean youth.

Introduction Understanding provider preferences for the design of HIV treatment packages could enhance the implementation of programs to support the adoption of long-acting injectable antiretroviral therapy (LAI ART) by people living with HIV who are interested in initiating this treatment modality. Methods We recruited providers from New York City (NYC), Rockland, Putman, and Westchester County Ryan White Part A Medical Case Management (MCM) programs to complete a discrete choice experiment (DCE) containing twelve tasks with two alternatives and an opt-out option, with additional survey questions about implementation readiness and choice motivations. The alternatives included four attributes--Type of ART Medication (monthly or bimonthly LAI ART), Service Location and Mode, Support for Clients, and Rewards for Clients--with 2-4 levels each. We ran latent class multinomial logit analyses (LCA) with 1-5 classes to estimate preferences and explore hypothesis-free preference heterogeneity. We estimated attribute influence using relative importances and preferences using zero-centered part-worth utilities for each level. Results One hundred seventy-seven providers completed the survey (July 2022-January 2023). About half (52%) were 40-59 years old, 72% identified as women, and the plurality (41%) identified as Latino/a. We chose the two-group LCA solution. Bimonthly LAI ART was preferred over monthly LAI ART overall and in both groups. Group 1 (n=45) preferred more traditional adherence supports (e.g., injections at the clinic by appointment, injection appointment reminders) whereas Group 2 (n=132) preferred more client-centered supports (e.g., injections at home by appointment, free transportation to injection appointments if at a clinic). Both groups preferred higher monetary value gift cards for clients for every on-time injection. The top-ranking motivations indicated that participants prioritized patient convenience over job satisfaction and administrative or financial feasibility for the agency. The scores for all implementation measures indicate readiness to implement LAI ART in both groups. Conclusions Our implementation science-focused study suggests that providers of MCM services in NYC and surrounding counties are motivated to offer services to support clients' access and adherence to LAI ART. More work is needed to understand how programs have, in fact, integrated supports for LAI ART into their services.

BackgroundSustained retention in HIV care is essential for achieving durable viral suppression and controlling the HIV epidemic. Loss to follow-up (LTFU) remains a persistent challenge in sub-Saharan Africa and shows substantial geographic variation. However, nationally representative analyses of routine monitoring data remain limited. Pharmacy refill data provide a scalable and objective approach for identifying individuals at risk of disengaging from care. We assessed the magnitude, spatial distribution, and predictors of LTFU among people living with HIV (PLHIV) receiving antiretroviral therapy (ART) across 26 mainland regions of Tanzania. MethodsWe conducted a retrospective cohort analysis using routinely collected program data from the National Care and Treatment Clinic (CTC-2) database of PLHIV receiving ART in Tanzania between 2017 and 2021. LTFU was defined as no recorded clinic visit for [&ge;]180 days after the last scheduled appointment, consistent with monitoring definitions used by the National AIDS and Sexually Transmitted Infections Control Programme (NASHCoP). Pharmacy refill adherence was calculated longitudinally and categorized as good ([&ge;]85%) or poor (<85%). Regional and district-level patterns were visualized using geospatial mapping. Multivariable logistic regression models were used to identify predictors of LTFU. ResultsA total of 52,828 PLHIV were included in the study, representing all 26 mainland regions of Tanzania. Overall, 26.6% were classified as LTFU during follow-up, with marked regional variation. The highest proportional LTFU was observed in Dar es Salaam (33.2%), followed by Njombe (32.9%) and Geita (32.7%), while the lowest was recorded in Mwanza (19.1%) and Iringa (20.3%). Good pharmacy refill adherence ([&ge;]85%) was strongly associated with lower odds of LTFU and remained the most robust independent predictor after adjustment (adjusted odds ratio [aOR] 0.34; 95% confidence interval [CI] 0.32-0.35). District-level analyses revealed substantial within-region heterogeneity, identifying localized clusters of elevated attrition not apparent in regional aggregates. ConclusionLTFU remains a major challenge to sustaining effective ART delivery in Tanzania. Pharmacy refill adherence may serve as a practical early indicator for identifying individuals at risk of disengagement from HIV care. Integrating refill-based monitoring with spatially informed analysis may support targeted retention strategies within routine HIV treatment programs.

