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AbstractIntroductionAlthough HIV prevalence is exceptionally high in South Africa, HIV testing rates remain below targeted guidelines. Older adults living with HIV are substantially more likely to remain undiagnosed than younger people. Cognitive function and literacy could play key roles in HIV status knowledge due to the decision‐making processes required around weighing the costs and benefits of testing, navigating testing logistics and processing results. We aimed to assess the independent relationships among each of cognitive function, literacy and education with HIV status knowledge in a population‐based sample of older adults living in a rural South African community with high HIV prevalence.MethodsWe analyzed data from a population‐based study of 5059 men and women aged 40 years and older in rural South Africa (Health and Aging in Africa: A Longitudinal Study of an INDEPTH community (HAALSI)). HAALSI surveys, conducted between 2014 and 2015, queried self‐reported literacy, educational attainment and HIV status knowledge. Laboratory tests were conducted to assess true HIV sero‐status. Cognitive function was assessed with a battery of cognitive tests measuring time orientation, immediate and delayed recall, and numeracy and coded using confirmatory factor analysis as a z‐standardized latent variable. We estimated the relationship between the outcome of HIV status knowledge and each of three exposures: (1) latent cognitive z‐score, (2) literacy and (3) education, using confounder‐adjusted modified Poisson regression models in the study population overall and stratified by HIV sero‐status.ResultsWe found that HIV status knowledge was higher among those with higher cognitive z‐scores (adjusted Prevalence Ratio (aPR) (95% CI): 1.18 (1.14, 1.21) per standard deviation unit), and among literate participants (aPR (95% CI): 1.24 (1.16, 1.32) vs. non‐literate participants). Taken together, the associations with literacy and cognitive function completely attenuated the otherwise positive association between educational attainment and HIV status knowledge. The magnitudes of effect were generally similar among laboratory‐confirmed HIV‐negative and HIV‐positive participants.ConclusionsCampaigns that target older adults in rural South Africa with HIV testing messages should carefully consider the cognitive and literacy levels of the intended audience. Innovations to ease the cognitive load associated with HIV testing could prove fruitful to increase HIV status knowledge.

Introduction Although HIV prevalence is exceptionally high in South Africa, HIV testing rates remain below targeted guidelines. Older adults living with HIV are substantially more likely to remain undiagnosed than younger people. Cognitive function and literacy could play key roles in HIV status knowledge due to the decision-making processes required around weighing the costs and benefits of testing, navigating testing logistics and processing results. We aimed to assess the independent relationships among each of cognitive function, literacy and education with HIV status knowledge in a population-based sample of older adults living in a rural South African community with high HIV prevalence. Methods We analyzed data from a population-based study of 5059 men and women aged 40 years and older in rural South Africa (Health and Aging in Africa: A Longitudinal Study of an INDEPTH community (HAALSI)). HAALSI surveys, conducted between 2014 and 2015, queried self-reported literacy, educational attainment and HIV status knowledge. Laboratory tests were conducted to assess true HIV sero-status. Cognitive function was assessed with a battery of cognitive tests measuring time orientation, immediate and delayed recall, and numeracy and coded using confirmatory factor analysis as a z-standardized latent variable. We estimated the relationship between the outcome of HIV status knowledge and each of three exposures: (1) latent cognitive z-score, (2) literacy and (3) education, using confounder-adjusted modified Poisson regression models in the study population overall and stratified by HIV sero-status. Results We found that HIV status knowledge was higher among those with higher cognitive z-scores (adjusted Prevalence Ratio (aPR) (95% CI): 1.18 (1.14, 1.21) per standard deviation unit), and among literate participants (aPR (95% CI): 1.24 (1.16, 1.32) vs. non-literate participants). Taken together, the associations with literacy and cognitive function completely attenuated the otherwise positive association between educational attainment and HIV status knowledge. The magnitudes of effect were generally similar among laboratory-confirmed HIV-negative and HIV-positive participants. Conclusions Campaigns that target older adults in rural South Africa with HIV testing messages should carefully consider the cognitive and literacy levels of the intended audience. Innovations to ease the cognitive load associated with HIV testing could prove fruitful to increase HIV status knowledge.

