PURPOSE:In South Africa, an estimated 62% of female sex workers (FSW) are living with HIV. Oral HIV pre-exposure prophylaxis (PrEP) is effective, but FSWs' PrEP use typically declines rapidly post-initiation in service settings. We examined a pilot individualized case management (ICM) intervention aiming to increase PrEP adherence and persistence among cisgender FSW initiating PrEP in eThekwini, South Africa. To assess pathways of intervention influence and potential effectiveness, we characterize the support participants received from the case manager (CM) and the ways in which it influenced their PrEP adherence and persistence. METHODS:FSW initiating PrEP through a non-governmental key populations program (n = 29) participated in the pilot ICM sessions for 12 weeks, as well as semi-structured, in-depth interviews (IDIs) at baseline, month 1, and month 3. We triangulated the IDIs with CM observation notes and PrEP program refill data through month 4. We coded textual data thematically, and produced narrative summaries and time-ordered matrices to summarize themes, assess changes over time, and compare participants who continued versus discontinued PrEP by month 4. We employed the "capability, opportunity, and motivation - behavior (COM-B)" system in interpreting the pathways through which the CM's support influenced participants' PrEP adherence and persistence and considering potential intervention enhancements. RESULTS:The CM provided emotional, instrumental, and informational support that positively influenced participants' PrEP use capability, opportunity, and motivation. She bolstered participants' PrEP use capability by providing reminder tools and information to manage side effects and dispel misunderstanding; opportunity by helping strategize covert PrEP use in the face of stigma, and directly resolving pill access problems stemming from mobility and housing insecurity; and motivation by providing care and accompaniment. Experiences of care, accompaniment, and other emotional support from the CM were deeply felt in context of sex work stigma, and more prominent in the narratives of participants continuing PrEP at month 4 (20/29; 69%) versus those who discontinued. Still, 31% (9/29) of participants discontinued PrEP, and key influential forms of CM support required her ongoing presence. CONCLUSIONS:Findings suggest both pathways of potential ICM effectiveness and impact and sustainability shortfalls, calling for larger-scale evaluation and complementary structural approaches, such as those bolstering FSW social cohesion and tackling socio-economic barriers.

PrEP uptake and continuation among women in sub-Saharan Africa, including adolescent girls, young women (AGYW), and female sex workers (FSW), remains suboptimal. Societal costs, like lost wages and time, are potential barriers. This study assessed the time and resources spent by patients and provider for PrEP-related care including HIV testing, STI screening, PrEP counseling, and prescription management of PrEP among AGYW and FSW in South Africa, exploring factors that may affect PrEP uptake and continuation. We conducted a cross-sectional time and motion study, representing a quantitative method used to assess the duration required to complete a defined series of tasks, at 13 decentralized PrEP service sites across nine districts in South Africa. The study measured time spent by clients (AGYW and FSW) receiving PrEP services and by healthcare providers delivering care. Wilcoxon rank-sum tests compared service durations, and opportunity costs (wages lost due to time receiving PrEP services) were estimated for all FSW. The study included 148 participants (40

