ABSTRACT Introduction In South Africa, which has the world's highest prevalence of HIV, intimate partner violence (IPV) and common mental health conditions are barriers to retention in HIV treatment and achieving viral suppression. The Common Elements Treatment Approach (CETA), a cognitive‐behavioural‐therapy‐based intervention designed for lay healthcare worker delivery, is effective in reducing mental and behavioural health problems but has not been trialled for effectiveness in improving HIV outcomes. We conducted a randomized control trial to evaluate the effectiveness of CETA in improving HIV treatment outcomes among women experiencing IPV in South Africa. Methods This was a single‐blind trial conducted among women living with HIV on antiretroviral therapy (ART) who experienced sexual and/or physical IPV in the last 12 months and had either an unsuppressed viral load or were at risk for poor medication adherence in the past year (e.g. defaulted on treatment, late or missed clinic visit). Women were randomized 1:1 to receive either 8–12 CETA counselling sessions or weekly safety text messages. The primary outcome was viral suppression (≤50 copies/mL) (which requires retention) at 12 months after baseline, which was evaluated using routinely collected medical records. A linear regression model was estimated to calculate risk differences and 95% confidence intervals (CI). Results Participants were enrolled from 11 November 2021 to 19 July 2023, with 202 women randomized to CETA and 197 randomized to the control arm. Median age was 41.0 years (interquartile range [IQR]: 34.0, 47.0) with a median time on ART of 8.2 years (IQR: 4.3, 12.5). Receiving CETA was associated with a 1‐percentage point (95% CI: −0.11, 0.09) decrease in retention and viral suppression compared to the control. When restricted to individuals who completed CETA (N = 144) compared to all controls, we observed a 7‐percentage point (95% CI: −0.03, 0.18) increase in retention and viral suppression. Conclusions Our estimates suggest overall there was no meaningful difference in retention and viral suppression at 12 months between individuals who received CETA compared to individuals who received the active safety control. Future work should seek to determine if CETA can be effective among those who complete the intervention.

An effective HIV vaccine could significantly reduce HIV incidence, but demand for future HIV vaccines will be affected by misinformation. We conducted an online survey (March-April 2024) to identify the misinformation claims most likely to deter young women in South Africa (n = 188) from receiving an HIV vaccine. Participants rated HIV-vaccine misinformation as most concerning (i.e. would make them not want to get vaccinated) and least concerning (i.e. would not change a decision to get vaccinated). From 54 misinformation claims found in peer-reviewed and grey literature (e.g., reports), participants viewed two sets of 9 randomly chosen claims. Within each set, they selected the 3 most concerning and 3 least concerning claims. Claims were ranked according to their likelihood of being selected as most or least concerning. Misinformation claims that were rated as most concerning were about HIV vaccine safety, particularly those suggesting severe adverse health effects (e.g. the vaccine “will kill you”, selected 85

Background:Timely linkage to HIV prevention and treatment services following HIV self-testing (HIVST) remains a challenge in many countries. While HIVST offers privacy and convenience for individuals to know their HIV status, many do not engage in follow-up care due to behavioral barriers like uncertainty about next steps, stigma, and privacy concerns. Objective:This study evaluated the acceptability, usability, and clinical appropriateness of Your Path, an AI-powered tool designed to facilitate access to HIV services following HIVST. Methods:This study was conducted with community members and health care providers, recruited from Indlela's Behavioral Hub in South Africa. Community members were randomly assigned a mock HIV result and completed a pretest survey assessing intentions to seek HIV services, followed by a simulated HIVST guided by Your Path, delivered via WhatsApp (Meta Platforms). The tool provides guidance for HIVST support, interpretation of results, emotional support, and delivers tailored information to access HIV services through an interactive chat interface. Community members then completed a posttest survey assessing intentions to seek HIV services and usability of the tool using the System Usability Scale (SUS) questions. A subsample completed in-depth interviews exploring their experience with Your Path. Health care providers reviewed interaction transcripts, assessing clinical appropriateness, completeness, and relevance of the summaries; qualitative data underwent thematic analysis using the Theoretical Framework of Acceptability. Results:A sample of 100 community members aged between 18 and 61 years was enrolled: 59 (59%) were female, and 51 (51%) were assigned a negative mock HIV result. Overall, the intervention had its strongest effect on participants' confidence in accessing HIV services, particularly among those with HIV-negative results (Wilcoxon P=<.001; Stuart-Maxwell P=.004). Intentions and perceived importance were high at baseline and remained largely unchanged over time in both groups. The tool demonstrated high usability, with a mean SUS score of 81.6 (SD 17.5) out of 100. Most found Your Path easy to use (84/100, 84%), 76 of 100 (76%) did not need assistance, and 95 of 100 (95%) expressed willingness to use it again. However, 15 of 100 (15%) noted it did not always provide consistent responses to questions. From qualitative interviews, the majority described Your Path as helpful, user-friendly, acceptable, and private. Participants appreciated its private and nonjudgmental tone and confidentiality, though some expressed information protection concerns. Twenty-five health care providers aged between 24 and 64 years participated in qualitative interviews. The majority found the summaries clinically appropriate, informative, and beneficial for HIV care linkage, but noted limited emotional responsiveness and language barriers. Conclusions:Your Path was acceptable, usable, and clinically appropriate for supporting access to HIV services after HIVST. Larger in-field studies are needed to understand the implementation, cost, and sustainability of digital interventions in public health.

