Post-release Retention in HIV Care for Ex-inmates in South Africa

Study Overview
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Brief Summary
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HIV remains the leading cause of death in South Africa as a result of a failure of people living with HIV to seek HIV treatment and be retained in care. After initiating antiretroviral therapy while incarcerated, most ex-inmates fail to remain engaged in care. The goal of this research is to reduce mortality, morbidity, and HIV transmission by developing an actionable approach to retaining these individuals in HIV care.

Detailed Description
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To pilot a randomized clinical trial (RCT) of a transition adherence club (TCAC) versus traditional care, among ex-inmates receiving antiretroviral therapy in South Africa, to study feasibility, acceptability, and preliminary effectiveness using mixed methods. Investigators will pilot an RCT of the TCAC compared to traditional care among inmates/ex-inmates measuring transition in care, six-month viral load suppression, and follow-up of participants. Feasibility will be assessed by process measures. Acceptability will be assessed using in-depth interviews among 36 participants and 10 staff. Effectiveness will be assessed by a difference in proportions in-care with an undetectable viral load at 6 months and difference in bonding social capital and care satisfaction between arms.

Official Title
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Corrections2Community: Post-release Retention in HIV Care for Ex-inmates in South Africa

Conditions
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Hiv, Adherence, Patient

Intervention / Treatment
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* Behavioral: Transition Community Adherence Club (TCAC)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Currently incarcerated (either an offender/sentenced inmates or awaiting trial inmate/remandee) Housed at one of the study correctional facilities (including participating satellite centres) Diagnosed with HIV Currently receiving antiretroviral therapy Anticipated release or trial date within 3 months of study enrollment Self-report expected to reside within Ekurhuleni, Tshwane, or Johannesburg districts of Gauteng Province and within proximity to one of the TCAC sites (within 20 km, 45 minute travel time, or two local taxi minibus rides) Agree to post-discharge follow-up Medically stable based on DCS health assessment (including not pregnant) On antiretroviral therapy (ART) for >3 months at the expected time of corrections release Exclusion Criteria: Failure to provide informed consent to be followed up by study staff after release Unable to speak one of the study languages (English, Sesotho, isiXhosa, isiZulu, Setswana, Xitsonga, and Afrikaans)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 100 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Individually randomized trial with 2:1 allocation to the intervention compared to care as usual
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Transition Community Adherence Club (TCAC)<br>Participants in this arm will be referred to join a facilitated group setting for HIV on release from incarceration. This arm will provide HIV care services in a facilitated group setting to provide medical and psychosocial needs of participants. | Behavioral: Transition Community Adherence Club (TCAC)<br>* A behavioral intervention targeting stigma and care challenges through care delivery, social capital through a group setting, improved job prospects through referrals and training, and substance use through referrals. Participants assigned to this group will meet at least every month in a group of 5-15 members for approximately 2 hours. During the meeting there will be facilitated group discussion, an interactive curriculum including life skills, economic skills, HIV and health, and disclosure and stigma. Individual health screening and distribution of prepackaged medications conclude the session. Individual referrals for specific services (e.g. mental health or substance use management) will be available.<br>* Other names: Transition Community Adherence Club;|
| No Intervention: Care as usual (CAU)<br>Care as usual participants will be referred to routine clinic HIV care on release from corrections. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants in Care at Six Months | Self-reported in TCAC or routine DoH clinical care | 6 months after corrections release | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of Participants Verified in Care at Six Months | Clinical record (electronic or paper) verified in care | 6 months after corrections release | 
| Time to Linkage to HIV Care | Number of days from end of intervention to first clinic visit | 6 months after corrections release | 
| Proportion of Participants Linked to Care Within 90 Days of Corrections Release | Self-reported in TCAC or DoH clinical care | 90 days after corrections release | 
| Viral Suppression (HIV RNA <400 c/mL) at Six Months | Viral load data at 6 months will be based on routinely collected viral load data (clinic records and the electronic National Health Laboratory System to determine 6 month viral load outcomes, successfully applied in prior studies) augmented by viral loads obtained by the study when 6 month viral load data are not available. | 6 months after corrections release | 
| Difference in Bonding Social Capital Score at Six Months | Assessed using a 12-item scale with a higher score indicating greater bonding social capital. The median scores will be compared. Range 0-48. | 6 months after corrections release | 
| Difference in HIV Stigma Index Score at Six Months | Assessed using 28-item Berger stigma scale with median score used per stigma construct (internalized, anticipated, experienced). Higher values indicate more stigma. Ranges: experienced 38; anticipated 6; internalized 6. | 6 months after corrections release | 
| Proportion of Participants Employed or Self-employed | Self-reported employment | 6 months after corrections release | 
| Feasibility of Implementation of Transition Community Adherence Clubs Per Protocol (Composite Score) | Feasibility of implementation will be assessed based on the proportion of participants meeting the following intervention milestones: TCAC visit, 6-month social capital questionnaire and stigma scale, and 6-month viral load ascertainment. The proportion of participants in the intervention arm who have completed all of these components with by used as a composite score (range 0-1) | 6 months after corrections release | 
| Acceptability of Transition Community Adherence Clubs | Qualitative outcome assessed using in-depth interviews exploring participant views on the acceptability of the transition community adherence clubs. This is a qualitative analysis based on thematic coding. | 6 months after corrections release | 
| Difference in Ex-inmate Stigma Index Score at Six Months | Assessed using 28-item hybrid (study specific) stigma scale with median score used per stigma construct (internalized, anticipated, experienced). Higher values indicate more stigma. Higher values indicate more stigma. Ranges: experienced 38; anticipated 6; internalized 6. | 6 months after corrections release | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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incarceration, linkage to care, retention in care