Background: Tuberculosis (TB) preventive treatment (TPT) is recommended to prevent the development of active disease among high-risk groups, including close TB contacts and people living with HIV. However, TPT uptake and completion are suboptimal in high-incidence settings like South Africa. This study explored perspectives on TPT completion in Khayelitsha, a township in Cape Town. Methods: We conducted in-depth interviews with 20 participants at six primary healthcare facilities in Khayelitsha, purposively sampled to capture diverse perspectives on TPT completion. The sample included 12 caregivers of children who completed (n=7) or stopped TPT (n=5), and 8 adults who completed (n=5) or stopped (n=3) TPT. Thematic analysis used inductive coding to identify initial themes, which were organised deductively according to the Health Belief Model (HBM) constructs of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Results: While participants mostly recognised they were at risk of TB, perceived susceptibility was impaired by gaps in knowledge about transmission, including understanding that child contacts could develop TB. Perceived severity of TB was high and was also associated with TB-related stigma, which was driven by fears of infectiousness. Participants did not all perceive the benefits of TPT due to gaps in knowledge of TB and specifically TPT. Barriers included unpleasant medication taste, lack of child-friendly formulations, missed appointments due to work commitments, and negative experiences with healthcare providers, which affected TPT uptake and completion. Most participants received 6H; however, those receiving 3HP praised the shorter regimen. Cues to action are prompts to start or continue health behaviour, including support from health workers, such as CHWs. Participants who completed TPT reported high self-efficacy afterwards, whereas those who stopped TPT experienced low self-efficacy and identified opportunities for enhanced support. Conclusions: Strategies to address barriers to TPT uptake and completion include providing child-friendly formulations, improving healthcare experiences more broadly, and implementing practical support strategies. Greater involvement of CHWs with community TPT delivery and support could reduce barriers. Interventions should incorporate family-centred counselling and training for healthcare providers on approaches to strengthen TPT uptake and completion and reduce TB incidence in high-burden settings.

Background Female sex workers (FSW) in South Africa are disproportionately impacted by HIV, yet daily oral pre-exposure prophylaxis (PrEP) initiation and continuation rates among FSW remain low. Long-acting injectable PrEP (LAI-PrEP) may alleviate many oral PrEP adherence challenges; however, LAI-PrEP remains largely unavailable in South Africa. Objectives Explore the multilevel contextual determinants likely to influence LAI-PrEP’s implementation among FSW to inform rollout strategies. Design Cross-sectional, qualitative study with in-depth interviews and focus group discussions. Methods From May to June 2024, 42 adult FSW not living with HIV and accessing services from two decentralized FSW delivery sites in eThekwini and Ehlanzeni participated in interviews (12 per study site; n=24 FSW total) and focus groups (1 per study site; n=18 FSW total). Four providers were also interviewed (2 per study site). Semi-structured guides, based on the Consolidated Framework for Implementation Research (CFIR), elicited client and provider perceptions of contextual factors hypothesized to influence future LAI-PrEP implementation, mapped to CFIR constructs through team-based, deductive thematic analysis. Results Many FSW conveyed strong acceptance and preferences for LAI-PrEP due to perceived advantages over oral PrEP including greater dosing privacy in clinical spaces, fewer dispensing intervals, and reduced stress from daily pill-taking. Providers perceived LAI-PrEP as a priority to augment existing HIV prevention services; however, financial investments, additional staff, and LAI-PrEP counseling training would be needed to enhance programmatic capabilities. Prioritization of non-discriminatory provider attitudes will be crucial to combat persistent racialized and economic inequities that exacerbate stigma against FSW in public healthcare facilities. Finally, decentralized delivery, utilizing community champions, and integrating LAI-PrEP with other health services emerged as promising strategies to ensure an equitable rollout of LAI-PrEP, assuming adequate global or national investment. Conclusion Findings suggest that LAI-PrEP is perceived by both potential recipients and deliverers to effectively address several barriers to oral PrEP continuation, making it a promising advancement in the landscape of HIV prevention. Implementation strategies that integrate identified stakeholder priorities and preferences, anticipated barriers, and existing programmatic strengths, will likely optimize LAI-PrEP rollout among a historically marginalized population in South Africa.