BackgroundSustained retention in care supports continuous access to antiretroviral therapy, routine clinical monitoring, and long-term viral suppression. ObjectiveTo compare the effectiveness of interventions for improving retention in care among people living with HIV (PLHIV). DesignSystematic review and network meta-analysis Data sourcesPubMed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Library from 1995 to December 2024. Eligibility criteriaRandomised controlled trials (RCTs) evaluating interventions to improve retention in care, viral load suppression, or quality of life (QoL) among PLHIV, compared with standard of care (SoC) or other interventions. Data extraction and synthesisPairs of reviewers independently screened studies, extracted data, and assessed risk of bias using ROBUST-RCT. We conducted a fixed-effect frequentist network meta-analysis and rated interventions categories relative to SoC based on effect estimates effects and the certainty of evidence.. Dichotomous outcomes were summarized as odds ratios (ORs) with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) with 95% CI. ResultsEighty-four trials enrolling 107 137 PLHIV evaluated 13 intervention categories. For retention in care, five interventions supported by moderate or high certainty evidence proved superior to SoC: multi-month dispensing (OR 2.02, 95% CI 1.32 to 3.09), task shifting (OR 1.94, 95% CI 1.42 to 2.66), differentiated service delivery (OR 1.47, 95% CI 1.22 to 1.76), behavioural counselling (OR 1.36, 95% CI 1.21 to 1.54), and supportive interventions (OR 1.31, 95% CI 1.11 to 1.55). For viral load suppression, two interventions supported by moderate or high certainty evidence proved superior to SoC: task shifting (OR 2.07, 95% CI 1.25 to 3.43) and behavioural counselling (OR 1.34, 95% CI 1.11 to 1.67). Across outcomes, no intervention demonstrated convincing superiority over other active interventions. ConclusionsAmong 13 intervention categories, only a subset provided moderate or high-certainty evidence of superiority to the standard of care, and no superiority to other interventions. Persistent evidence gaps for key populations, diverse settings, and long-term outcomes support the need for context-sensitive and patient-centred interventions. RegistrationPROSPERO CRD42024589177 Strengths and limitations of this study[tpltrtarr] This systematic review followed Cochrane methods and was reported in accordance with PRISMA-NMA guidelines. [tpltrtarr]The network meta-analysis integrated direct and indirect evidence to compare multiple intervention categories within a single framework. [tpltrtarr]Risk of bias and certainty of evidence were assessed using ROBUST-RCT and the GRADE approach for network meta-analysis, respectively. [tpltrtarr]Some networks were sparse, and limited representation of key populations and long-term follow-up constrained the strength and generalisability of inferences.

BackgroundLoss to follow-up (LTFU) undermines the success of antiretroviral therapy (ART) programs, especially in high HIV prevalence regions like Njombe, Tanzania. Understanding factors influencing LTFU is critical to enhance patient retention. AimTo assess the prevalence and predictors of LTFU among people living with HIV (PLHIV) receiving ART in Njombe, Tanzania, from 2017 to 2021 MethodsWe conducted a retrospective cohort study using the National Care and Treatment Clinic (CTC2) database, defining LTFU as absence from care for 180 days or more. Logistic regression identified factors associated with LTFU. Data were cleaned using Microsoft Excel and analyzed using IBM SPSS Statistics version 26. Descriptive statistics were used to summarize demographic and clinical characteristics, and logistic regression was used to identify independent predictors of LTFU ResultsOf the 37,642 PLHIV initiated on ART, 13,411 (35.6%) were LTFU during the five-year study period. The highest annual incidence of LTFU occurred in 2020 (n = 4,069), coinciding with the onset of the COVID-19 pandemic. District-level disparities were substantial: Wangingombe recorded the highest disengagement prevalence (46.7%), while Makete recorded the lowest (23.7%). Multivariable analysis revealed that gender and age were not independent predictors of attrition (p > 0.05). However, significant associations with LTFU were observed for lower pharmacy refill adherence, marital status (single and divorced), and district of residence. Notably, patients in Wangingombe had more than double the odds of LTFU compared to those in Njombe (AOR 2.09; 95% CI: 1.95-2.24), whereas the 2021 initiation cohort demonstrated a significantly lower risk of disengagement (AOR 0.25; 95% CI: 0.22-0.28). ConclusionLTFU remains a critical challenge in the Njombe Region. Targeted interventions, including strengthened pharmacy refill monitoring, district-specific strategies, and psychosocial support for PLHIV, are essential to improve retention and sustain progress toward national HIV treatment goals.

