BACKGROUND: With the largest antiretroviral therapy (ART) programme globally, demand for effective HIV management is increasing in South Africa. While viral load (VL) testing is conducted, VL follow-up and management are sub-optimal OBJECTIVES: The objective of this study was to address gaps in the VL cascade to improve VL testing and management METHODS: Antiretroviral therapy records were sampled for an in-depth review. The study team then reviewed individual records, focusing on ART management, virological suppression and retention. Multifaceted interventions focused on virological control, including a clinical summary chart for ART care; streamlining laboratory results receipt and management; monitoring VL suppression, flagging virological failure and missed visits for follow-up; down-referral of stable patients eligible for the chronic club system; and training of personnel and patients RESULTS: Pre-intervention, 78% (94/120) of eligible patients had VL tests, versus 92% (145/158) post-intervention (p = 0.0009). Pre-intervention, 59% (71/120) of patients accessed their VL results, versus 86% (136/158) post-intervention (p < 0.0001). Post-intervention, 73% (19/26) of patients eligible for ART change were appropriately managed, versus 11% (4/36) pre-intervention (p < 0.0001). Only 27% had no regimen changes (7/26) post-intervention, versus 81% (29/36) pre-intervention (p < 0.0001 CONCLUSION: Service delivery was streamlined to facilitate HIV services by focusing on VL test monitoring, protocol training and accessibility of results, thereby improving clinical management

HIV and food insecurity are two prominent causes of morbidity and mortality in sub-Saharan Africa. Food insecurity has been associated with risky sexual practices and poor access to healthcare services. We describe the association between household food insecurity and previous HIV testing and HIV status. We used logistic regression to analyse the association between food insecurity and prior HIV counselling and testing (HCT) and testing HIV positive. A total of 2742 adults who presented for HCT at three primary healthcare clinics in KwaZulu-Natal, South Africa, participated in the study. The prevalence of household food insecurity was 35%. The prevalence of food insecurity was highest in adults who had incomplete high schooling (43%), were unemployed (39%), and whose primary source of income was government grants (50%). Individuals who were food insecure had significantly higher odds of testing HIV positive (adjusted odds ratio 1.41, 95% CI 1.16-1.71), adjusted for demographic and socio-economic variables. There was no association between food insecurity and prior HCT. The findings of this study highlight the important role food insecurity may play in HIV risk. Interventions to turn food-insecure into food-secure households are needed to reduce their household members' vulnerability to HIV acquisition. The absence of such interventions is likely to severely impact ambitious global targets of ending AIDS by 2030 through the 90-90-90 targets and test-and-treat-all initiatives. Significance: • One in three adults presenting for HIV counselling and testing came from households with some degree of food insufficiency. • Experience of food insecurity was very high in young people who did not complete high school and were currently not studying. • Findings support the need for socio-economic and structural interventions to transform food-insecure into food-secure households. • Failure or lack of such interventions will contribute to the failure to achieve global targets like the UNAIDS 90-90-90 programme.

Participant recruitment, retention and product adherence are necessary to measure the efficacy or effectiveness of an intervention in a clinical trial. As part of a Phase III HIV prevention trial in a rural area in Kwazulu-Natal, South Africa, a peer educator programme was initiated to aid in recruitment and retention of trial participants from the community. Enrolled trial participants who had completed at least 6 months of trial participation and who had honoured all of their scheduled trial visits within that period were approached to be peer educators. Following additional selection criteria, 24 participants were eligible to be trained as peer educators. Training topics included HIV/AIDS, sexually transmitted infections, nutrition, antiretrovirals, clinical trials, and methods of disseminating this information to the community. The role of peer educators was to bring interested women from their community to the trial site for comprehensive education and information about the trial and possibly trial participation. A total of 1879 women were educated by peer educators between July 2004 and December 2006. Of these, 553 women visited the trial site for further education and screening for participation in the trial. Peer educators provided continuous education and support to women enrolled in the trial which also promoted retention, ultimately contributing to the site's 94% retention rate. Recruitment and retention efforts of trial participants are likely to be enhanced by involving trial participants as peer educators. Such trial participants are in a better position to understand cultural dynamics and hence capable of engaging the community with appropriate HIV prevention and trial-related messaging.