BACKGROUND:Tailored implementation strategies to promote the uptake and scale-up of antiretroviral therapy (ART) among female sex workers (FSWs) in South Africa are needed, because <50% of FSW living with HIV are on ART and <40% are virally suppressed. SETTING:We conducted a randomized trial testing 2 HIV treatment support strategies (decentralized treatment provision; individualized case management) among 777 FSW living with HIV and not virally suppressed (≥50 copies/mL) in Durban, South Africa, June 2018-January 2022. METHODS:We defined strategy engagement in a 6-month interval if the monthly strategy session was delivered and the FSW participated. Group-based trajectory modeling with logit response function was used to identify engagement trajectories and describe correlates of trajectories. We used Poisson regression analysis with robust variance estimation to assess the association between assigned trajectory group and 18-month retention and viral suppression (<50 copies/mL). RESULTS:We identified 4 trajectories: no engagement (12%), late engagement (10%), engagement corresponding with study visits (53%), and consistent engagement (25%). FSW who were older, unmarried, receiving ART at enrollment, and decentralized treatment provision assignment were more likely to be classified in the consistently engaged trajectory compared with the no engagement trajectory. The prevalence of 18-month retention and viral suppression was higher among FSW assigned to the consistent engagement trajectory than FSW assigned to the no engagement trajectory (prevalence ratio = 3.2, 95% confidence interval: 1.6 to 6.3). CONCLUSIONS:Person-centered HIV services that address unmet treatment needs could improve health, viral suppression, and subsequently reduce population-level HIV transmission. CLINICAL TRIAL REGISTRATION:NCT03500172.

People who inject drugs (PWID) are disproportionately burdened with hepatitis C virus (HCV) infection in South Africa (SA). Transmission dynamics can be inferred using phylogenetic clustering to inform prevention interventions. We utilized Core-E2 sequences and demographic data to investigate factors associated with HCV phylogenetic clustering among PWID and men who have sex with men (MSM) who inject drugs in SA. Previously genotyped samples (n = 285) that met the selection criteria were extracted, amplified, and Sanger sequenced. Phylogenetic trees were inferred using maximum likelihood implemented in RAxML (Cipres Gateway). Transmission clusters were determined in Clusterpicker using a 90% bootstrap threshold and a genetic distance cut-off on genetic similarity of ≤3.5%. Factors associated with clustering were assessed using logistic regression. Phylogenetic clustering of Core-E2 sequences was observed for 55% (78 of 141) of participant samples that were successfully sequenced, including 50 (64.1%) with genotype 1a and 28 (35.9%) with genotype 3a. Twelve clusters were identified, including six clusters each for genotypes 1a and 3a. Among genotype 1a, the cluster size ranged from 3 to 15 participants. Among genotype 3a, the cluster size ranged from 3 to 9 participants. Clustering among the mixed ancestry group in Cape Town was noted for ages 18-55. Factors independently associated with phylogenetic clustering included sharing a needle (adjusted odds ratio [aOR] 4.02, 95% confidence interval [CI] 1.08-14.87, p = 0.037), age ≥ 29 years (aOR 3.00, 95% CI 1.22-7.37, p = 0.016), and mixed ancestry race (aOR 6.11, 95% CI 1.87-19.95, p = 0.003). These data highlight the urgent need to reduce transmission by providing sufficient sterile needles and syringes and tailored education to prevent HCV transmission among older, experienced PWID.

Background: Hepatitis B virus (HBV) and hepatitis C virus (HCV) are estimated to be of the most prevalent infectious diseases in correctional settings worldwide. However, viral hepatitis services have not been routinely integrated into South African correctional facilities. We aimed to assess prevalence of HBV infection and HCV infection among people accessing HIV services and assess the feasibility of viral hepatitis service integration in a South African correctional centre. Methods: Voluntarily participating people in a correctional services facility were offered free hepatitis B surface antigen (HBsAg) and anti-HCV point-of-care testing in addition to routine HIV testing and treatment services on a first-come, first-served basis during June 2021-March 2022. Off-site laboratory testing (HBV and HCV molecular testing and non-invasive liver fibrosis staging) and screening for hepatocellular carcinoma informed further management. A general practitioner at the facility managed participants, with virtual support from hepatologists. Data on age and history of injecting was collected and point-of-care and laboratory results were recorded. Data were analysed using descriptive statistics. Results: The median age of the 765 people who participated was 32.5 years (IQR 27.5 - 38.2), with 2.2% (17/ 765) reporting having ever injected a drug. The sample prevalence was 3.9% (30/765) for HBV infection, 0.5% (3/665) for HCV infection, and 1.2% (9/765) for HIV-HBV coinfection. Thirty people had reactive HBsAg pointof-care tests. Among those with reactive HBsAg point-of-care tests 90.0% (27/30) received work-up, among whom 48.1% (13/27) were monitored, 44.4% (12/27) were placed on treatment and two people were released before a management plan could be finalised. Of those treated 33.3% (4/12) started tenofovir/emtricitabine and 66.7% (8/12) antiretroviral therapy. Of the eligible participants, 27.3% (201/735) received at least one hepatitis B vaccine dose and 26.9% (54/201) received three doses. All three participants who had confirmed HCV infection were started on direct-acting antivirals. Of the two completing treatment one achieved sustained virological response at 12 weeks (SVR12), one person was released before SVR12 was done. One person was lost to follow-up. No clinical adverse events were reported. Conclusion: There was a notable viral hepatitis burden among people in this correctional centre and integration of viral hepatitis services into the existing HIV services was acceptable and feasible. Further efforts to sustain and expand access to viral hepatitis services in South African correctional centres could catalyse national viral hepatitis elimination efforts.