Background:The quality of interactions between healthcare providers (HCPs) and recipients of care (ROC) are important for assessing HIV vulnerability and determining PrEP eligibility. However, these conversations are often limited because of high HCP workload and time constraints. Conversational agents powered by large language models (LLM) offer a promising solution to support such interactions. We explored the potential of an LLM-powered app prototype "Your Choice" to engage people who have recently tested HIV negative in discussions on HIV prevention and PrEP. Objective:We assessed usability, acceptability, feasibility and appropriateness of the LLM-powered app prototype "Your Choice" in identifying HIV vulnerability and summarizing relevant information to support HCPs in designing personalised HIV prevention plans. Methods:Using a human-centred design (HCD) approach, we co-developed the "Your Choice" app. Between August 2023 and March 2024, we conducted surveys with ROCs and HCPs following app use. We also analysed app-user interactions for themes and content patterns. Quantitative data were analysed descriptively; qualitative data underwent content analysis. Results:We enrolled a total of 150 participants (130 ROC + 20 HCPs). Among the ROCs, most were male (77/130; 59.2%) and aged 18-34 years (93/130; 71.5%). ROCs rated the app highly acceptable and appropriate (AIM and IAM scores >4.9/5), with excellent usability scale scores (SUS >92/100, indicating exceptional usability). HCPs (n = 16) experienced in PrEP service delivery reviewed the summaries and the interactions with ROC from the app. In the pre-evaluation survey, only one expressed concern about trusting technology (1/16; 6.3%) and two thirds preferred their own judgement for ROC care (11/16; 68.8%). HCPs rated the app with a high usability scale score (SUS 78/100, indicating good usability). The app fostered open, stigma-free discussions on sex, sexuality, and HIV prevention. Conclusion:An LLM-powered conversational agent like "Your Choice" shows promise for private, stigma-free HIV prevention support, including PrEP uptake, supporting the decision-making around PrEP initiation. It can also help providers deliver more targeted care. Future research should address technological trust and clinical integration.

Background:HIV remains a major public health challenge in South Africa, with gaps in early diagnosis and linkage to care driving onward transmission. Adolescent girls and young women face barriers to timely care, including stigma, privacy concerns, and limited clinic access, while healthcare providers work in resource-constrained settings with high client volumes. We evaluated the Self-Care from Anywhere (SCFA) toolkit, an AI-enabled intervention comprising an AI Companion for AGYW and a provider-facing Clinical Portal to support HIV prevention, testing, and linkage to care. The AI Companion is designed to complement and extend human-delivered services, particularly in resource constrained settings, rather than replace in-person counselling. Methods:We conducted an exploratory study to assess the usability, feasibility, and acceptability of the SCFA toolkit in Gauteng Province (November 2024-May 2025). AGYW engaged with the AI Companion, and a subset completed a simulated HIV self-testing activity with AI-delivered counselling. Pre and post-intervention surveys, including the System Usability Scale (SUS), were administered. Usability testing of the Clinical Portal involved healthcare providers using the toolkit without formal training to capture first impressions. A subset of AGYW and healthcare providers participated in separate focus group discussions or in-depth interviews. Quantitative data were analysed using descriptive statistics, and qualitative data were analysed thematically. Results:A total of 97 AGYW were enrolled; 75.3% had completed high school and 91.8% were unemployed or full time students. Most participants (85.6%) self-reported HIV-negative status, and 63.9% reported sexual activity in the past 12 months. The AI Companion demonstrated high usability (mean SUS 87.7, SD 12.7) and was perceived as acceptable and useful, particularly for its personalisation and confidentiality features. Healthcare providers had a mean age of 34 years (SD 6.5), with about half serving as HIV testing and screening counsellors. Most providers rated the Clinical Portal's ease of use, comprehension, and client support as positive to very positive, though 23% expressed concerns regarding workflow efficiency and their ability to manage additional client volume. Providers also highlighted the Clinical Portal's value for case management. Conclusion:AI-powered digital health tools, such as the SCFA toolkit, show potential to enhance user engagement and support care delivery, with high usability and acceptability demonstrated among AGYW and healthcare providers. Continued user-centred refinement is essential to ensure these tools remain responsive to the evolving needs and care contexts of diverse user groups.