IntroductionSustaining long-term viral suppression among people living with HIV (PLHIV) remains a major public health challenge in sub-Saharan Africa, despite widespread access to antiretroviral therapy (ART). Evidence on time to first-line ART failure and its predictors at a national scale remains limited, particularly for dolutegravir (DTG)-based regimens. We aimed to estimate the time to first-line ART failure and identify associated predictors among PLHIV in Tanzania using national programmatic data. MethodsWe conducted a retrospective cohort study using routinely collected data from the National Care and Treatment Clinic database (CTC-2) in Tanzania. The analysis included PLHIV aged [&ge;]11 years who initiated first-line ART between January 2017 and December 2021 and had at least six months of follow-up. Time to first-line ART failure was defined as the duration from ART initiation to the first documented virological failure (viral load [&ge;]1,000 copies/mL). Kaplan-Meier methods were used to estimate failure-free survival, and Cox proportional hazards models were used to identify predictors of failure. Non-proportional hazards for DTG-based regimens were addressed using an extended Cox model with a time-varying coefficient. ResultsThe final analytic cohort comprised 36,764 individuals and 789 first-line treatment failure events. Median follow-up time varied across regimen groups. Failure-free survival differed significantly by regimen anchor (log-rank p<0.001). In multivariable Cox models, age and gender were significantly associated with treatment failure. DTG-based regimens demonstrated a time-varying effect: compared with non-DTG regimens, DTG was associated with a substantially lower hazard of failure early after initiation, with the protective effect attenuating over time. Estimated hazard ratios for DTG versus non-DTG regimens were 0.37, 0.67, and 1.22 at 6, 12, and 24 months of follow-up, respectively. ConclusionsIn this large national cohort, the risk of first-line ART failure varied by regimen and patient characteristics. DTG-based regimens showed strong early protection against failure, but this effect diminished over time, highlighting the importance of continued virological monitoring after ART initiation. Time-to-event analyses using routine programmatic data provide important evidence for optimizing ART delivery and informing HIV programme decisions in Tanzania and similar settings.

BackgroundLong-acting injectable HIV pre-exposure prophylaxis (PrEP), including Lenacapavir, has the potential to accelerate HIV incidence declines in eastern and southern Africa (ESA). However, high product and delivery costs and constrained budgets necessitate efficient prioritization strategies to maximize impact and achieve cost-effectiveness. MethodsWe used district-level HIV incidence estimates published by UNAIDS to estimate the direct health and economic impact of prioritizing Lenacapavir delivery according to geography, age, and sex across 837 districts in 11 high-burden ESA countries. Infections and disability-adjusted life years (DALY) averted, number needed to treat (NNT), cost per DALY averted, and price thresholds to achieve cost-effectiveness were estimated across geographic prioritization scenarios. Cost-effectiveness was assessed against a $500 per DALY averted threshold, assuming $5,000 discounted lifetime HIV treatment costs and 10 DALYs per HIV infection. Sensitivity analyses varied Lenacapavir costs (commodities + delivery) per person per year (pppy) ($125 versus $55), DALYs per HIV infection (7.5), and the risk differentiation among those who uptake long-acting PrEP. ResultsHIV incidence varied substantially across ESA, with 50% of new infections in districts containing less than 20% of at-risk adults. Lenacapavir cost-effectiveness varied accordingly, with high-incidence districts exhibiting substantially lower NNT and higher price thresholds for cost-effective delivery. In high-incidence districts, [>5/1,000 person-years (py)], of South Africa, Mozambique, Lesotho, and eSwatini, Lenacapavir would be cost-effective at $50-100 pppy. In South Africa, at annual cost $55 pppy, Lenacapavir was cost-effective in all 52 districts when provided to women aged 15-24 years with incidence exceeding twice the district average and could reach approximately 18-20% of new infections while covering 4% of the full HIV-negative adult population aged 15-49 years. Geographically optimized prioritization in South Africa with minimal age and risk-group stratification achieved efficiency comparable to country-level prioritization to high-risk groups and key populations ([~]20% incidence reduction with 3-5% coverage). Impact and cost-effectiveness were sensitive to assumptions about risk heterogeneity. ConclusionsLenacapavir impact and cost-effectiveness varies substantially across geographic settings, driven primarily by variation in HIV incidence. Simple incidence-based models can identify where universal provision to certain demographic groups is both impactful and cost-effective, particularly in high-incidence districts and age groups.

