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Objective Antiretroviral therapy (ART) significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In high HIV prevalence settings, outreach strategies are needed to find asymptomatic HIV positive persons, link them to HIV care and ART, and achieve viral suppression. Methods We conducted a prospective intervention study in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda. The intervention included home HIV testing and counseling (HTC), point-of-care CD4 count testing for HIV positive persons, referral to care, and one month then quarterly lay counselor follow-up visits. The outcomes at 12 months were linkage to care, and ART initiation and viral suppression among HIV positive persons eligible for ART (CD4≤350 cells/μL). Findings 3,393 adults were tested for HIV (96% coverage), of whom 635 (19%) were HIV positive. At baseline, 36% of HIV positive persons were newly identified (64% were previously known to be HIV positive) and 40% were taking ART. By month 12, 619 (97%) of HIV positive persons visited an HIV clinic, and of 123 ART eligible participants, 94 (76%) initiated ART by 12 months. Of the 77 participants on ART by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV positive persons, the proportion with viral suppression (<1,000 copies/mL) increased from 50% to 65% (p=<0.001) at 12 months. Interpretation Community-based HTC in rural South Africa and Uganda achieved high testing coverage and linkage to care. Among those eligible for ART, a high proportion initiated ART and achieved viral suppression, indicating high adherence. Implementation of this HTC approach by existing community health workers in Africa should be evaluated to determine effectiveness and costs.

Background Community-based delivery of antiretroviral therapy (ART) for HIV, including ART initiation, clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral suppression, reducing the gap in access to care for individuals who have detectable HIV viral load, including men who are less likely than women to be virally suppressed. We aimed to test the effect of community-based ART delivery on viral suppression among people living with HIV not on ART. Methods We did a household-randomised, unblinded trial (DO ART) of delivery of ART in the community compared with the clinic in rural and peri-urban settings in KwaZulu-Natal, South Africa and the Sheema District, Uganda. After community-based HIV testing, people living with HIV were randomly assigned (1:1:1) with mobile phone software to community-based ART initiation with quarterly monitoring and ART refills through mobile vans; ART initiation at the clinic followed by mobile van monitoring and refills (hybrid approach); or standard clinic ART initiation and refills. The primary outcome was HIV viral suppression at 12 months. If the difference in viral suppression was not superior between study groups, an a-priori test for non-inferiority was done to test for a relative risk (RR) of more than 0•95. The cost per person virally suppressed was a co-primary outcome of the study. This study is registered with ClinicalTrials.gov, NCT02929992.

Background We hypothesized that community-based HIV testing with counselor support and point-of-care CD4 count testing would increase uptake of antiretroviral therapy (ART) and male circumcision. Methods We conducted a randomized study of linkage strategies following community-based HIV testing in rural South Africa and Uganda. HIV-positive persons were randomized to 1) lay counselor follow-up home visits, lay counselor clinic linkage facilitation, or standard clinic referral; and then to either 2) point-of-care CD4 testing, or referral for CD4. HIV-negative uncircumcised men who could receive secure text messages were randomized to text message reminders, lay counselor visits, or referral. The primary outcomes were viral suppression at 9 months in HIV-positive persons and uptake of male circumcision by HIV-negative, uncircumcised men at 3 months. The study was registered at ClinicalTrials.gov (NCT02038582). Findings Between June 2013 and February 2015, 15,332 participants were tested; 1,325 HIV-positive persons and 750 HIV-negative uncircumcised men were randomized to linkage strategies. Among HIV-positive persons, overall clinic linkage was 93% (1,218/1,303) but ART initiation was only 37% (488/1,303). The proportion of persons who were virally suppressed ranged from 47%-52% (214/422 in the clinic referral arm, 219/419 in the clinic facilitation arm, and 202/431 in the lay counselor follow-up arm; p=0.668 and p=0.273, for the clinic facilitation and lay counselor follow-up arms, respectively, compared with clinic referral). There was no difference in viral suppression at 9 months by study arm. In the male circumcision clinic referral (standard of care) arm, 62/224 men (28%) were circumcised, compared to 137/284 (48%) in the text message reminder arm (RR=1.72, 95% CI 1.36-2.17) and 106/226 (47%) in the lay counselor follow-up arm (RR=1.67, 95% CI 1.29-2.14). Interpretation All the community-based strategies achieved very high rates of linkage of HIV positive persons to HIV clinics, approximately one-third of whom initiated ART, and approximately half were virally suppressed by 9 months. Clinic barriers to ART initiation must be addressed in future strategies to increase knowledge of HIV serostatus and linkage to HIV care. Uptake of male circumcision was almost two-fold higher among men who received text message reminders or lay counselor visits.