BACKGROUND:Rates of intimate partner violence (IPV) and HIV in South Africa are among the highest globally. IPV is associated with a range of adverse mental health and HIV outcomes. The Common Elements Treatment Approach (CETA) is a transdiagnostic, evidence-based intervention delivered by lay providers. OBJECTIVE:To compare the effectiveness of CETA to active attention control in reducing IPV, depression, post-traumatic stress disorder (PTSD) and substance use among women at risk of poor HIV outcomes who have experienced IPV. METHODS:Women living with HIV with an unsuppressed viral load or at risk for poor adherence and experienced past 12-month IPV were recruited from Johannesburg-area clinics and randomised 1:1 to CETA or control (SMS HIV appointment reminders plus safety checks and planning). The primary trial outcome was HIV retention and viral suppression, under review elsewhere. This paper reports secondary outcomes, evaluated at 3 and 12 months: IPV, depression, PTSD and substance use. FINDINGS:Participants were enrolled between 11 November 2021 and 19 July 2023 and randomised to CETA (N=202) or control (N=197). In the intent to treat analysis, the Cohen's d treatment effect for depression at 3 months was 0.24 (difference in mean change -3.1; 95% CI -6.1 to 0.1) and 0.48 at 12 months (-6.2; 95% CI -9.5 to -2.8). The PTSD treatment effect was 0.39 at 3 (-0.3; 95% CI -0.5 to -0.1) and 0.47 at 12 months (-0.3; 95% CI -0.5 to -0.2). Effect sizes were larger in a subgroup of participants with the top 50% of baseline symptom scores (depression: d=0.50, d=0.74; PTSD: d=0.58, d=0.94, at 3 and 12 months, respectively). There were no statistically significant differences in change for substance use or IPV. At baseline, only 12% of participants had past 3-month substance use and 32% had past 3-month or ongoing experiences of IPV, which made these outcomes challenging to evaluate. CONCLUSIONS:CETA was effective for reducing depression and PTSD, including among high severity participants and at an extended follow-up. Future studies with increased power for substance use and IPV outcomes are warranted. CLINICAL IMPLICATIONS:CETA is a recommended treatment for depression and PTSD among this population. TRIAL REGISTRATION NUMBER:NCT04242992.

BACKGROUND:Delayed and missed diagnoses are a persistent barrier to tuberculosis (TB) control, driven by difficulties collecting sputum and an unmet need for decentralized testing. Household contact investigation with point-of-care (POC) testing of noninvasive specimens may offer a cost-effective solution to strengthen active case finding. METHODS:In-home molecular POC testing was conducted using sputum and tongue specimens collected from household contacts of people with confirmed TB residing in South Africa. A health economic assessment was executed to estimate and compare the cost and cost-effectiveness of different in-home POC testing strategies against centralized sputum testing (standard of care) from a provider's perspective. The primary cost-effectiveness outcome was measured as the incremental cost per additional household contact with TB detected and linked to treatment. Decision analytic modeling was used to estimate and compare incremental cost-effectiveness ratios across strategies. RESULTS:The total implementation cost of delivering the standard of care to 300 households over a 2-year period was $85 188. Strategies that integrated in-home POC testing ranged from $88 672 to $97 271. The cost per test for in-home POC sputum testing was the highest at $20.08. Two strategies, POC sputum testing and POC combined sputum and individual tongue swab testing, were the most cost-effective with incremental cost-effectiveness ratios of $641 and $775, respectively, both below a $2760 willingness-to-pay threshold. CONCLUSIONS:In-home POC molecular TB testing strategies that use combination testing of tongue swabs and sputum specimens can meaningfully improve the number of people tested, diagnosed, and notified during household contact investigation while being cost-effective.