BackgroundRoutine viral load monitoring is central to assessing treatment effectiveness in HIV care, and dolutegravir (DTG)-based regimens are now preferred in many treatment programmes. However, national routine data analyses comparing 48-week viral load suppression across antiretroviral therapy initiation regimens in Tanzania remain limited. MethodsWe conducted a retrospective cohort analysis using routinely collected HIV programme data from Tanzanias National AIDS, STIs and Hepatitis Control Programme database. After de-duplication and data processing, the working analysis warehouse contained 49,547 patients and 1,008,137 visits. The primary analysis included 6,991 patients with a valid viral load measured 48 weeks after initiation of antiretroviral therapy. Viral suppression was defined as a viral load <1,000 copies/mL. We compared suppression between DTG-based and non-DTG-based initiation groups and across individual initiation regimens. Treatment change episodes and early DTG switching patterns were summarized as secondary analyses. ResultsOf the 6,991 included patients, 6,113 (87.4%) achieved viral load suppression at 48 weeks. Suppression was higher among DTG initiators than non-DTG initiators (917/1,000, 91.7% vs. 5,196/5,991, 86.7%). TDF+3TC+EFV was the most common non-DTG initiation regimen, whereas TDF+3TC+DTG was the most common regimen among DTG initiators. ConclusionsViral suppression at 48 weeks was high overall but was higher among patients initiated on DTG-based regimens than among those initiated on non-DTG regimens. By anchoring outcomes to a fixed post-initiation time point, this study complements existing Tanzanian evidence on viral load testing uptake and geographic variation. It provides regimen-specific insights into the effectiveness of early treatment under routine programme conditions.

BackgroundRetention in HIV care is associated with higher rates of antiretroviral treatment adherence and viral suppression, as well as lower risk of AIDS-related morbidity and mortality. However, the multidimensional nature of retention complicates measurement standardization, limiting comparability and global evaluation. This study explored how HIV stakeholders define and assess retention, aiming to develop a patient-centred and conceptually robust understanding to inform research and practice. MethodsWe conducted a qualitative study using Interpretive Description (ID) methodology, an applied qualitative approach designed to generate practice-relevant knowledge in health research. We purposively sampled 20 stakeholders representing diverse areas of expertise and geographic regions across World Bank country income classifications. We conducted, video-recorded, and transcribed in-depth, semi-structured interviews. Using constant comparative analysis (CCA), we identified recurring, convergent, and contradictory patterns. ResultsThe analysis identified five overarching themes. The first two, exploratory themes, included: Patient-Centred Understanding of Retention in HIV Care, which captured how stakeholders conceptualized retention in their respective contexts, and Operationalization of Retention Measures, which explored the key components used to measure retention. The next two, explanatory themes, included Purpose-Driven Definitions of Retention, which described how retention measures were selected based on their intended use; and Building Capacity through Shared Understanding and Integrated Action, which emphasized retention as a cyclical, interconnected process dependent on collaboration between patients and health systems. The final, prescriptive theme, Advancements Shaping Retention, reflected stakeholders shared vision of improving retention through innovations in HIV treatment and technology. ConclusionsThe findings suggest that stakeholders operationalize retention measures in line with specific objectives and individual health goals, while remaining attentive to contextual realities. Retention measures should remain flexible and patient-centred, rather than relying on a single rigid standard.