Female sex workers (FSW) are disproportionately impacted by HIV and substance use. Substance use has been linked to poor HIV treatment outcomes, necessitating exploration of substance use patterns — including polysubstance use — and predictors among FSW living with HIV.Data were obtained for 777 FSW living with HIV who were not virally suppressed and previously randomized to Siyaphambili, a trial of HIV treatment support strategies implemented through TB HIV Care in eThekwini, South Africa. FSW were asked about recent marijuana, opioid, stimulant, and hazardous alcohol use at enrollment and semi-annually for 18 months from June 2018-January 2022. We estimated incidence of substance use initiation/cessation post-enrollment and used Kaplan-Meier plots and lasagna plots to visualize trends. Cox proportional hazards models assessed baseline predictors of substance use initiation/cessation.Overall, 454 FSW (58.4%) reported any opioid and/or stimulant use. Prior visit hazardous alcohol use (aHR: 0.20, 95% CI 0.09-0.41) and prior-visit stimulant use (aHR: 2.80, 95% CI 1.23-6.37) were negatively and positively associated with opioid initiation, respectively. Prior visit marijuana use (aHR: 1.75, 95% CI 1.11-2.75) and opioid use (aHR: 5.31, 95% CI 3.32-8.51) were positively associated with stimulant initiation.We found a high prevalence of substance use among FSW living with HIV that was dynamic over time, including a shared relationship between opioid and stimulant use that suggests intertwined substance use. Further investigation into the impact of polysubstance use patterns on success of HIV support strategies is needed to inform HIV treatment and harm reduction programming.

Background Challenges and gaps with routine tuberculosis (TB) data and surveillance systems are well-known. To address them, numerous TB data and evidence-related tools (e.g. surveys, assessments) have been developed to help countries collect, analyze, and use TB-related data. The “TB Data Optimization Project” aimed to assess the use and usefulness of these tools and propose best practices. Methods Phase one of this mixed-methods project included structured key informant interviews (KIIs) with TB data experts, literature review, and mapping tools' indicators and metrics. Phase two consisted of case studies in five countries (Ethiopia, Kenya, Pakistan, Uganda, and Vietnam). Structured KIIs and a use case discussion were conducted with TB program staff and partners in each country, and TB-related documents were reviewed. Phase three was an online survey for national TB programs. Qualitative data were recorded, transcribed, coded, and inductively analyzed. Quantitative data were analyzed descriptively. Findings were triangulated and summarized into key themes. Results Seventy-two KIIs were conducted, 42 countries completed surveys, and 212 documents were reviewed. Six key themes emerged: usefulness, opportunities and challenges with planning and implementation, technical assistance and financial support, timing and coordination, motivating factors for implementation, and the role of tools in relation to routine data systems. The tools provide critical information and most were considered worth the investment. Challenges include suboptimal implementation of the recommendations from the tools, poor timing and coordination of implementation, and insufficient capacity building. A set of best practices was developed. Conclusion While the long-term goal is to strengthen and integrate routine data systems, TB data tools currently play an important role in filling gaps. Findings from this project provide considerations for optimal use of TB data tools; however, there is still need for further guidance on selecting the most critical tools to fill gaps during TB programmatic and strategic planning.