Background:Oral pre-exposure prophylaxis (PrEP) is a highly efficacious biomedical HIV prevention tool, yet despite being recommended by the World Health Organization (WHO) since 2015, uptake and persistence remain limited in much of the world, including sub Saharan Africa (SSA). There is a dearth of evidence-based interventions to improve PrEP uptake and persistence in SSA, and the full costs of PrEP programs implemented in routine care settings remain largely unknown. This study aimed to evaluate the cost of delivery of daily oral PrEP, and associated outcomes, to different key and priority populations across different service delivery models (SDMs) in South Africa. Methods:We conducted bottom-up micro-costing of PrEP service delivery from the provider perspective within twelve urban SDMs providing routine PrEP services to various key and propriety populations in Gauteng and KwaZulu-Natal provinces in South Africa. The SDMs included in-facility and outreach models that focused on men who have sex with men (MSM), female sex workers (FSW) and adolescent girls and young women (AGYW). We identified all within- and above-facility activities supporting PrEP delivery, obtained input costs from program budgets, expenditure records and staff interviews, and determined individual resource usage between February 2019 and February 2020 through retrospective medical record review. Our primary outcome was PrEP coverage at six months (defined as having sufficient PrEP drug dispensed at the last visit to be covered at six months post PrEP-initiation). A subset (N=633) of all enrolled subjects had the potential for 12 months of follow-up and were included in a 12-month outcome analysis. We report the cost per client initiated on PrEP in 2021 United States Dollars (USD). Findings:We collected medical record data from 1,281 people who initiated PrEP at 12 SDMs between February and August 2019 and had at least six months of potential follow-up. The average number of visits was 2.3 for in-facility models and 1.5 for outreach models and 3,086 months of PrEP was dispensed. PrEP coverage at six months varied greatly across SDMs, from 41.8% at one MSM-focused fixed clinic to 0% in an MSM-focused outreach model. In general, in-facility programs had higher six-month coverage than outreach programs. Across all SDMs with PrEP clients with potential for 12 months of follow-up (n=633), PrEP coverage at 12 months was 13.6%, with variability between SDMs. The average six-month cost per client initiated on PrEP ranged from $29 to $590, with higher average costs generally observed for the in-facility programs ($152 in-facility versus $84 for outreach). The average monthly cost per PrEP client who had six-month PrEP coverage ranged from $18 to $160 dependent on SDM. Interpretation:This study is an important addition to the PrEP outcome and cost literature in the SSA region. Results show that costs and outcomes vary considerably across different SDMs and populations in real world PrEP programs and provide crucial information for further scale-up of the oral PrEP program in South Africa and the greater SSA region.

Introduction Effective strategies are essential for early tuberculosis (TB) detection. Reliance on passive case detection, symptom screening and collection of sputum results in delayed or undiagnosed TB, contributing to on-going TB transmission. This study assessed the acceptability of in-home targeted universal TB testing (TUTT) using GeneXpert MTB/RIF Ultra at point-of-care (POC) during household contact investigations (HCIs) and the feasibility of using sputum and tongue swab specimens.Methods The TB Home Study sought to evaluate the predictive value of different specimen types for use as a household-level triage test for TB. Household contacts of people with TB residing in the Buffalo City Metro Health District (Eastern Cape Province, South Africa) who received in-home POC TUTT through the TB Home Study were asked to complete a post-test acceptability survey. The survey assessed the level of comfort, confidence in the test results and perceived appropriateness of in-home POC TUTT. A feasibility framework was used to assess the feasibility of using sputum and tongue swab specimens for testing.Results Of the 325 eligible household contacts, 281/325 (86.5%) provided consent. Of those contacts, 278/281 (98.9%) provided a tongue swab, and 50/281 (17.8%) could expectorate sputum. All specimens were successfully prepared for immediate in-home testing. Of the 172 tongue swab-based tests performed, 169 (98.3%) produced a valid result, whereas 47 of 49 (95.9%) sputum-based tests had a valid result. An immediate tongue swab-based test result was available for 274/278 (98.6%) clients compared with 47/49 (95.9%) sputum-based test results. The mean in-home POC TUTT acceptability score (5=highly acceptable) was 4.2/5 (SD=0.4).Conclusion In-homePOC TUTT using sputum and tongue swab specimens was highly acceptable and feasible. Tongue swabs greatly increased the testing rates owing to the high sample collection yield. Combining sputum and tongue swabs for in-home POC testing offers a promising strategy to improve TB case detection and reduce diagnostic delays.