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Introduction: Among people living with HIV in South Africa, viral suppression is lower among men than women. The study aim was to test the impact of lottery incentives, which reward positive health choice (e.g. antiretroviral therapy (ART) linkage) with a chance to win a prize, on strengthening the HIV care continuum including ART initiation and viral suppression for men. Methods: We conducted a randomized, prospective trial of lottery incentives in the context of HIV testing and linkage to ART in rural KwaZulu-Natal, South Africa. Men living with HIV were randomly allocated to: lottery incentives and motivational text messages or motivational text messages only. Lottery prize eligibility was conditional on clinic registration, ART initiation, or viral suppression by one, three and six months respectively. After completing each continuum step, participants in the lottery group were notified whether they had won and were encouraged to continue in care. Lottery prizes were either a mobile phone, data or a gift card (valued at R1000/$100). Kaplan-Meier curves were plotted to determine time to ART initiation by study group. The primary outcome was viral suppression at six months. Results: Between November 2017 and December 2018, we tested 740 men for HIV and enrolled 131 HIV-positive men who reported not being on ART. At baseline, 100 (76%) participants were 30 years and older, 95 (73%) were unemployed and the median CD4 count was 472 cells/lL. At study exit, 84% (110/131) of participants had visited a clinic and 62% (81/131) were virally suppressed. Compared to motivational text messages, lottery incentives decreased the median time to ART initiation from 126 to 66 days (p = 0.0043, age-adjusted Cox regression) among all participants, and, from 134 days to 20 days (p = 0.0077) among participants who were not virally suppressed at baseline. Lottery incentives had an inconclusive effect on clinic registration (RR = 1.21, 95% CI: 0.83 to 1.76) and on viral suppression at six months (RR = 1.13, 95% CI: 0.73 to 1.75) compared to motivational text messages. Conclusions: Conditional lottery incentives shortened the time to ART initiation among South African men. Behavioural economics strategies strengthen linkage to ART, but the study power was limited to see an impact on viral suppression. Clinical Trial Number: NCT03808194.

Recent attempts to integrate geographic information systems (GIS) and participatory techniques, have given rise to terminologies such as participatory GIS and community-integrated GIS. Although GIS was initially developed for physical geographic application, it can be used for the management and analysis of health and health care data. Geographic information systems, combined with participatory methodology, have facilitated the analysis of access to health facilities and disease risk in different populations. Little has been published about the usefulness of combining participatory methodologies and GIS technology in an effort to understand and inform community-based intervention studies, especially in the context of HIV. This article attempts to address this perceived gap in the literature. The authors describe the application of participatory research methods with GIS in the formative phase of a multisite community-based social mobilization trial, using voluntary counseling and testing and post-test support as the intervention.

Objectives: To identify potential risk factors for pre- and postoperative seizures and epilepsy in children with congenital heart disease. Methods: Retrospective cohort study of neonates and infants <3 months of age with congenital heart disease who underwent cardiopulmonary bypass from November 24, 2006, until June 1, 2015. Children with seizures were classified based on time of occurrence into early preoperative, early postoperative, and late postoperative. Children with recurring seizures 30 days after cardiac surgery met criteria for epilepsy. Results: 247 patients completed follow-up; 2.4% had seizures early preoperation and 1.6% early postoperation. Late postoperative epilepsy occurred in 5.3% of the cohort. The majority of seizures in the late postoperative epilepsy group started after 1 year of age (mean 1.53 years, range = 0.18-4.7 years). One of the 13 patients with epilepsy had a seizure during their intensive care unit hospitalization. Potential risk factors for seizures included brain injury ( P < .001), high-risk surgery (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score ≥3, P = .024), and low birth weight ( P < .04). Infants with stroke were more likely to develop epilepsy ( P = .04). Presence of seizures was associated with increased length of stay ( P < .001). Conclusions: Our study suggests an association between children with congenital heart disease diagnosed with stroke in the neonatal/infancy period and the development of epilepsy. These children may not have prior early pre- and postoperative seizures. Risk factors for seizures include brain injury, high-risk surgery, and lower birth weight. Seizures were associated with an increased length of stay but did not necessarily lead to subsequent epilepsy.