Digital tools for improving antiretroviral adherence among people living with HIV in Africa

The estimated number of people living with HIV (PLHIV) in India in 2023 is 2.54 million (range 2.16-3.03 million). With the initiation of antiretroviral therapy (ART) and the "Test and Treat" policy, the life expectancy of PLHIV on ART has substantially increased, consequently leading to a higher rate of comorbidities among PLHIV. The Joint United Nations Programme on HIV/AIDS (UNAIDS) 2025 targets aim for about 90% of PLHIV to have access to integrated and comprehensive health care services, with a concerted effort to reach the End of AIDS by 2030. Hence, the National Integrated Bio-Behavioral Surveillance (IBBS) among PLHIV (IBBS-PLHIV) has been implemented for the first time in India to establish a baseline understanding of the prevalence of sexually transmitted infections (STIs), noncommunicable diseases (NCDs), and related risk behaviors among PLHIV. The primary aim of IBBS-PLHIV is to estimate the levels of HIV-related risk behaviors and the prevalence of other STIs and NCDs among PLHIV. The specific objectives are identifying the levels of HIV-related sexual and injecting risk behaviors; estimating the prevalence of STIs such as syphilis, hepatitis B virus, and hepatitis C virus; estimating the prevalence of NCDs such as diabetes and hypertension; understanding the lifestyle and behavioral risks associated with NCDs; and assessing the levels of violence, stigma, and discrimination experienced by PLHIV. IBBS-PLHIV will be a cross-sectional, biennial surveillance among PLHIV aged 15 years or older. The first round will be implemented at 120 ART centers across 28 states, accounting for approximately 95% of the total estimated PLHIV. Consenting, eligible PLHIV will be recruited through consecutive sampling. The overall sample size at each ART center is approximately 225, and the surveillance period is 3 months. Behavioral data on demographics, reproductive and sexual health, lifestyle and sexual behaviors, stigma, and discrimination will be collected. Blood samples will also be collected to test for STIs and NCDs. IBBS-PLHIV was initiated on January 1, 2024, in a phased manner. Data collection was carried out over 3 months and completed by June 2024 across all 120 sites. A total of 25,257 PLHIV were recruited for the surveillance, including 11,921 males, 11,855 females, and 1481 hijra/transgender individuals. Data entry, followed by data matching and validation of all records, was completed in December 2024. The data are currently being analyzed, and the final findings are expected to be disseminated by December 2025. Data collected through IBBS-PLHIV will help monitor the levels of HIV-related sexual and injecting risk behaviors among PLHIV. Additionally, it will provide estimates of the prevalence of NCD comorbidities and STI coinfections such as diabetes, hypertension, syphilis, and viral hepatitis. These findings will serve as a baseline and are expected to offer valuable insights for facilitating comprehensive HIV care and management through the effective integration of HIV and broader health service delivery. DERR1-10.2196/58252.

A rapid, reliable, and accurate test for the diagnosis of infection with Helicobacter pylori is needed for screening dyspeptic patients before referral for endoscopy. To compare a new rapid whole blood test (Helisal rapid blood, Cortecs), two serum enzyme linked immunosorbent assays (ELISAs; Helico-G, Shield and Helisal serum, Cortecs), and a salivary assay (Helisal saliva, Cortecs), with slide biopsy urease, 13C-urea breath test, and histology. Three hundred and three consecutive dyspeptic patients attending for gastroscopy underwent two antral biopsies for histology, and one for rapid slide biopsy urease test for assessment of H pylori status. Blood and saliva were also collected. One hundred of the patients also underwent a 13C-urea breath test. Gold standard positives were defined as those with at least two positive tests among slide urease, breath test, or histology, and gold standard negatives as those with all these (or two when the breath test was not done) negative. Of 300 patients (median age 63, range 28-89) eligible for analysis, 137 (46%) were gold standard positives, of which Helisal rapid blood identified 116, Helico-G 129, Helisal serum 130, and Helisal saliva 120; 137 (46%) were gold standard negatives of which the number falsely identified as positive was 30 by Helisal rapid blood, 45 by Helico-G, 41 by Helisal serum, and 41 by Helisal saliva. Sensitivities and specificities were: for the whole blood test 85% and 78% respectively; for Helico-G 94% and 67%, for Helisal serum 95% and 70%, and for Helisal saliva 84% and 70%. If endoscopy had been undertaken only on patients with positive tests two of 16 duodenal ulcers would have been missed if the Helisal rapid blood test was used, and one if any of the ELISA tests were used. None of the blood tests would have missed any of six gastric ulcers, but the salivary test would have missed one.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set the global goal of ending the AIDS world epidemic by 2030. In order to end this epidemic they have established a 90-90-90 goal to be achieved by 2020, which may be problematic, especially in low- and middle-income countries. This goal includes 90% of individuals with HIV globally being diagnosed, on treatment, and virologically suppressed. Based on global estimates from 2014–2015, approximately 36.9 million individuals are living with HIV. Of those, 53% have been diagnosed with HIV, 41% are on antiretroviral therapy (ART), and 32% have viral suppression with <1000 copies/ml. Comprehensive approaches are needed to improve the number of people living with HIV (PLWH) who are diagnosed, linked, and engaged in care. Once PLWH are retained in care, treatment is key to both HIV prevention and transmission. The development and advancement of new ART is necessary to assist in reaching these goals by improving safety profiles, decreasing pill burden, improving quality of life and life expectancy, and creating new mechanisms to overcome resistance. The focus of this review is to highlight and review data for antiretroviral agents recently added to the market as well as discuss agents in various stages of development (new formulations and mechanisms of action).