Mycobacterium tuberculosis (TB) antigen-based skin tests, known as TB-specific skin tests (TBSTs), have been recommended by the World Health Organization (WHO) to test for TB infection (TBI). In light of these new recommendations, we conducted a situational analysis and market assessment to evaluate the utility of testing for TBI in general and of the new TBSTs in South Africa. We found the following barriers to acceptability of testing for TBI overall, regardless of the test: the perceived high prevalence of TBI; prior experiences of poor TB preventive treatment (TPT) uptake, which has led to the removal of TBI tests from the current TPT guidelines; and a poor sensitivity of previous TBI tests in people living with HIV (PLHIV). In addition, further barriers to the new TBSTs in particular were as follows: patient level barriers linked to repeat visits; the need for cold chains; and the need for a strong laboratory system, which reduces the need for point-of-care options. TBI testing was thought to be potentially useful to determine the eligibility for TPT in these use cases: healthcare workers, pregnant women living with HIV and prisoners. One other use case was in the TB diagnoses of children, where it was thought that a positive immunological test (TST/IgRA/TBST) could indicate a TB contact and serve as a ‘rule in’ test to strengthen the evidence for TB disease as a cause.

Since 2014, the multi-country DREAMS programme has aimed to prevent HIV acquisition among highly vulnerable adolescent girls and young women through a multi-dimensional and comprehensive intervention. TB HIV Care ─ a DREAMS implementing partner in South Africa ─ adapted the programme to address local needs, developing an innovative component to positively influence mental health outcomes and further protect adolescent girls and young women from HIV infection. This paper details the integration of TB HIV Care’s mental health component into the programme, and argues that this approach offers a model and lessons for the adoption of better mental health services within the Primary Health Care system. Adolescent girls and young women aged 10─24 years were recruited in five districts with high HIV prevalence in the Eastern Cape and KwaZulu-Natal, where TB HIV Care implements the DREAMS programme. Once enrolled in age-appropriate educational sessions, each participant received comprehensive mental health risk screening by trained psychosocial support workers. TB HIV Care’s specially developed electronic risk-reduction screening tool incorporates aspects of Pfizer’s patient health questionnaire; the general anxiety disorder form; the alcohol use disorders identification test, and the drug use disorders identification test, and is used to identify mental health concerns and substance use disorders. This screening system enables the mental health risk profile of clients to be identified for their prompt referral to appropriate treatment services. Between October 2022 and May 2024, 145 605 participating adolescent girls and young women underwent mental health screening. While most participants were in a low-risk mental health category, over 5 000 were in need of first-line counselling; 934 required higher-level support, and 506 moderate- to high-risk cases needed in-depth support. TB HIV Care implemented its mental health treatment cascade with these clients, with encouraging results. This paper provides lessons for the government in addressing weaknesses and gaps in existing mental health services, not only for adolescent girls and young women, but also for the broader population. Such approaches should be better integrated into the Primary Health Care system to reduce the impact of mental health disorders on young people.

PURPOSE:In South Africa, female sex workers (FSW) living with HIV have suboptimal treatment outcomes. The Siyaphambili trial tested two strategies to promote viral suppression. This paper identifies why and under what conditions the strategies were appropriate, feasible, implemented with fidelity, and ultimately effective for FSW living with HIV. METHODS:Guided by the Consolidated Framework for Implementation Research, we conducted in-depth interviews with 36 Siyaphambili participants using maximum variation sampling and purposively selected 12 key informant implementors. We generated 'Context + Mechanism = Outcome' configurations using deductive coding and retroductive inference. RESULTS:Overall, strategy appropriateness for FSW reflected how "the needs of innovation recipients" enhanced/challenged the "relative advantage" of the strategies. Feasibility of implementation resulted from the interaction of the "work infrastructure", "available resources", and access to "knowledge and resources," which activated/dampened the "design" of the strategies. Fidelity of implementation relied on how "partnerships", "relational connections" and "communication" influenced strategy "complexity" and "adaptability." Strategy effectiveness depended on the influence of FSW "capability" on their "motivation and opportunity." CONCLUSIONS:Understanding the conditions in which these strategies did or did not work aids in understanding the why this pragmatic trial failed to achieve anticipated results and informs potential success that can be taken forward to better optimize treatment outcomes for FSW.

