ART Denial: Results of a Home-Based Study to Validate Self-reported Antiretroviral Use in Rural South Africa
There is increasing interest in home based testing and treatment of HIV to expand access to treatment in sub-Saharan Africa. Such programs rely on self-reported HIV history and use of antiretroviral therapy (ART). However, the accuracy of self-reported ART use in community settings is not well described. In this study, we compared self-reported ART (SR-ART) use in a home based survey against biological exposure to ART (BE-ART), in a population study of older adults in South Africa. Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa (HAALSI) is a cohort of adults aged 40 +. The baseline home-based interview included self-reported HIV status and ART use. All participants also underwent biological testing for HIV antibodies, viral load and exposure to emtricitabine (FTC) or lamivudine (3TC), which are included in all first-line and second-line ART regimens in the public-sector South African HIV program. We calculated the performance characteristics for SR-ART compared to BE-ART and fit multivariable logistic regression models to identify correlates of invalid SR-ART responses. Of 4560 HAALSI participants with a valid HIV test result available, 1048 (23%) were HIV-positive and 734 [70% of people living with HIV (PLWH)] were biologically validated ART users (BE-ART). The sensitivity of SR-ART use was 64% (95% CI 61–68%) and the specificity was 94% (95% CI 91–96%); the positive predictive value (PPV) was 96% (95% CI 94–98%) and negative predictive value (NPV) was 52% (95% CI 48–56%). We found no sociodemographic predictors of accurate SR-ART use. Over one in three individuals with detectable ART in their blood denied current ART use during a home-based interview. These results demonstrate ongoing stigma related to HIV and its treatment, and have important implications for community health worker programs, clinical programs, and research studies planning community-based ART initiation in the region.
KeywordsAntiretroviral therapy Home-based testing Self-report Validation
We would like to thank The Division of Clinical Pharmacology Laboratory at the University of Cape Town for their assistance in performing tests of exposure to emtricitabine and lamivudine.
This work was supported by the National Institute of Aging at the National Institutes of Health (Grant Number 1P01AG041710-01A1, HAALSI—Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The HAALSI study is nested within the Agincourt Health and Socio-demographic Surveillance System site, funded by the University of the Witwatersrand and Medical Research Council, South Africa, and the Wellcome Trust, UK (058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z). Till Bärnighausen received funding from the Alexander von Humboldt Foundation through the Alexander von Humboldt professor award, which is financed by the German Federal Ministry of Education and Research; the European Commission; the Clinton Health Access Initiative: UNAIDS; and from NICHD of NIH (R01-HD084233), NIA of NIH (P01-AG041710), NIAID of NIH (R01-AI124389 and R01-AI112339) as well as FIC of NIH (D43-TW009775).
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Conflict of interest
The authors declare no conflicts of interest.
- 3.Joint United National Programme on HIV/AIDS (UNAIDS). Ambitious treatment targets: writing the final chapter of the AIDS epidemic, Geneva; 2014.Google Scholar
- 5.Labhardt ND, Ringera I, Lejone TI, et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho: the CASCADE randomized clinical trial. JAMA. 2018;319(11):1103–12.CrossRefPubMedCentralGoogle Scholar
- 6.Gaziano TA, Abrahams-Gessel S, Denman CA, et al. An assessment of community health workers’ ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study. Lancet Glob Health. 2015;3(9):e556–63.CrossRefPubMedCentralGoogle Scholar
- 8.Grabowski MK, Reynolds SJ, Kagaayi J, et al. The validity of self-reported antiretroviral use in persons living with HIV: a population-based study. AIDS. 2018;32(3):363–9.Google Scholar
- 13.Tollman SM, Herbst K, Garenne M, Gear JS, Kahn K. The Agincourt demographic and health study–site description, baseline findings and implications. S Afr Med J. 1999;89(8):858–64.Google Scholar
- 16.Rohr JK, Gómez-Olivé FX, Rosenberg M, Manne-Goehler J, Geldsetzer P, Wagner W, Houle B, Salomon J, Kahn K, Tollman S, Berkman L, Bärnighausen T. Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study. J Int AIDS Soc. 2017;20:21691.CrossRefPubMedCentralGoogle Scholar