Men in South Africa are disproportionately underrepresented in HIV care, and men who migrate face challenges using HIV services. Positive coping skills are critical for effective healthcare decision-making, yet little is known how men's HIV status and mobility-related stressors affect their coping strategies. Johannesburg is home to ∼5 million people who have relocated from elsewhere, mostly men. From February-April 2024, we conducted a cross-sectional survey among men who moved to Johannesburg, including questions on HIV status and the Soweto Coping Scale, with problem-focused/emotional and religious coping scores as summed responses. We fitted linear regression models using data from 157 men with complete responses to assess associations between coping scores with HIV status and mobility variables. Religious coping score was 2.21 points higher among men living with HIV versus others (p = 0.026). Religious (2.34 points higher; p = 0.024) and problem-focused/emotional (2.93 points higher; p = 0.022) scores were higher among men with citizenship/permanent versus those without. Targeted coping support for men without permanent residency status may improve engagement in HIV care. Although our findings are not generalizable to all migrant population, further research may help to understand how religious beliefs impact coping and clinical outcomes among South African men living with HIV to inform interventions.

Johannesburg, South Africa is a major destination for men moving from within and outside the country. Mobile men face challenges across the HIV care continuum. From March to May 2023, we conducted in-depth interviews with 29 mobile men and focus groups with 12 healthcare providers to explore factors influencing HIV prevention and care for mobile men. We used semi-structured guides, recorded and transcribed interviews, and analyzed data using inductive and deductive thematic analysis. Participants had a median age of 34. They described how relocating to Johannesburg created stress that deprioritized healthcare. They reported barriers at five key stages of status-neutral HIV care: awareness, decision to access care, experience of care, uptake of PrEP/ART, and adherence. Socio-economic needs, mobility, and masculine norms influenced men's engagement, and providers highlighted language barriers. Interventions to improve service uptake should address poverty, offer peer support, facilitate clinic transferability, and accommodate multiple languages to strengthen HIV services.

Timely linkage to HIV prevention and treatment services following HIV self-testing (HIVST) remains a challenge in many countries. While HIVST offers privacy and convenience for individuals to know their HIV status, many do not engage in follow-up care due to behavioural barriers like uncertainty about next steps, stigma, and privacy concerns. This study evaluated the acceptability, usability, and clinical appropriateness of Your Path, an Artificial Intelligence (AI)-powered tool designed to facilitate linkage to appropriate HIV services following HIVST. This study was conducted with community members (CMs) and healthcare providers (HCPs), recruited from Indlela's Behavioural Hub (B-Hub) in Gauteng province, South Africa. CMs were randomly assigned a mock HIV test result and completed a pre-test survey assessing intentions to seek HIV services, followed by a simulated HIVST session guided by Your Path. A post-test survey then evaluated changes in intention to seek care (a proxy for uptake of care) and a System Usability Scale (SUS) measured usability of the tool. A sub-sample of 25 CMs completed in-depth interviews exploring their experience with Your Path. HCPs reviewed transcripts of CM tool interactions to assess clinical appropriateness, completeness and relevance of the generated summaries. Qualitative data were analysed thematically, and results aligned with the Theoretical Framework of Acceptability (TFA). Of the 100 enrolled CMs, 59.0% were female and 51.0% received a mock HIV-negative result. After interacting with Your Path, 91.0% of CMs reported that it positively influenced their intention to access HIV services. The tool demonstrated high usability, with a mean SUS score of 81.6 (SD 17.5). Most found Your Path easy to use (83.7%) and did not need assistance (76.4%), and 94.9% expressed willingness to use it again. However, 15.3% noted that it did not always provide consistent responses to questions and that responses varied or were unclear. CMs described Your Path as a helpful guide with a user-friendly design. Most appreciated its private, non-judgmental tone, which helped reduce stigma during interactions. Some valued the sense of confidentiality offered by the tool, while others expressed concerns about the protection of their information. HCPs found the conversational summaries clinically appropriate, and cited the tool as informative and beneficial for supporting linkage to HIV care. Limitations in emotional responsiveness and potential language barriers were noted. Recommendations included integrating local languages, offering data-free access, and aligning with existing healthcare systems to improve reach and coordination of care. Your Path was acceptable, usable, and clinically appropriate for supporting linkage to HIV services after HIVST, and showed potential to support intentions to seek HIV care. Larger in-field studies are needed to understand the implementation, cost and sustainability of digital interventions in public health. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The research reported in this publication was supported by the South African Medical Research Council (SAMRC) with funds received from the National Department of Health and the Gates Foundation. LL was supported by the National Institute of Mental Health of the National Institutes of Health under grant number K01MH119923. The content and findings reported/illustrated are the sole deduction, view, and responsibility of the researchers and do not reflect the official position and sentiments of the SAMRC, Gates Foundation or the National Institutes of Health. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Wits Human Research Ethics Committee (Medical) (Reference number 211122) approved the study, and was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The manuscript has no associated data in a public repository. The datasets generated and/or analysed during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request.

