Abstractobjective The ambitious '90-90-90' treatment targets require innovative models of care to support quality antiretroviral therapy (ART) delivery. While evidence for differentiated models of ART delivery is growing, there are few data on the feasibility of scale-up. We describe the implementation of the Adherence Club (AC) model across the Cape Metro health district in Cape Town, South Africa, between January 2011 and March 2015.methods Using data from monthly aggregate AC monitoring reports and electronic monitoring systems for the district cohort, we report on the number of facilities offering ACs and the number of patients receiving ART care in the AC model.results Between January 2011 and March 2015, the AC programme expanded to reach 32 425 patients in 1308 ACs at 55 facilities. The proportion of the total ART cohort retained in an AC increased from 7.3% at the end of 2011 to 25.2% by March 2015. The number of facilities offering ACs also increased and by the end of the study period, 92.3% of patients were receiving ART at a facility that offered ACs. During this time, the overall ART cohort doubled from 66 616 to 128 697 patients. The implementation of the AC programme offset this increase by 51%.conclusions ACs now provide ART care to more than 30 000 patients. Further expansion of the model will require additional resources and support. More research is necessary to determine the outcomes and quality of care provided in ACs and other differentiated models of ART delivery, especially when implemented at scale.keywords antiretroviral, drug delivery systems, community-based distribution, medication adherence, loss to follow-up

In 2018, it was estimated that 1.6 million adolescents between the ages of 10 and 19 years, globally, were infected with HIV, accounting for 4% of all people living with HIV. [1] The United Nations Children's Fund (UNICEF) reported that of the estimated 770 000 people who died of AIDS-related illnesses, 33 000 were adolescents, comprising 4% of total deaths in 2018. Sub-Saharan Africa (SSA) has the highest number of HIV-infected adolescents (~1.5 million (89%)). It is estimated that 310 000 adolescents were living with HIV in South Africa (SA) in 2018, with 24 per 100 000 annual AIDS-related deaths. An alarming trend over the past decade is the increase in AIDSrelated deaths among adolescents, which contrasts with the decrease in deaths among all other age groups. [2] Globally, AIDS-related deaths decreased by almost 40% between 2005 and 2013 for all age groups, except among adolescents (aged 10-19 years). HIV is the leading cause of adolescent mortality in SSA and the second highest worldwide. [3] In 2012, the leading cause of death in all age groups in SA was HIV/ AIDS: 50.7% among children (5-14 years) and 51.9% among adults (15-44 years). [4] The national household HIV study estimated that 131 052 children (0-14 years) and 273 981 adolescents and young adults (15-24 years) had been exposed to antiretroviral therapy (ART) in 2017, and 51.9% and 47.7% had achieved viral load suppression (VLS), respectively. [5] Although SSA has recorded comparably better adherence rates among adolescents on ART than other regions, [6] the main treatment outcome-VLS-remains unsatisfactory. [7-9] A meta-analysis of 8 studies in SA reported VLS among adolescents and young adults receiving ART as 81%. [10] Earlier studies conducted in SA reported VLS among adolescents at 12 months as 76% in selected public clinics in Gauteng and Mpumalanga provinces between 2004 and 2010; and 27% in a Cape Town-based ART clinic between 2002 and 2009. Despite the poor treatment outcomes regarding VLS displayed by adolescents receiving ART, their situations are often overlooked because routine reporting in HIV programmes focus mainly on outcomes for paediatric (0-14 years) and adult (≥15 years) populations. Understanding treatment outcomes for adolescents (10-19 years) is critical, because during this period patients are made aware of their HIV status (infected vertically), and have to learn to self-manage their disease (i.e. adhere to treatment regimens and attend clinic appointments) as they are transitioned to the adult HIV treatment programme. Objectives We report findings on 2-year treatment outcomes (VLS) of adolescent patients who were newly initiated on ART in public health facilities in the Metropole of Western Cape Province in 2013, and the risk factors associated with VLS at 4, 12 and 24 months after ART initiation. Methods Design We conducted a retrospective cohort analysis of adolescents aged This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Globally, it has been estimated that 190 000 (59 000-380 000) adolescents, between the ages of 10 and 19 years, were newly infected with human immunodeficiency virus (HIV) in 2018, and the total number of adolescents living with HIV (ALWH) was 1.6 million (1.1-2.3 million), which accounts for 4% of all people living with HIV (PLWH). 1 Sub-Saharan Africa has the highest number of HIV-infected adolescents with about 1.5 million of them. In South Africa (SA), it is estimated that 280 000 children aged between 0 and 14 years were living with HIV in 2017, and that just under 7 million persons aged ≥ 15 years were PLWH. 2 The national HIV household survey estimated HIV prevalence in 0-14-year-olds to be 3.0% and 2.4% for females and males, respectively. 3 In 15-19-yearolds, it was 5.8% in females and 4.7% in males. The number of adolescents aged 15-19 years receiving antiretroviral therapy (ART) in SA increased tenfold between 2005-2008 and 2013-2016. 4 This increase is attributed to perinatally infected infants surviving into adolescence and to a rising incidence of HIV in behaviourally infected 15-19-year-olds.Despite success in ART roll-out in most countries over the last decade, acquired immune deficiency syndrome (AIDS)-related deaths amongst adolescents have increased whilst declining in other age groups. 5 To prevent AIDS-related deaths, the infected must be diagnosed, receive ART and remain in care to maintain viral load (VL) suppression. This would help achieve the 90-90-90 targets of the Joint United Nations Programme on HIV and AIDS (UNAIDS). 6 Retention on ART is particularly challenging for key populations, such as adolescents, amongst others, and has been noted as a global priority for action. 7,8 Previous studies confirm that adherence, retention in care (RiC) and treatment outcomes for adolescents in southern Africa are worse, compared with adults. 9,10,11 Background: Long-term retention of adolescents aged 10 -19 years on antiretroviral therapy (ART) is crucial to achieve viral load suppression. However, it is reported globally that adolescents have lower retention in care (RiC) on ART, compared with children and adults.Objectives: To determine the prevalence and predictors of RiC of adolescents over 2 years following initiation onto ART in public health facilities in the Metropole District Health Services of the Western Cape province in 2013.Methods: Data of 220 adolescent patients who were newly initiated on ART in 2013 were extracted from the provincial electronic database, and subjected to univariate and bivariate analyses using SPSS. Results:The rate of RiC post-initiation was low throughout the study period, that is, 68.6%, 50.5% and 36.4% at 4, 12 and 24 months, respectively. The corresponding post-initiation viral load suppression levels on ART of those remaining in care and who had viral loads monitored were 84.1%, 77.4% and 68.8% at 4, 12 and 24 months, respectively. Retention in care after initiation on ART was higher amongst younger adolescents (10-14 years), compared with older adolescen...

Background Tuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients. Methods We conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool. Results We identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1–34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1–23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1–23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7–30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9–8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis. Conclusions In South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables. Systematic review registration The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018108622. This study was funded by the Bill and Melinda Gates Foundation (Investment ID OPP1173131) via the South African TB Think Tank.