OBJECTIVE: To estimate the potential impact of using hormonal contraceptives on rates of infection with human immunodeficiency virus type 1 (HIV-1) and pregnancy by theoretically removing the use of hormonal contraceptives from a study population. METHODS: A prospective cohort study included 3704 HIV-negative women who were enrolled in two biomedical trials that tested two vaginal microbicides (PRO 2000 and Carraguard®) for the prevention of HIV-1 in Durban, South Africa, in 2004-2009. Cox proportional hazards regression models along with partial population attributable risks (PARs) and their 95% confidence intervals (CIs) were calculated to assess the relative population-level impact of the use of hormonal contraceptives on HIV-1 seroconversion rates and on pregnancy rates. FINDINGS: Women who reported using hormonal contraceptives at enrolment in the trial had a higher risk of HIV-1 seroconversion (adjusted hazards ratio: 1.24; 95% CI: 0.97-1.58) than women who reported using other types of contraceptives at enrolment. At the population level, the use of hormonal contraceptives (pills or injectables) at baseline and during study follow-up accounted for approximately 20% (95% CI: 16-22) of HIV-1 seroconversions. However, the partial PAR indicated a relative impact of 12% (95% CI: 9.0-15.7). On the other hand, 72% (95% CI: 66-77) of the pregnancies could have been avoided if all women had used hormonal contraceptives. CONCLUSION: Women using hormonal contraceptives need comprehensive counselling on simultaneous prevention of HIV-1 infection.

OBJETIVO: Calcular el posible impacto del uso de anticonceptivos hormonales sobre las tasas de infección por el virus de la inmunodeficiencia humana del tipo 1 (VIH-1) y sobre el embarazo bajo el supuesto de eliminar el uso de anticonceptivos hormonales de la población estudiada. MÉTODOS: Entre los años 2004 y 2009, un estudio de cohortes prospectivo incluyó a 3704 mujeres VIH negativas inscritas en dos ensayos biomédicos que evaluaron dos microbicidas vaginales (PRO 2000 y Carraguard®) para la prevención del VIH-1 en Durban, Sudáfrica. Se calcularon los modelos de regresión de Cox junto con los riesgos parciales atribuibles a la población y sus intervalos de confianza (IC) del 95% para evaluar el impacto relativo del uso de anticonceptivos hormonales sobre las tasas de seroconversión del VIH-1 y las de embarazo entre la población. RESULTADOS: El riesgo de seroconversión del VIH-1 fue superior en las mujeres que declararon utilizar anticonceptivos hormonales en el momento de la inscripción en el ensayo (índice de riesgos ajustado: 1,24; IC del 95%: 0,97-1,58) que en las mujeres que declararon utilizar otros tipos de anticonceptivos. Entre la población, el uso de anticonceptivos hormonales (píldoras o inyectables) en el punto de partida y durante el seguimiento del estudio representó aproximadamente el 20% (IC del 95%: 16-22) de las seroconversiones del VIH-1. No obstante, el riesgo parcial atribuible a la población indicó un impacto relativo del 12% (IC del 95%: 9.0-15.7). Por otra parte, el 72% (IC del 95%: 66-77) de los embarazos podría haberse evitado si todas las mujeres hubieran tomado anticonceptivos hormonales. CONCLUSIÓN: Las mujeres que usan anticonceptivos hormonales necesitan un asesoramiento amplio sobre la prevención de la infección por el VIH.

OBJECTIF: Estimer l'impact potentiel de l'utilisation de contraceptifs hormonaux sur les taux d'infection par le virus d'immunodéficience humaine de type 1 (VIH-1) et sur la grossesse par suppression théorique de l'utilisation de contraceptifs hormonaux dans une population témoin. MÉTHODES: Une étude de cohorte prospective comprenait 3704 femmes séronégatives qui étaient inscrites dans deux études biomédicales testant deux microbicides vaginaux (PRO 2000 et Carraguard®) pour la prévention du VIH-1 à Durban, en Afrique du Sud, de 2004 à 2009. Les modèles de régression à risque proportionnel de Cox ainsi que les risques attribuables dans la population (RAP) partielle et leurs intervalles de confiance (IC) de 95% ont été calculés pour évaluer l'impact relatif au niveau de la population de l'utilisation de contraceptifs hormonaux sur les taux de séroconversion du VIH-1 et sur les taux de grossesse. RÉSULTATS: Les femmes qui ont déclaré utiliser des contraceptifs hormonaux lors de l'inscription à l'essai clinique présentaient un risque accru de séroconversion du VIH-1 (taux de risque ajusté: 1,24; IC de 95%: 0,97 à 1,58) par rapport aux femmes qui ont déclaré utiliser d'autres types de contraceptifs lors de l'inscription. Au niveau de la population, l'utilisation de contraceptifs hormonaux (comprimés ou injectables) au début et au cours du suivi de l'étude a représenté environ 20% (IC de 95%: 16 à 22%) des séroconversions du VIH-1. Toutefois, le RAP partiel a indiqué un impact relatif de 12% (IC de 95%: 9 à 15,7%). D'autre part, 72% (IC de 95%: 66 à 77%) des grossesses auraient pu être évitées si toutes les femmes avaient utilisé des contraceptifs hormonaux. CONCLUSION: Les femmes qui utilisent des contraceptifs hormonaux nécessitent des conseils détaillés sur la prévention simultanée de l'infection par le VIH-1.