One-way text messaging to re-engage people in HIV care has shown promise, but little is known about two-way messaging. We evaluated a behaviourally-informed two-way text messaging intervention to increase re-engagement in care following missed visits. We conducted an individual-level randomised controlled trial between February and March 2023 in Capricorn District, South Africa. Adults aged ≥ 18 years who had missed an ART visit by > 28 days were randomised to (1) a standard one-way text message, or (2) behaviourally-informed two-way text messages. The primary outcome was return to care within 45 days, analysed as (1) intention to treat, and (2) restricted to successful message delivery. 3,695 participants were randomised: 1,845 to the one-way message group and 1,850 to the two-way message group. 27.9% (515/1845) of participants sent a one-way message and 27.2% (503/1850) sent a two-way message returned for an ART visit within 45 days (proportion difference: -0.7%, p-value: 0.622). In an analysis restricted to participants whose text message was delivered, 28.3% (310/1094) in the one-way message group compared to 28.3% (304/1076) in the two-way message group returned to care (proportion difference: -0.09%, p-value: 0.966). 19.5% (210/1076) responded to the two-way message. The two most reported reasons for missed appointments were being out of town (41.0%) and still having medication (31.0%.). Behaviourally-informed two-way text messages did not improve return to care over one-way messages. However, they elicited reasons for disengagement. Additional research is needed on the mode, content and timing of two-way messages intended to increase return to care. Clinical Trial Number : PACTR202202748760768 & DOH-27-042022-6703. 28 February 2022.

To understand what preferences are important to university students in South Africa when engaging with a hypothetical artificial intelligence-powered health care assistant (AIPHA) to access health information using a discrete choice experiment. We conducted an unlabeled, forced choice discrete choice experiment among adult South African university students through Prolific, an online research platform, from June 26, 2024 to August 31, 2024. Each choice option described a hypothetical AIPHA using 8 attribute characteristics (cost, confidentiality, security, health care topics, language, persona, access, and services). Participants were presented with 10 choice sets each comprised of 2 choice options and asked to choose between the 2. A conditional logit model was used. Three hundred participants were recruited and enrolled. Most participants were Black, born in South Africa, heterosexual, working for a wage, and had a mean age of 26.5 years (SD, 6.0). Language, security, and receiving personally tailored advice were the most important attributes for AIPHA. Participants strongly preferred the ability to communicate with the AIPHA in any South African language of their choosing instead of only English and receive information about health topics specific to their context including information on clinics geographically near them. The results were consistent when stratified by sex and socioeconomic status. Participants had strong preferences for security and language, which is in line with previous studies where successful uptake and implementation of such health interventions clearly addressed these concerns. These results build the evidence base for how we might engage young adults in health care through technology effectively.