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners set the 90-90-90 target for the year 2020: diagnose 90% of all people living with HIV (PLHIV); treat 90% of people who know their status; and suppress the virus in 90% of people on treatment. In 2015, countries began reporting to UNAIDS on progress against 90-90-90 using standard definitions and methods. We used data submitted to UNAIDS from 170 countries to assess country-specific progress towards 90-90-90 through 2018. To assess global and regional progress, overall and by sex for adults aged 15 years and older, we combined country-reported data with estimates generated with a Bayesian hierarchical model. A total of 60 countries reported on all three 90s in 2018, up from 23 in 2015. Among all PLHIV worldwide, 79% (67-92%) knew their HIV status. Of these, 78% (69-82%) were accessing treatment and 86% (72-92%) of people accessing treatment had suppressed viral loads. Of the 37.9 million (32.7-44.0 million) PLHIV worldwide, 53% (43-63%) had suppressed viral loads. The gap to fully achieving 73% of PLHIV with suppressed viral load was 7.7 million; 15 countries had already achieved this target by 2018. Increased data availability has led to improved measures of country and global progress towards the 90-90-90 target. Although gains in access to testing and treatment continue, many countries and regions are unlikely to reach the 90-90-90 target by 2020.

BackgroundHigh uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.MethodsA CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.ResultsWe estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.ConclusionsThe EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

BackgroundIn 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) issued treatment goals for human immunodeficiency virus (HIV). The 90-90-90 target specifies that by 2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. Consistent methods and routine reporting in the public domain will be necessary for tracking progress towards the 90-90-90 target.Methods and findingsFor the period 2010–2016, we searched PubMed, UNAIDS country progress reports, World Health Organization (WHO), UNAIDS reports, national surveillance and program reports, United States President’s Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans, and conference presentations and/or abstracts for the latest available national HIV care continuum in the public domain. Continua of care included the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed out of the estimated number of PLHIV. We ranked the described methods for indicators to derive high-, medium-, and low-quality continuum. For 2010–2016, we identified 53 national care continua with viral suppression estimates representing 19.7 million (54%) of the 2015 global estimate of PLHIV. Of the 53, 6 (with 2% of global burden) were high quality, using standard surveillance methods to derive an overall denominator and program data from national cohorts for estimating steps in the continuum. Only nine countries in sub-Saharan Africa had care continua with viral suppression estimates. Of the 53 countries, the average proportion of the aggregate of PLHIV from all countries on ART was 48%, and the proportion of PLHIV who were virally suppressed was 40%. Seven countries (Sweden, Cambodia, United Kingdom, Switzerland, Denmark, Rwanda, and Namibia) were within 12% and 10% of achieving the 90-90-90 target for “on ART” and for “viral suppression,” respectively. The limitations to consider when interpreting the results include significant variation in methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain.ConclusionsRelatively few complete national continua of care are available in the public domain, and there is considerable variation in the methods for determining progress towards the 90-90-90 target. Despite bearing the highest HIV burden, national care continua from sub-Saharan Africa were less likely to be in the public domain. A standardized monitoring and evaluation approach could improve the use of scarce resources to achieve 90-90-90 through improved transparency, accountability, and efficiency.