Background Interruptions in HIV care pose a major challenge to achieving HIV control goals in many countries, with 30% of clients who initiate antiretroviral therapy (ART) in South Africa experiencing an interruption of >28 days during their first six months on treatment. South Africa introduced revised guidelines in 2023 to improve outcomes during this early treatment period, but guideline compliance remains incomplete and gaps in the support provided to both clients and providers to optimize service delivery and health outcomes. Protocol BRIDGE (Behavioral Risk Identification and Decision Guidance for Engagement) is a mixed-methods evaluation of a package of light-touch, low-cost interventions aimed at improving the experiences of both clients and providers of care, increasing compliance with the 2023 guidelines, supporting clients to remain in care, and ultimately reducing the incidence of missed visits during the early treatment period. Components of the BRIDGE Retention Toolkit include an intervention navigator to help clients self-assess areas of vulnerability for disengagement from care and identify appropriate interventions; client roadmap to explain the treatment journey for the early treatment period; WhatsApp-based counseling tool for clients; guideline reference for providers; and tracing job aids. The tookit will be piloted at 6-8 public sector primary health facilities for a one-month period. The primary outcome will be the probability of returning less than 28 days late for the next scheduled clinic visit, assessed using electronic medical record data for the pilot and comparison sites. Pilot outcomes will be compared to both their own probabilities prior to the pilot and to probabilities from comparable non-pilot facilities. Implementation outcomes to be assessed using qualitative interview data from both clients and providers will include reach, implementation fidelity, adoption (uptake), costs, feasibility, appropriateness, and acceptability. Discussion The evaluation will assess the implementation and preliminary effectiveness of a set of interventions designed to improve client outcomes during the early HIV treatment period. If some or all of the BRIDGE tools are found to be helpful and/or are associated with a reduction in missed clinic visits, they will comprise a readily scalable and affordable intervention to help address a major barrier in large-scale HIV treatment programs.

HIV testing remains the primary entry point to HIV prevention, treatment, and care. Although Zambia has made substantial progress in its HIV response, men remain less consistently reached by HIV testing services. This study assessed trends and determinants of HIV testing uptake among men aged 15-59 years in Zambia using repeated nationally representative survey data. We pooled mens data from the Zambia Demographic and Health Surveys (ZDHS) conducted in 2007, 2013/14, 2018, and 2024. The outcome was HIV testing uptake, defined as ever tested for HIV and received results (DHS variable mv781). Analyses accounted for the complex survey design using sampling weights in Stata 14.2. Trends were examined using weighted proportions and design-adjusted chi-square tests. Determinants were assessed using multilevel logistic regression with men nested within clusters, reporting adjusted odds ratios (AORs) and 95% confidence intervals (CIs). HIV testing uptake increased markedly from 20.7% (2007) to 62.9% (2013/14) and peaked at 77.4% (2018), with a modest decline in 2024 (73.5%); differences across survey years were statistically significant (p<0.05). In the fully adjusted model, survey year remained a strong predictor of testing compared with 2007 (2013/14 AOR 6.91, 95% CI 5.62-8.49; 2018 AOR 13.85, 95% CI 11.21-17.12; 2024 AOR 7.24, 95% CI 5.86-8.95). Older age was associated with higher odds of testing (25-34 AOR 3.51; 35-49 AOR 3.08; 50-59 AOR 1.65 vs 15-24). Rural residence was associated with lower testing (AOR 0.82, 95% CI 0.72-0.93). Higher education showed a strong gradient (primary AOR 1.55; secondary/higher AOR 4.19 vs none). Married men (AOR 4.33, 95% CI 3.56-5.27) and employed men (AOR 1.32, 95% CI 1.17-1.49) had higher odds of testing. Significant regional differences persisted after adjustment. HIV testing uptake among men in Zambia rose substantially from 2007 to 2018 and remained high in 2024, though gaps persisted among younger men, rural residents, and selected provinces. Targeted, male-friendly strategies especially for younger and rural men and geographically tailored programming are needed to sustain gains and reduce inequities in HIV testing.