Objective:To understand what preferences are important to university students in South Africa when engaging with a hypothetical artificial intelligence-powered health care assistant (AIPHA) to access health information using a discrete choice experiment. Patients and Methods:We conducted an unlabeled, forced choice discrete choice experiment among adult South African university students through Prolific, an online research platform, from June 26, 2024 to August 31, 2024. Each choice option described a hypothetical AIPHA using 8 attribute characteristics (cost, confidentiality, security, health care topics, language, persona, access, and services). Participants were presented with 10 choice sets each comprised of 2 choice options and asked to choose between the 2. A conditional logit model was used. Results:Three hundred participants were recruited and enrolled. Most participants were Black, born in South Africa, heterosexual, working for a wage, and had a mean age of 26.5 years (SD, 6.0). Language, security, and receiving personally tailored advice were the most important attributes for AIPHA. Participants strongly preferred the ability to communicate with the AIPHA in any South African language of their choosing instead of only English and receive information about health topics specific to their context including information on clinics geographically near them. The results were consistent when stratified by sex and socioeconomic status. Conclusion:Participants had strong preferences for security and language, which is in line with previous studies where successful uptake and implementation of such health interventions clearly addressed these concerns. These results build the evidence base for how we might engage young adults in health care through technology effectively.

Background:Disengagement from antiretroviral therapy (ART) is common in the first 6 months of HIV treatment in sub-Saharan Africa. Using mixed-methods we aimed to understand preferences during this early treatment period. Methods:Between 8/2023-11/2023, adults who had initiated/re-initiated ART a median of 8 months prior were enrolled at 18 healthcare facilities across South Africa (SA) and Zambia to participate in a discrete choice experiment (DCE) and focus group discussion (FGD). In the DCE, participants made 9 choices between unique service delivery scenarios (each comprised of 8 attributes). Analyzed using a conditional logit model, we report findings using odds ratios (95% confidence intervals). Following the DCE, FGDs explored barriers to care seeking and care preferences. Thematic analysis was used to interpret FGDs. DCE and FGD findings were triangulated to understand preferences. Results:We enrolled 250 respondents: 128 in Zambia (55% female, median age 35); 122 in SA (83% female, median age 33). Community-based services were less favorable to respondents than clinic-based care (SA: 0.62 (95% CI 0.52, 0.75); Zambia: 0.44 (0.36, 0.53)). Respondents preferred 6-month dispensing (SA: 1.3 (1.1, 1.6); Zambia: 2.1 (1.8, 2.6)) to 1-month intervals. Respondents also preferred accessing services from friendly providers. Qualitative insights corroborated DCE findings. They also revealed frustrations with long wait times at clinics. Conclusion:Utilizing a decision experiment with qualitative methods allowed us to uniquely capture drivers of client decision-making and the nuanced factors that shape experiences. Results suggest that enrollment in lower-intensity models may improve client experiences during the early treatment period.

Expanding free HIV testing service (HTS) access to include private clinics could increase testing rates. A donor funded programme, GP Care Cell, offered free HIV testing at selected private doctor-led clinics but uptake was low. We investigated whether HTS demand creation materials that used behavioural economics principles could increase demand for HIV testing at these clinics. We conducted a randomised controlled trial in Johannesburg, South Africa (January-April 2022) distributing brochures promoting HTS to adults in five private doctor-led clinic catchment areas. Individuals were randomised to receive three brochure types: (1) "Standard of care" (SOC) advertising a free HIV test and ART; (2) "Healthy lifestyle screening" promoted free low-cost health screenings in addition to HTS; and (3) "Recipient of care voucher" leveraged loss aversion and the endowment effect by highlighting the monetary value of free HTS. The primary outcome was presenting at the clinic following exposure to the brochures. Logistic regression compared outcomes between arms. We found that of the 12,129 brochures distributed, 658 were excluded because of errors or duplicates and 11,471 were analysed. About 59% of brochure recipients were male and 50,3% were aged 25-34 years. In total, 448 (3.9%) brochure recipients presented at the private doctor-led clinics of which 50.7% were males. There were no significant differences in clinic presentation between the healthy lifestyle screening and SOC arm (Adjusted Odds Ratio [AOR] 1.02; 95% CI 0.79-1.32), and similarly between the recipient of care voucher and SOC arm (AOR 1.08; 95% CI 0.84-1.39). Individuals were more likely to attend centrally-located clinics that had visible HTS branding (AOR = 5.30; 95% CI: 4.14-6.79). Brochures that used behavioural insights did not increase demand for HTS at private doctor-led clinics. However, consistent distribution of the brochures may have potential to increase HIV testing uptake at highly visible private doctor-led clinics.

Abstract Background South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. Methods We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020–11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. Results Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported “never visiting a health facility,” as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). Conclusions Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants’ challenges.

