CROI 2025 Abstract eBook

Abstract eBook

Oral Abstracts

186

Clinic Switching and Elevated HIV Viral Load in 6 African Countries: A Population-Based Study Joseph G. Rosen 1 , M. Kate Grabowski 2 , Robert Ssekubugu 3 , Caitlin E. Kennedy 2 , Larry W. Chang 4 , Gertrude Nakigozi 3 , Fred Nalugoda 3 , Ronald Galiwango 3 , Godfrey Kigozi 3 , Steven J. Reynolds 5 , Joseph Kagaayi 3 1 Brown University, Providence, RI, USA, 2 The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 3 Rakai Health Sciences Program, Kalisizo, Uganda, 4 The Johns Hopkins University School of Medicine, Baltimore, MD, USA, 5 National Institute of Allergy and Infectious Diseases, Baltimore, MD, USA Background: Clinic transfers in African countries with high HIV burdens are common, but nationally representative data on clinic switching are scarce, and the relationship between facility switching and HIV care engagement is poorly understood, especially at the population level. Methods: We pooled data from six Population-based HIV Impact Assessment (PHIA) surveys (2020-21) in Eswatini, Lesotho, Malawi, Mozambique, Uganda, and Zimbabwe to estimate the prevalence and characteristics of past-year HIV clinic switching, as well as its association with HIV viral load (VL), in log 10 RNA copies/mL, and past-month antiretroviral therapy (ART) non-adherence (missing 2+ doses). Using multistage cluster sampling, PHIA recruited nationally representative samples of persons completing structured bio-behavioral surveys, including serologic HIV status confirmation and plasma VL quantification. Multivariable weighted logistic regression with jackknife variance estimation, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI), quantified correlates and HIV care outcomes of clinic switchers relative to non switchers—overall and stratified by sex and past-year mobility (spending 30+ days away from home), respectively. Results: Of the 118999 participants across 56759 households, 12551 (10.5%) were living with HIV and reported current ART use (mean age: 41.0 years, 65.9% female, 12.7% mobile, 92.4% VL <1000 copies/mL). The prevalence of HIV clinic switching was 14.5%, ranging from 9.8% in Mozambique to 21.4% in Uganda. Clinic switching was more common in persons with depressive symptoms, past year ART regimen changes, longer-term (12+ months) ART use, ART prescription duration <3 months, travel-related barriers to clinic visits, and past-year mobility ( Figure ). While observed multivariable correlations between clinic switching and HIV clinical outcomes were null overall ([elevated VL, per log 10 unit-increase] aOR=1.02, CI: 0.97-1.08; [ART non-adherence] aOR=1.18, CI: 0.86-1.61), clinic switching was significantly associated with elevated VL in mobile persons (aOR=1.07, CI: 1.02-1.13) and females (aOR=1.06, CI: 1.01-1.11), as well as ART non-adherence in mobile persons (aOR=1.90, CI: 1.01-3.55). Conclusions: We observed high frequencies of facility switching at population level and elevated odds of viremia in mobile persons and females with clinic transfer histories. Optimizing efficiency and ease of clinic transfers to prevent care disruptions is imperative for HIV epidemic control efforts in Africa.