COVID-19 disrupted global health service delivery, particularly among children and adolescents living with HIV (CALHIV), increasing the risk of poor treatment adherence. This study assessed the impact of the COVID-19 pandemic on WHO-recommended early warning indicators (EWIs) of HIV drug resistance (HIVDR) among CALHIV. We conducted a descriptive, longitudinal, retrospective study among children (0-9 years) and adolescents (10-19 years) receiving antiretroviral therapy (ART) in five health facilities in the Littoral region of Cameroon. Seven EWIs were monitored: ART attrition, viral load (VL) suppression, VL coverage, appropriate second VL, ARV medicine stock-outs, antiretroviral drug refills at the pharmacy, and appropriate switch to second-line ART. EWI were collected from January 2018 to December 2021 and classified as "poor," "fair," or "desirable" according to WHO criteria. Trend analyses were performed using Pearsons Chi-squared test with Yates correction in R (version 4.1.1). In 2021, 817 participants were included, comprising 214 children and 603 adolescents. Overall performance was poor for most EWIs in both age groups, except for ART attrition and VL coverage, which showed desirable performance across years. A slight improvement in most indicators was observed between 2018 and 2019, followed by a significant decline in 2020 (p<0.001), coinciding with strict COVID-19 restrictions, and a subsequent improvement in 2021 (p<0.01) as mitigation measures were eased. Despite this recovery, children consistently experienced worse outcomes, including higher ART attrition (9.4% vs 4.4%, p<0.05), lower VL suppression (75.3% vs 82.1%, p<0.05), and poorer access to confirmatory VL testing (15.1% vs 69.5%, p<0.001). Overall, the COVID-19 pandemic negatively affected HIV service delivery during its early phase, although the health system demonstrated adaptive capacity one year later. Targeted public health actions are therefore needed to prevent their long-term effects and improve treatment outcomes in this vulnerable population, especially among children.

BackgroundIn trials, three-month weekly rifapentine and isoniazid (3HP) showed higher adherence and completion than the six-month daily isoniazid (6H) regimen for TB preventive treatment (TPT). However, programmatic outcome data remain limited. MethodologyWe evaluated the TPT cascade among people with HIV (PWH) aged >15 years newly enrolled in HIV care in western Kenya. Initiation and completion of 6H (Jan to Sept 2022) were compared to 3HP (Oct 2022-Sept 2023) using Chi-square tests. Correlates of non-initiation and non-completion were assessed using Poisson regression with generalized linear models. Mortality within 24 months was evaluated using Cox proportional hazards regression. ResultsOf 1,930 PWH (median age 33 years [IQR=27-41]), 65.8% were female, and 19.5% had AHD at enrolment. Overall, 1,922 (99.6%) were screened for active TB, of whom 1,790 (97.5%) were TPT-eligible; 1577 (88.1%) of these initiated TPT. TPT initiation was higher with 3HP than 6H (89.8% vs. 84.2%; p<0.001). TPT completion was similar for 3HP and 6H (89.2% vs. 88.8% p=0.77). TB incidence (per 1,000 person-months) was lower among TPT-completers (0.22; 95% CI 0.15-0.35) than those who neither initiated (4.25; 95% CI 1.77-10.23) nor completed TPT (3.75; 95% CI 2.49-5.64). AHD was associated with higher risk of TPT non-initiation (aRR=2.14; 95% CI 1.59-2.87) and non-completion of both 6H (aRR=2.56; 95% CI: 1.55-4.23) and 3HP (aRR=1.68; 95% CI 1.07-2.63). Conclusions3HP increased TPT initiation but did not improve completion rates compared to 6H. Targeted interventions are needed to support 3HP completion, particularly in PWH with AHD Key pointsWe compared 3HP and 6H for TB prevention in people with HIV in western Kenya. 3HP led to better initiation and both had high completion rates. Advanced HIV disease affected participation and non-completers faced significant mortality.