Aims: Single-tablet regimens (STRs) can improve antiretroviral therapy (ART) adherence; however, the relationship between long-term adherence and patient healthcare resource utilization (HRU) is unclear. The objective of this study was to assess long-term ART adherence among people living with HIV (PLHIV) using STRs and multi-tablet regimens (MTRs) and compare HRU over time by adherence. Materials and methods: This retrospective study analyzed medical and pharmacy claims (Optum Clinformatics® Data Mart Database). Included PLHIV were aged ≥18 years, had ≥1 medical claim with an HIV diagnosis, and had pharmacy claims for a complete STR or MTR. Adherence was analyzed as proportion of days covered (PDC), stratified as ≥95%, very high; 90–95%, high; 80–90%, moderate; <80%, low. Cumulative all-cause and HIV-related HRU were calculated across 4 years. Among PLHIV with ≥4-year follow-up, HRU was assessed by adherence. Results: Among 15,153 PLHIV included, 63% achieved PDC ≥90% during Year 1. Among the subgroup of PLHIV with ≥4-year follow-up (N = 3,818), the proportion maintaining PDC ≥90% fell from 67% in Year 1 to 54% by Year 4. Difference from Years 1 to 4 in the proportion of PLHIV with PDC ≥90% was 13% and 17% in the STR and MTR groups, respectively. Cumulative HRU across the 4-year follow-up was higher in PLHIV with low vs high adherence (27% with low adherence had ≥1 emergency room visit vs 17% for very high, p < 0.0001; 15% with low adherence had ≥1 inpatient stay vs 7% for very high, p < 0.0001). Conclusions: ART adherence showed room for improvement, particularly over the long-term. PLHIV receiving STRs exhibited higher adherence vs those receiving MTRs; this difference increased over time. The proportion of PLHIV with higher HRU was significantly higher among those with lower adherence, and became greater over time. Interventions and alternative therapies to improve adherence among PLHIV should be explored.

The need for standardisation of the HIV continuum of care

BackgroundFor people living with HIV (PLWH), antiretroviral therapy (ART) adherence is crucial to attain better health outcomes. Although research has leveraged consumer health information technologies to enhance ART adherence, no study has evaluated feasibility and clinical outcomes associated with the usage of a commercially available, regularly updated mobile health (mHealth) app for improving ART adherence among PLWH.ObjectiveThis study aimed to assess the feasibility, acceptability, and clinical outcomes of Care4Today, an existing, free, biprogrammatic mHealth app for improving ART adherence among PLWH.MethodsThe Florida mHealth Application Adherence Project (FL-mAPP) was a 90-day longitudinal pilot study conducted in 3 public HIV clinics in Florida, United States. After obtaining informed consent, 132 participants completed a survey and then were given the option to try an existing mHealth app to help with ART adherence. Of these, 33.3% (44/132) declined, 31.1% (41/132) agreed but never used the app, and 35.6% (47/132) used the app. All were asked to complete follow-up surveys at 30 days and 90 days after enrollment. Usage data were used to assess feasibility. Clinical outcomes of self-reported ART adherence and chart-obtained HIV viral load and CD4+ T-cell counts were compared among those who used the platform (users) versus those who did not (nonusers). Participants and HIV care providers also provided responses to open-ended questions about what they liked and did not like about the app; comments were analyzed using thematic analysis.ResultsOf 132 participants, 47 (35.6%) and 85 (64.4%) were categorized as users and nonusers, respectively. Among users, a Kaplan-Meier plot showed that 25 persons (53%) continued using the app after the 90-day follow-up. At 30-day follow-up, 13 (81.3%) of those who used the mHealth app reported ≥95% ART adherence, compared with 17 (58.6%) nonusers (P=.12). Overall, 39 (82%) users liked or somewhat liked using the platform. Participants’ favorite features were medication reminders, ability to create custom reminders, and adherence reports.ConclusionsThis longitudinal study found that a commercially available medication adherence mHealth app was a feasible and acceptable intervention to improve ART adherence among PLWH and engaged in clinical care across 3 public HIV clinics in the state of Florida. Overall, participants liked the Care4Today app and thought the medication reminders were their favorite feature. Generally, self-reports of ART adherence were better among users than nonusers, both at 30- and 90-day follow-ups. Further clinical research needs to address user fatigue for improving app usage.

The role of antiretroviral therapy (ART) in HIV prevention has generated hope for an AIDS-free generation but also interest in behavioural outcomes of people living with HIV (PLHIV). This is from the knowledge that the benefits of ART in terms of enhancing PLHIV health outcomes and preventing HIV transmission depend on PLHIV’s behaviours including sexual risk, disclosure, treatment adherence and retention. The purpose of this study was to examine whether PLHIV in Nigeria who participate in support group activities have different behavioural outcomes than those who do not. A cross-sectional design was used to compare stigma, disclosure, sexual risk behaviors and ART adherence rates of PLHIV who participate in support group activities and those who do not. Respondents were adult PLHIV enrolled in ART from January 1, 2010 to December 31, 2012. Study sites and respondents were selected using multistage probability sampling. Data were collected using a self-administered questionnaire from 1,676 respondents between February and May 2014. Data were analysed using STATA. Univariate analysis was carried out to generate descriptive statistics while Chi-square tests were used to examine if there was any association between participation in support group activities and PLHIV selected behavioral outcomes. PLHIV who participated in support group activities differed from those who did not in terms of HIV-related stigma (p =< 0.001), positive HIV status disclosure (p = 0.005), ART adherence (p = 0.021), and sexual risk behaviors (p = 0.045). PLHIV who participated in support group activities were more likely to have less internal HIV-related stigma, disclose their positive HIV status, adhere to ART and live less risky sexual lives. These findings suggest that PLHIV who participate in support group activities are more likely to adopt positive behaviors than those who do not.