BACKGROUND:People in correctional settings are a key population for HIV epidemic control. We sought to demonstrate scale-up of universal test and treat in correctional facilities in South Africa and Zambia through a virtual cross-sectional analysis. METHODS:We used routine data on 2 dates: At the start of universal test and treat implementation (time 1, T1) and 1 year later (time 2, T2). We obtained correctional facility census lists for the selected dates and matched HIV testing and treatment data to generate virtual cross-sections of HIV care continuum indicators. RESULTS:In the South African site, there were 4193 and 3868 people in the facility at times T1 and T2; 43% and 36% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 1803 (43%) and 1386 (36%) had known HIV status, 804 (19%) and 845 (21%) were known to be living with HIV, and 60% and 56% of those with known HIV were receiving antiretroviral therapy (ART). In the Zambian site, there were 1467 and 1366 people in the facility at times T1 and T2; 58% and 92% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 857 (59%) and 1263 (92%) had known HIV status, 277 (19%) and 647 (47%) were known to be living with HIV, and 68% and 68% of those with known HIV were receiving ART. CONCLUSIONS:This virtual cross-sectional analysis identified gaps in HIV testing coverage, and ART initiation that was not clearly demonstrated by prior cohort-based studies.

Background:Given intersecting social and structural factors, female sex workers (FSW) exhibit elevated risk of HIV and substance use. However, there is limited study of how distinct substance use typologies influence HIV treatment outcomes among FSW.Setting:A cross-sectional survey with objective viral load assessments of 1391 FSW enrolled into a treatment optimization-focused trial in Durban, South Africa (2018-2020).Methods:We used latent class analysis to uncover discrete patterns in past-month self-reported use of the following substances: heavy alcohol use, cannabis, cocaine, crack, ecstasy, methamphetamine, heroin, and Whoonga. We used Wald tests to identify multilevel predictors of latent class membership and multivariable mixture modeling to quantify associations of substance use classes with HIV viremia (>= 50 RNA copies/mL).Results:Substance use (87%) and HIV viremia (62%) were highly prevalent. Latent class analysis uncovered 3 polysubstance use profiles: Heavy Alcohol Use Only (similar to 54%); Cannabis, Heavy Alcohol, & Crack Use (similar to 28%); and Whoonga & Crack Use (similar to 18%). Whoonga & Crack Use was associated with social and structural adversities, including homelessness, outdoor/public sex work, HIV stigma, and violence. Relative to Heavy Alcohol Use Only, HIV viremia was significantly higher in the Whoonga & Crack Use class (adjusted odds ratio 1.97, 95% confidence interval: 1.13 to 3.43), but not in the Cannabis, Heavy Alcohol, & Crack Use class (adjusted odds ratio 1.17, 95% confidence interval: 0.74 to 1.86).Conclusion:HIV viremia differed significantly across identified polysubstance use profiles among South African FSW. Integrating drug treatment and harm reduction services into HIV treatment programs is key to improving virologic outcomes in marginalized communities.