IntroductionA substantial number of patients with HIV in South Africa have failed first‐line antiretroviral therapy (ART). Although individual predictors of first‐line ART failure have been identified, few studies in resource‐limited settings have been large enough for predictive modelling. Understanding the absolute risk of first‐line failure is useful for patient monitoring and for effectively targeting limited resources for second‐line ART. We developed a predictive model to identify patients at the greatest risk of virologic failure on first‐line ART, and to estimate the proportion of patients needing second‐line ART over five years on treatment.MethodsA cohort of patients aged ≥18 years from nine South African HIV clinics on first‐line ART for at least six months were included. Viral load measurements and baseline predictors were obtained from medical records. We used stepwise selection of predictors in accelerated failure‐time models to predict virologic failure on first‐line ART (two consecutive viral load levels >1000 copies/mL). Multiple imputations were used to assign missing baseline variables. The final model was selected using internal‐external cross‐validation maximizing model calibration at five years on ART, and model discrimination, measured using Harrell's C‐statistic. Model covariates were used to create a predictive score for risk group of ART failure.ResultsA total of 72,181 patients were included in the analysis, with an average of 21.5 months (IQR: 8.8–41.5) of follow‐up time on first‐line ART. The final predictive model had a Weibull distribution and the final predictors of virologic failure were men of all ages, young women, nevirapine use in first‐line regimen, low baseline CD4 count, high mean corpuscular volume, low haemoglobin, history of TB and missed visits during the first six months on ART. About 24.4% of patients in the highest quintile and 9.4% of patients in the lowest quintile of risk were predicted to experience treatment failure over five years on ART.ConclusionsAge, sex, CD4 count and having any missed visits during the first six months on ART were the strongest predictors of ART failure. The predictive model identified patients at high risk of failure, and the predicted failure rates over five years closely reflected actual rates of failure.

AbstractIntroduction: In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home‐based interventions where testing is not always feasible. We evaluate the accuracy of self‐reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing.Methods: Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self‐reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at‐home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self‐reported status compared to "gold standard" biomarker results. Log‐binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self‐report.Results: Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self‐report was 94.1% (95% confidence interval (CI): 92.0–96.0), NPV was 87.2% (95% CI: 86.2–88.2), sensitivity was 51.2% (95% CI: 48.2–54.3) and specificity was 99.0% (95% CI: 98.7–99.4). Participants on ART were more likely to report their HIV‐positive status, and participants reporting false‐negatives were more likely to have older HIV tests.Conclusions: The majority of participants were willing to share their HIV status. False‐negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self‐reported status should be considered as a routine first step to establish HIV status.

AbstractIntroductionParticipation in antiretroviral therapy (ART) programmes has been associated with greater utilization of care for hypertension and diabetes in rural South Africa. The objective of this study was to assess whether people living with HIV on ART with comorbid hypertension or diabetes also have improved chronic disease management indicators.MethodsThe Health and Aging in Africa: a longitudinal study of an INDEPTH Community in South Africa (HAALSI) is a cohort of 5059 adults >40 years old. Enrollment took place between November 2014 and November 2015. The study collected population‐based data on demographics, healthcare utilization, height, weight, blood pressure (BP) and blood glucose as well as HIV infection, HIV‐1 RNA viral load (VL) and ART exposure. We used regression models to determine whether HIV care cascade stage (HIV‐negative, HIV+ /No ART, ART/Detected HIV VL, and ART/Undetectable VL) was associated with diagnosis or treatment of hypertension or diabetes, and systolic blood pressure and glucose among those with diagnosed hypertension or diabetes. ART use was measured from drug level testing on dried blood spots.Results and discussionCompared to people without HIV, ART/Undetectable VL was associated with greater awareness of hypertension diagnosis (adjusted risk ratio (aRR) 1.18, 95% CI: 1.09 to 1.28) and treatment of hypertension (aRR 1.24, 95% CI: 1.10 to 1.41) among those who met hypertension diagnostic criteria. HIV care cascade stage was not significantly associated with awareness of diagnosis or treatment of diabetes. Among those with diagnosed hypertension or diabetes, ART/Undetectable VL was associated with lower mean systolic blood pressure (5.98 mm Hg, 95% CI: 9.65 to 2.32) and lower mean glucose (3.77 mmol/L, 95% CI: 6.85 to 0.69), compared to being HIV‐negative.ConclusionsParticipants on ART with an undetectable VL had lower systolic blood pressure and blood glucose than the HIV‐negative participants. HIV treatment programmes may provide a platform for health systems strengthening for cardiometabolic disease.