ART adherence, essential to preventing disease progression for people living with HIV (PLHIV), remains challenged by factors like poor mental health condition, insufficient social support, and substance use. This study investigates the roles of social support and substance use as mediators in the relationship between mental health and antiretroviral therapy (ART) adherence among PLHIV in a multisite, international context. Cross-sectional data from N = 1598 PLHIV across eight countries were analyzed using parallel mediation analyses in R. Results indicated that both social support and substance use independently mediated the relationship between mental health and ART adherence. Hallucinogens mediated the mental health-adherence link. Cocaine, Amphetamine-type stimulants, inhalants, and opioids directly influenced adherence but did not mediate this relationship. In contrast, no significant effects were observed for tobacco, alcohol, cannabis or sedatives. This large-scale, nurse-led, international study offers critical insights into the roles of social support and substance use as psychosocial influencers in the cascade of care for PLHIV. Clinical implications include prioritizing educative, preventative, and harm-reductive approaches to specific substances that impact ART adherence. Findings may also inform interventions that emphasize strengthening social support to improve adherence in ART and care while addressing substance use as a barrier to care and well-being.

Mean Age of First Sex: Do They Know What We Mean?

Chronic disease management coupled with education may improve outcomes for those with chronic disease. As Human Immunodeficiency Virus (HIV) is now a chronic disease, addressing the needs of as people living with HIV (PLWH) is essential as they experience an accelerated aging process due to the mechanisms of the disease and medications taken. Although studies exist on the management of chronic HIV, few discuss the implications of medication adherence and activities of daily living related to falls among PLWH. To inform occupational therapy services for PLWH, this case-control study used extracted data from the electronic medical records of PLWH who had received occupational therapy (OT) at a large academic hospital. Two-hundred-and-four subjects were included in the final dataset; sixty-eight were cases that reported a fall within the last 12 months, while 136 were controls which were PLWH who had not sustained a fall. The association between falls and antiretroviral therapy adherence indicated males who were ART non-adherent and had balance deficits were more likely to fall. The association between ADL dysfunction and falls among PLWH showed those more likely to fall had moderate ADL dysfunction and balance deficits. The findings suggest further examination of the person factors of PLWH who are categorized clinically as non-adherent with antiretroviral therapy and have ADL dysfunction may improve health outcomes and reduce falls when paired with occupation-based interventions.

IntroductionIn recent decades, there has been a proliferation of mobile health (mHealth) interventions to address public health challenges such as HIV/AIDS. Hence, there is a need for standardizing the report of mHealth interventions and frameworks to enable effective knowledge sharing and promote developments. This study aims to review publications on mobile applications used for antiretroviral therapy (ART) adherence among people living with HIV (PLHIV) to evaluate their compliance with the standard reporting guideline by the WHO.MethodA comprehensive search of published literature was conducted on PubMed, PubMed Central, and MEDLINE databases. We selected randomized controlled trials reporting mobile applications used to improve ART adherence among PLHIV. Only studies published in the last 10 years and the English language were included. Each selected study was reviewed by two independent reviewers against the standard 16-item checklist developed by the WHO.ResultsA total of 16 studies were included in the review. Most of the studies were conducted in the United States of America (n = 7). Only 4 (25%) of the studies reported more than 70% (11/16) of the items on the standard reporting checklist by WHO. More than 80% of the studies reported the intervention content (n = 15) and intervention delivery (n = 13). The least reported items were; interoperability/Health Information Systems (HIS) context (n = 2), infrastructure (population level such as electricity, internet connectivity, etc.) (n = 4), and cost assessment (n = 4). However, these are important factors that ensure the sustainability and usability of mHealth intervention, especially in low- and middle-income countries.ConclusionMost mHealth interventions promoting ART adherence did not comply with the standard reporting guideline. The lack of standardization of mHealth interventions may be responsible for increased siloed mobile applications. Hence, there is a need for global adoption of the checklist by Ministries of Health, international organizations, journals, and relevant authorities.

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z = − 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z = − 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z = − 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z = − 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z = − 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.