PURPOSE:This study assesses risk factors of loss to follow-up (LTFU) and estimates mortality risk among female sex workers (FSW) with HIV in Durban, South Africa, in 2018-2021. METHODS:We used data from the Siyaphambili trial, which evaluated strategies for improved viral suppression. FSW with HIV aged ≥ 18 years with viral load ≥ 50 copies/mL were followed up for 18 months. LTFU was defined as absence from study or intervention visits for 6 months. We traced LTFU participants by calling/in-person visit attempts to ascertain their vital status. We used Cox regression to determine risk factors of LTFU and inverse probability of tracing weights to correct mortality risk. RESULTS:Of 777 participants, 10 (1.3%) had died and 578 (74.4%) were initially LTFU. Among those LTFU, 36.3% (210/578) were traced successfully, with 6 additional deaths ascertained. Recent physical and sexual violence, and non-viral suppression were associated with increased LTFU. The unweighted and weighted 18-month mortality risks were 2.4% (95% CI: 0.8%-3.9%) and 3.7% (95% CI: 1.8%-5.9%), respectively. CONCLUSIONS:LTFU is common among FSW with HIV in South Africa with additional investigation of vital status demonstrating under-ascertained mortality. These data suggest the need for comprehensively addressing risks for mortality among FSW.

After nearly a decade of HIV pre-exposure prophylaxis (PrEP) rollout in sub-Saharan Africa, there has been limited study of PrEP messaging in news media. We selected twenty South African newspapers with the highest circulation volumes to retrieve articles published in 2012-2021 mentioning PrEP (N = 249). Using inductive content analysis, we developed a structured codebook to characterise PrEP-related content and sentiments, as well as their evolution over time, in the South African press. Many articles espoused favourable attitudes towards PrEP (52%), but a sizeable fraction espoused unfavourable attitudes (11%). Relative to PrEP-favourable articles, PrEP-unfavourable articles were significantly more likely to emphasise the drawbacks/consequences of PrEP use, including adherence/persistence requirements (52% vs. 24%, p = .007), cost (48% vs. 11%, p < .001), and risk compensation (52% vs. 5%, p < .001). Nevertheless, the presence of these drawbacks/consequences in print media largely declined over time. Key populations (e.g. adolescents, female sex workers) were frequently mentioned potential PrEP candidates. Despite message variations over time, prevention effectiveness and adherence/persistence requirements were the most widely cited PrEP benefits and drawbacks, respectively. Study findings demonstrate the dynamic nature of PrEP coverage in the South African press, likely in response to PrEP scale-up and real-world PrEP implementation during the study period.

Supplemental Digital Content is Available in the Text. Background:People in correctional settings are a key population for HIV epidemic control. We sought to demonstrate scale-up of universal test and treat in correctional facilities in South Africa and Zambia through a virtual cross-sectional analysis.Methods:We used routine data on 2 dates: At the start of universal test and treat implementation (time 1, T1) and 1 year later (time 2, T2). We obtained correctional facility census lists for the selected dates and matched HIV testing and treatment data to generate virtual cross-sections of HIV care continuum indicators.Results:In the South African site, there were 4193 and 3868 people in the facility at times T1 and T2; 43% and 36% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 1803 (43%) and 1386 (36%) had known HIV status, 804 (19%) and 845 (21%) were known to be living with HIV, and 60% and 56% of those with known HIV were receiving antiretroviral therapy (ART). In the Zambian site, there were 1467 and 1366 people in the facility at times T1 and T2; 58% and 92% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 857 (59%) and 1263 (92%) had known HIV status, 277 (19%) and 647 (47%) were known to be living with HIV, and 68% and 68% of those with known HIV were receiving ART.Conclusions:This virtual cross-sectional analysis identified gaps in HIV testing coverage, and ART initiation that was not clearly demonstrated by prior cohort-based studies.

