Prior antiretroviral therapy exposure among clients presenting for HIV treatment initiation in South Africa: an exploratory mixed-methods study using multiple indicators of exposure

  1. Mariet Benade
  2. Mhairi Maskew
  3. Vinolia Ntjikelane
  4. Nancy Scott
  5. Nkosinathi Ngcobo
  6. Brooke Nichols
  7. Lufuno Malala
  8. Musa Manganye
  9. Sydney Rosen

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Abstract

Background The era of universal treatment for HIV has seen high rates of disengagement from antiretroviral therapy (ART) programs and re-engagement after interruptions, with modeled estimates of non-naive initiators >50% in many places. Most re-engagers are reluctant to admit prior antiretroviral exposure, and non-self-reported data on proportions of re-initiators are scarce. We synthesized data from multiple sources to explore the proportion of people who present for initiation with evidence of prior ART use in South Africa. Methods We enrolled a sequential sample of adults presenting to initiate ART or to re-initiate ART after an interruption >3 months and collected 1) self-reported previous treatment experience; 2) electronic medical record (EMR) evidence of prior ART clinic visits; 3) baseline blood tests for metabolites of tenofovir diphosphate; and 4) laboratory records indicating prior ART-related tests. Interviews were conducted with a sub-sample of clients who self-reported no prior ART use but had evidence of metabolites. Results Among 89 enrolled participants (median age 32.5, 62% female), 16 (18%) self-reported previously taking ART >3 months prior to enrolment. An additional 33 (45%) who did not self-report prior exposure had EMR or laboratory evidence of prior ART use, for a total of 49 (55%) clients with known prior treatment exposure at initiation. Sensitivity of self-report was 40%, EMR 43%, metabolite testing 45%, and laboratory records 73%. Interviewees (n=11) reported opting to present as naive because they perceived that disclosure of prior disengagement would cause delays accessing treatment, require additional documentation, and elicit negative responses from healthcare workers. Study limitations included short duration of metabolite detectability (90 days), inability to link individuals within the EMR to discern ART experience at other facilities, and lack of baseline viral load testing. Conclusions At least 55% of clients initiating ART in South Africa have prior treatment experience, but only a third of re-initiators voluntarily reveal this. Laboratory records, which reflect long-term experience, yielded the most accurate results for ascertaining prior treatment exposure. As numbers re-engaging in HIV care after a treatment interruption increase, understanding reluctance to self-report ART experience and exploring opportunities to overcome barriers are critical for preventing repeated interruptions.

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  1. PREreview

    This Zenodo record is a permanently preserved version of a Structured PREreview. You can view the complete PREreview at https://prereview.org/reviews/14157907.

    Does the introduction explain the objective of the research presented in the preprint? Yes The authors clearly stated the objective in the last statement of the introduction: "To start to build a reliable evidence base on this topic for sub-Saharan Africa, we conducted an exploratory, mixed-methods sub-study that collected multiple indicators of prior use for a sample of ART initiators in South Africa."
    Are the methods well-suited for this research? Somewhat appropriate Authors clearly defined a mixed-methods approach of quantitative and qualitative data collection in Table 1. However, it is a non-random sample and lacks a baseline for viral load testing. Authors should include a baseline for viral load testing for comparison.
    Are the conclusions supported by the data? Highly supported Interpretation of qualitative interviews were not overreaching as it was evident that the reluctance to reveal previous ART exposure was "due to the negative attitude that the healthcare providers portray towards them". The authors recognized the limitations of their findings as it serves as exploratory results that are not generalizable to larger populations, but as a guide for future work.
    Are the data presentations, including visualizations, well-suited to represent the data? Highly appropriate and clear Data presentations were clear and easy to follow.
    How clearly do the authors discuss, explain, and interpret their findings and potential next steps for the research? Very clearly The authors effectively explained their findings and interpretations and summarized the strengths and limitations of their methodology but could have provided a nuanced guide for next steps, especially regarding the National Welcome Back Campaign Strategy.
    Is the preprint likely to advance academic knowledge? Moderately likely The authors' use of mixed-methods is novel and has implications for future interventions regarding reluctance to reveal previous ART exposure. The findings reconfirms other literature.
    Would it benefit from language editing? No There are minor issues regarding inconsistent tense and minor misspellings that do not impact the preprint's clarity or understanding.
    Would you recommend this preprint to others? Yes, but it needs to be improved Healthcare providers and policymakers can have an interest in using the author's mixed methods as a guide to explore other types of disengagement of other disease treatments. Improvements include expansion of future implications.
    Is it ready for attention from an editor, publisher or broader audience? Yes, after minor changes

    Competing interests

    The authors declare that they have no competing interests.

  2. Version published to 10.1101/2024.08.23.24312454v1 on medRxiv