Objective: Treatment interruptions are a barrier to successful antiretroviral therapy (ART). ‘Fresh start messages’, which leverage significant days on the calendar (e.g., new year, public holiday) in order to prompt action, have the potential to encourage people with HIV (PWH) to return to care. We evaluated a ‘fresh start’ intervention (text messages) to increase return to care in PWH who had missed their last appointment. Design: A three arm 1 : 1:1 individual randomised controlled trial. Methods: We randomized adults in Capricorn District who had missed ART appointments by >28 days to: no text message; unframed messages (fresh start not mentioned); or framed messages (fresh start mentioned). Randomization was stratified by treatment interruption duration and across two holidays (Youth Day, Mandela Day). The primary outcome was an ART-related clinic visit at ≤45 days of the first message. Results: 9143 participants were randomised. For Youth Day, 1474 and 1468 were sent unframed and framed messages respectively, with 13.4% sent these messages having an ART visit vs. 11.9% not sent a message [adjusted odds ratio (aOR) 1.2; 95% confidence interval (CI): 1.0–1.4, P-value = 0.075]. For Mandela Day, 1336 and 1334 were sent unframed and framed messages respectively, with 6.7% sent these messages having an ART-related clinic visit vs. 5.4% not sent a message (aOR 1.2; 95% CI: 1.0–1.6; P-value = 0.100). Conclusions: Low-cost text messages sent around a ‘fresh start’ date may increase the likelihood that patients who miss appointments return to care. This study suggests the potential of text messaging for motivating return to care.

Background Drug-resistant (DR) tuberculosis (TB) is typically characterized by resistance to a single or combination of first- and/or second-line anti-TB agents and commonly includes rifampicin-resistant (RR)-TB, multidrug-resistant (MDR)-TB, pre-extensively drug-resistant (pre-XDR)-TB and XDR-TB. Historically, all variations of DR-TB required treatment with second-line drugs which are less effective and more toxic than first-line options, have a longer treatment duration and are more expensive to both patients and providers. The World Health Organization (WHO) now recommends a new second-line 3-drug 6-month all-oral regimen consisting of bedaquiline, pretomanid, and linezolid referred to as BPaL. We estimate patient and provider costs of DR-TB treatment with BPaL compared to the current standard of care in South Africa. Methods and findings In coordination with South Africa’s BPaL clinical access programme (CAP) we conducted an economic evaluation of A) patient costs through a cross-sectional patient cost survey and B) provider costs through a bottom-up costing analysis consisting of a retrospective medical record review (patient resource-use) and top-down financial record review (fixed/shared costs such as overhead). Across both costing perspectives, we compare costs of 1) BPaL, to current standard of care options including the 2) 9-11-month standard short oral regimen (SSOR) and 3) 18-21-month standard long oral regimen (SLOR). Eligible patients included those ≥14 years old with confirmed sputum pulmonary RR/MDR-TB, pre-XDR or XDR-TB. All costs are reported in 2022 United States Dollar (US$). A total of 72 patients were enrolled and completed the patient cost survey (41.7% on BPaL, 16.7% on the SSOR and 41.7% on the SLOR). Mean on-treatment patient costs were lowest among those on BPaL ($56.6) and increased four-fold among those on the SSOR ($228.1) and SLOR ($224.7). Direct medical patient costs were negligible across all treatment regimens, while direct non-medical patient and guardian costs for travel, food and nutritional supplementation accounted for the largest proportion of total costs ($54.6, $227.8 and $224.3 for BPaL, the SSOR and SLOR respectively). In assessing provider costs, a total of 112 medical records were reviewed (37.5%, 41.1% and 21.4% on BPaL, the SSOR and SLOR respectively). Total provider costs for producing a favorable treatment outcome (cured/completed treatment) were similar among those on BPaL ($4,948.7 per patient) and the SSOR ($4,905.6 per patient) with costs increasing substantially among those on the SLOR ($8,919.9 per patient). Based on incremental cost-effectiveness ratios (ICERs), at even the lowest willingness to pay (WTP) threshold, treatment with the new BPaL regimen was more cost-effective than current standard of care treatment options (ICER: $311.4 < WTP: $3,341). Conclusions When using the newly recommended BPaL regimen, cost to patients decreased by 75% compared to current standard of care treatment options in South Africa. Due in part to higher resource-use within the BPaL CAP offsetting the shorter treatment duration, cost of treatment provision through BPaL and the 9-11-month SSOR were similar. However, when considering cost and treatment outcomes, BPaL was more cost-effective than other standard of care regimens currently available for DR-TB in South Africa.