IntroductionHIV testing for children of women living with HIV (WLHIV) is an efficient method of diagnosing HIV in children. We analyzed pooled data from 13 Population-based HIV Impact Assessments (PHIA) conducted from 2015 through 2019 to determine the gap in diagnosing HIV in children of WLHIV. MethodsIn each PHIA, children younger than 15 years in a subset of households were sampled for HIV testing. Mother-reported responses on childs status were linked to maternal interviews and biomarker data. Analysis was restricted to children whose mothers were alive, older than 15 years and aware of their HIV-positive status prior to the survey. We calculated weighted proportions of children who were never previously tested and proportion of children living with HIV (CLHIV) with no evidence of antiretroviral treatment (ART) use (categorized as newly diagnosed). Survey weights were pooled across all PHIAs to account for survey design and nonresponse. ResultsOf 4,234 WLHIV, 3,436 were aware of their HIV status and had at least one child (n=6,173) for whom responses were obtained. Of the 6,173 children, 43.5% (n=2,371) were reported as never been tested. Overall, 5,500 children provided blood for HIV testing during the survey. Newly diagnosed test positivity was 1.7% (90/5,191); 2.9% (61/2,120) among those with reported unknown HIV status and 0.9% (29/3,071) among those with reported HIV negative status. Among children with reported HIV positive status, 94.5% were confirmed by survey testing and of these, 91% had antiretrovirals (ARVs) detected. ConclusionsOver 40% of children of WLHIV who were aware of their HIV positive status had never been tested for HIV. HIV positivity ranged between 0.9% to 2.9% while 9.0% of children known to be HIV positive were not on ART. The study calls for renewed efforts to enhance testing of children and treatment linkage for those diagnosed with HIV.

BackgroundAdolescents and young adults with perinatally acquired HIV (APHIV) face complex psychosocial and structural challenges that may undermine resilience, a modifiable psychosocial determinant of treatment engagement, and health outcomes. Evidence on peer-led interventions targeting resilience among APHIV in South Asia remains limited. We evaluated resilience and its correlates among participants in the ImPossible Fellowship, a peer-led mentorship intervention in India. MethodsWe conducted a cross-sectional evaluation of 216 APHIV following completion of the 24-month ImPossible Fellowship in southern India in 2024. Surveys administered by trained youth investigators assessed sociodemographic, educational, and clinical characteristics. Resilience was measured using the Child and Youth Resilience Measure-Revised (CYRM-R), a validated multidimensional tool capturing personal and relational resilience dimensions. Low resilience was defined as CYRM-R threshold score [&le;]33rd percentile. Multivariate logistic regression identified independent correlates of low resilience, and sensitivity analyses explored alternative CYRM-R thresholds. ResultsParticipants had a mean age of 18.7 years (range 9-24); 50% had no surviving parents, and 43% lived in child care institutions. Median resilience scores were high (74, Interquartile range [IQR] 69-78), and 91% achieved viral suppression. In multivariate analyses, three factors were independently associated with low resilience: loss of both parents (adjusted odds ratio [aOR] 4.35, 95% CI 2.09-9.06), school discontinuation (aOR 2.43, 95% CI 1.10-5.34), and self-reported communication barriers at HIV clinics (aOR 5.83, 95% CI 2.69-12.64). These associations were consistent across sensitivity analyses at alternative resilience thresholds. At the most stringent threshold of low resilience (CYRM-R score [&le;]15th percentile), unsuppressed viral load also emerged as a significant correlate, suggesting that treatment failure may be concentrated among those with the most severely compromised resilience. ConclusionsAPHIV participating in a peer-led mentorship program demonstrated high overall resilience and viral suppression, but also revealed addressable vulnerabilities mapping to specific programmatic priorities. Peer-led models offer a promising foundational platform; however, complementary structural and psychosocial enhancements targeting these modifiable determinants are essential to optimize outcomes for those facing the greatest cumulative adversity.

BackgroundAbrupt cessation of USAID and CDC resources to KwaZulu Natal province in South Africa, threatens the progress over decades to address HIV. MethodsWe used a previously developed validated HIV transmission model with input from the KZN Department of Health and local stakeholders to estimate impact of funding cuts on HIV incidence and mortality at 12-months and through 2030. We applied the model to estimate the impact of restoring funds on HIV incidence and mortality. ResultsHIV incidence increased at 12 months and through 2030 by 3.4% and 22.8%, leading to 35,300 and 116,100 additional infections, and 12,800 and 42,300 additional deaths, respectively. Restoring funding after a 12-month pause, reallocated to focus on long-acting PrEP, would avert 12,600 new infections. ConclusionThis model application demonstrates that the sudden cessation of USAID and CDC commitments in the largest HIV epidemic in the world leads to increased incidence and mortality and threatens decades of progress in KZN, South Africa. Restoring funding within 12 months and increasing efficiency of HIV interventions can reestablish KwaZulu Natal province, South Africas trajectory toward EHE goals.