This paper focused on the prevention of HIV transmission for adolescent girls and young women (AGYW), through a layered approach which included economic strengthening as a core strategy, especially for the most vulnerable. Based on multi-year data in KwaZulu-Natal, South Africa, we assessed the outcomes of an economic strengthening model developed by TB HIV Care (THC) in the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) HIV prevention programme. The methods used are primarily qualitative. In 2021, 2022, and 2024 DREAMS implementation staff (n = 72) and economic strengthening beneficiaries (n = 73) from four districts were interviewed on the dynamics of the model and its emerging outcomes. The qualitative data were supplemented by monitoring data. The study results showed that, while longer-term outcomes for the beneficiaries were unclear, the short and medium-term benefits of economic strengthening activities for vulnerable AGYW were highly promising. Not only did beneficiaries gain valuable technical and life skills through training, but they showed increased confidence and hope for the future, and a new sense of empowerment. They also experienced social asset building and an increase in their social, economic, and emotional efficacy. Importantly, beneficiaries also showed signs of behaviour change, away from risky behaviours towards protective ones. The paper concludes that layered economic strengthening initiatives targeted towards those most at risk AGYW, is an important pillar of efforts to reduce HIV infection; however, challenges around taking such initiatives to scale and tracking long-term outcomes remain.

In South Africa >60% of female sex workers (FSW) are living with HIV, the majority of whom are not virally suppressed. Identifying multi-level determinants of viral suppression is central to developing implementation strategies to promote retention in HIV care and viral suppression among FSW with unmet treatment needs. Adult cisgender FSW living with HIV for ≥6 months, conducting sex work as their primary source of income, and residing in Durban (South Africa) were enrolled into the Siyaphambili Study, a sequential multiple assignment randomized trial. Baseline viral load and CD4 were assessed, and an interviewer-administered survey was conducted, capturing socio-demographic, reproductive and sexual history and behaviors, vulnerabilities, substance use, mental health, and stigma. We assessed baseline determinants of viral suppression (<50 copies/mL) using bivariate and multivariable robust poisson regression, considering associations across the individual, network, environmental and macrostructural levels. From June 2018 -March 2020, 1,644 women were screened, with 1,391 eligible FSW living with HIV enrolled. The analyses were conducted among the 1,373 participants with baseline data. Overall, 65% (889/1,373) of participants were reported to be on antiretroviral therapy and 38% (520/1,373) were virally suppressed. In the multivariable model, FSW who experienced a lack of housing in the prior six months were less likely to be virally suppressed (aPR: 0.72, 95%CI 0.56-0.91), while older FSW (aPR: 1.46 95%CI: 1.16-1.83 for 30-39 years old vs. 18-29 years old; aPR: 2.15 95%CI: 1.64-2.80 for 40+ years vs. 18-29 years old) and FSW reporting hormonal or long-acting contraception use were more likely to be virally suppressed (aPR: 1.19 95% CI: 1.00-1.43). We found vulnerability to be high among FSW living with HIV in South Africa and identified individual and structural determinants associated with viral suppression. Taken together these results suggest optimizing HIV treatment outcomes necessitates supporting younger sex workers and addressing housing instability. Trial registration: NCT03500172.

People in correctional settings are a key population for HIV epidemic control. We sought to demonstrate scale-up of universal test and treat (UTT) in correctional facilities in South Africa and Zambia through a virtual cross-sectional analysis. We used routine data on two dates: at the start of UTT implementation (time 1, T1) and one year later (time 2, T2). We obtained correctional facility census lists for the selected dates and matched HIV testing and treatment data to generate virtual cross-sections of HIV care continuum indicators. In the South African site, there were 4,193 and 3,868 people in the facility at times T1 and T2; 43% and 36% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 1803 (43%) and 1,386 (36%) had known HIV status, 804 (19%) and 845 (21%) were known to be living with HIV, and 60% and 56% of those with known HIV were receiving antiretroviral therapy (ART). In the Zambian site, there were 1,467 and 1,366 people in the facility at times T1 and T2; 58% and 92% were matched with HIV testing or treatment data, respectively. At T1 and T2, respectively, 857 (59%) and 1263 (92%) had known HIV status, 277 (19%) and 647 (47%) were known to be living with HIV, and 68% and 68% of those with known HIV were receiving ART. This virtual cross-sectional analysis identified gaps in HIV testing coverage and ART initiation not clearly demonstrated by prior cohort-based studies.