to incentives over time, particularly after they are removed, could guide more effective interventions. In our study, we explore the dynamic effectiveness of small, short-term monthly financial incentives on HIV care-seeking behaviors during and after incentive removal. Methods: We conducted a 32-site cluster randomized controlled trial (NCT04201353) among adult ART initiates (<30 days) in four regions of Lake Zone, Tanzania. HIV care and treatment clinics (CTCs) were randomly assigned 1:1 to the intervention or the standard of care. Participants at intervention clinics had the opportunity to receive up to six monthly (>=25 days apart) cash transfers of 22,500 TZS each (~10 USD), conditional on appointment attendance. Using time to-event analysis, we assess the effect of incentives on three HIV-care seeking behaviors (missed appointment by >4 days, <90% ART adherence, and ART interruption of >28 days) over the entire study period, during and after incentive delivery, and for each month of the follow-up period. Results: Among 1990 participants (mean age: 37, 60% female, mean days on ART: 3.5) included in the final sample, we found large and significant reductions in rate of missed appointments (adjusted hazard ratio (aHR), 95% CI: 0.51, 0.39 0.68), <90% ART adherence (aHR, 95% CI: 0.58, 0.41-0.83), and ART interruption (>28 days without ART) (aHR, 95% CI: 0.54, 0.35-0.83) during the six months of incentives, but no effects after their removal. Hazard ratios by month reveal similar findings, with dramatic and consistent reductions in risk concentrated in months two through six that disappear in month seven, immediately after incentives are discontinued. Conclusions: Our study provides a detailed assessment of dynamic incentive effects that are often hidden in cross-sectional evaluations of incentive interventions. In this setting, financial incentives significantly improved HIV care seeking behaviors over standard services while they were delivered, but effects returned to levels in the standard of care group immediately after incentives were removed. These results highlight the value of short-term incentives for initiating new care-seeking behaviors, and emphasize a need for innovative design choices, such as escalating rewards or incorporation of time- or context-based cues, that may help motivate sustained behavior change after their removal. Effect of a Person-Centered Care Intervention on Reengagement After Care Interruptions in Zambia Aaloke Mody 1 , Kombatende Sikombe 2 , Sandra Simbeza 2 , Laura Beres 3 , Jake M. Pry 4 , Njekwa Mukamba 2 , Anjali Sharma 2 , Jacob Mutale 2 , Alida Dube 2 , Musunge Mulabe 2 , Chuck Goss 1 , Carolyn Bolton-Moore 2 , Izukanji Sikazwe 2 , Elvin H. Geng 1 1 Washington University in St Louis, St Louis, MO, USA, 2 Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, 3 The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 4 University of California Davis, Davis, CA, USA Background: Poor client-provider interactions lead to reinforcing cycles of treatment interruptions (TIs) and fear of return, undermining sustained retention. We previously demonstrated a multicomponent person-centered care intervention (PCCi) targeting healthcare worker (HCW) behavior improved client experience and retention in care. To understand mechanisms of improved retention, we evaluated the effect of PCCi on return after TIs and sustained retention after return, hypothesizing that friendlier HCW attitudes enable successful reengagement into care. Methods: We implemented PCCi at 24 clinics in Zambia in a stepped-wedge, cluster-randomized trial. PCCi targeted caring aspects of HCW behavior using 1) training and coaching on PCC practices, 2) measurement and feedback of client experience (via exit interviews), and 3) small facility-level incentives. We examined individuals who became >30 days late to a scheduled visit (i.e., TI) during the study, categorizing exposure to intervention vs. control based on the last visit prior to the TI (only first TI during study included). We used electronic health records to assess the effect of PCCi on 1) return to care after a TI, and 2) repeat TIs among those who returned. We used multistate analytic methods with bootstrapped confidence intervals to estimate incidence of return and prevalence of sustained reengagement after return. Individuals were censored at intervention crossover or database closure. Results: From Aug 2019 to Nov 2021, 128,901 clients (n=69670 control, n=59231 intervention) became >30 days late (64.3% female, median age 38y [IQR 31, 45], median years in care 3y [IQR 1, 7]). PCCi led to an increased incidence of return after TI at 6-months (64.7% intervention vs. 61.7% control, risk difference [RD] +3.0 [CI 2.6–3.3%]) and 12-months (72.3% vs. 67.7%, RD +4.6% [CI 4.2–5.0%]). Among returners, PCCi decreased incidence of repeat TIs (44.3% vs. 55.6%, RD -11.4% [CI -12.2– -10.8%]) and increased the proportion in care (with or without repeat TIs) (82.7% vs. 73.4%, RD +9.3 [CI 8.7–10.0%])

Oral Abstracts

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How Do Repeated Financial Incentives Affect HIV Care-Seeking Behaviors Over Time? Solis Winters 1 , Emmanuel Katabaro 2 , Babuu Joseph 2 , Kassim Hassan 2 , Hamza Maila 2 , Janeth Msasa 2 , Amon Sabasaba 2 , Prosper Njau 3 , William Dow 1 , Sandra I. McCoy 1 1 University of California Berkeley, Berkeley, CA, USA, 2 Health for a Prosperous Nation, Dar es Salaam, United Republic of Tanzania, 3 National AIDS, STIs and Hepatitis Control Program (NASHCoP), Dodoma, Tanzania Background: Financial incentives are known to help initiate routine healthcare behaviors. However, a more nuanced understanding of behavioral responses

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CROI 2025