Effective medical treatment for HIV/AIDS requires patients’ optimal adherence to antiretroviral therapy (ART). In resource-constrained settings, lack of adequate standardized counseling for patients on ART remains a significant barrier to adherence. Masivukeni (“Lets Wake Up” in Xhosa) is an innovative multimedia-based intervention designed to help people living with HIV in resource-limited settings achieve and maintain high levels of ART adherence. Adapted from a couples-based intervention tested in the United States (US), Masivukeni was developed through community-based participatory research with US and South African partners and informed by Ewart’s Social Action Theory. Innovative computer-based multimedia strategies were used to translate a labor- and training-intensive intervention into one that could be readily and widely used by lay counselors with relatively little training with low-literacy patients. In this paper, we describe the foundations of this new intervention, the process of its development, and the evidence of its high acceptability and feasibility.
HIV; ART adherence; intervention; multimedia; task-shifting
To examine substance abuse treatment providers’ views on engaging clients in Pre-exposure Prophylaxis (PrEP) care and research trials.
Thirty-six medical and counseling service providers in six New York City outpatient substance abuse treatment programs participated in semi-structured qualitative interviews. Thematic content analysis was conducted by three coders, independently.
Providers’ perspectives toward PrEP were characterized by six salient themes: 1) Limited PrEP awareness. 2) Ambivalence about PrEP; 3) Perception of multiple challenges to delivery; 4) Uncertainty about clients’ ability to be adherent to medication; 5) Concerns about medication safety/side effects; and 6) Perception of multiple barriers to conducting clinical trials.
Despite anticipated challenges, providers supported the introduction of PrEP in outpatient substance abuse treatment. Comprehensive training for providers is needed and should include PrEP eligibility criteria, strategies to support adherence and medication monitoring guidelines. Linkages between substance abuse treatment and primary care and/or enhancement of capacity within clinics to offer PrEP may help facilitate PrEP delivery. When conducting research in outpatient clinics, it is particularly important to protect client confidentiality.
PrEP; Substance abuse treatment; Providers’ perspectives; Integration of HIV prevention; Substance abuse treatment
To use electronic drug monitoring to determine if adherence to HIV antiretroviral therapy changes over time, whether changes are linear, and how the declines vary by study.
We conducted a longitudinal study of pooled data from 11 different studies of HIV infected adults using antiretroviral therapy. The main outcome was antiretroviral therapy adherence (percent of prescribed doses taken) measured by electronic drug monitoring. We modeled and compared changes in adherence over time using repeated measures linear mixed effects models and generalized additive mixed models. Indicator variables were used to examine the impact of individual studies, and the variation across studies was evaluated using study-specific parameter estimates calculated by using interaction terms of study and time.
The mean age of the subjects was 41 years, 35% were female, most had high school education or less, and 46% were African-American. In generalized additive mixed models, adherence declined over time. The generalized additive mixed models further suggested that the decline was non-linear, and in both sets of models there was considerable study-to-study variability in how adherence changed over time.
Findings may not be generalizable to non-US populations or to patients not in clinical studies.
Although overall antiretroviral therapy adherence declined with time, not all studies showed declines, and a number of patterns of change were seen. Studies that identify clinical and organizational factors associated with these different patterns are needed. Models of changes in adherence with time should take account of possible non-linear effects.
human immunodeficiency virus; highly active antiretroviral therapy; medication adherence; patient compliance; longitudinal studies; meta-analysis
Online social networking use has increased rapidly among African American and Latino men who have sex with men (MSM), making it important to understand how these technologies can be used to reach, retain, and maintain individuals in care and promote health wellness. In particular, the Internet is increasingly recognized as a platform for health communication and education. However, little is known about how primarily Spanish-speaking populations use and engage with each other through social media platforms.
We aimed to recruit eligible couples for a study to adapt “Connect ‘n Unite” (an HIV prevention intervention initially created for black gay couples) for Spanish-speaking Latino gay couples living in New York City.
In order to successfully design and implement an effective social media recruitment campaign to reach Spanish-speaking Latino gay couples for our ongoing “Latinos en Pareja” study, our community stakeholders and research team used McGuire’s communication/persuasion matrix. The matrix guided our research, specifically each marketing “channel”, targeted “message”, and target population or “receiver”. We developed a social media recruitment protocol and trained our research staff and stakeholders to conduct social media recruitment.
As a result, in just 1 month, we recruited all of our subjects (N=14 couples, that is, N=28 participants) and reached more than 35,658 participants through different channels. One of the major successes of our social media recruitment campaign was to build a strong stakeholder base that became involved early on in all aspects of the research process—from pilot study writing and development to recruitment and retention. In addition, the variety of “messages” used across different social media platforms (including Facebook, the “Latinos en Pareja” study website, Craigslist, and various smartphone applications such as Grindr, SCRUFF, and Jack’d) helped recruit Latino gay couples. We also relied on a wide range of community-based organizations across New York City to promote the study and build in the social media components.
Our findings highlight the importance of incorporating communication technologies into the recruitment and engagement of participants in HIV interventions. Particularly, the success of our social media recruitment strategy with Spanish-speaking Latino MSM shows that this population is not particularly “hard to reach”, as it is often characterized within public health literature.
social media; online recruitment strategies; Spanish-speaking Latino men who have sex with men (MSM); Latino gay couples; Latino MSM; HIV prevention
Men who have sex with men, including transgender women, comprise a heterogeneous group of individuals, whose sexual behaviors and gender identities may varying widely between cultures and among individuals. Their sources of increased vulnerability to HIV are diverse, including the increased efficiency of HIV transmission via unprotected anal intercourse, sexual role versatility, asymptomatic sexually transmitted infections, as well as behavioral factors that may be associated with condomless sex with multiple partners. Societal stigmatization of homosexual behavior and gender non-conformity may result in internalized negative feelings that lead to depression, other affective disorders, and substance use, which in turn are associated with increased risk taking behaviors. Social stigma and punitive civil environments may lead to delays in seeking HIV and STD screening, and later initiation of antiretroviral therapy. The iPrEX study demonstrated that chemoprophylaxis can decrease HIV acquisition in MSM, and the HPTN 052 study established the biological plausibility that earlier initiation of HAART can decrease HIV transmission to uninfected partners. Despite these advances, MSM remain among the most significantly HIV-affected population in resource rich and limited settings. New studies will integrate enhanced understanding of the biology of enhanced rectal transmission of HIV and the focused use of antiretrovirals for prevention with culturally-tailored approaches that address the potentiating social and behavioral factors associated with enhanced HIV spread among MSM.
Men who have sex with men; Transgender Women; HIV Prevention; HIV Transmission
After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). ART adherence is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV.
A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation.
Recommendations are provided for monitoring of entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.
There is a strong need in South Africa for neuropsychological tests that can help detect HIV-associated neurocognitive disorder (HAND) in the country’s 5.6 million people living with HIV. Yet, South African neuropsychologists are challenged to do so, as few neuropsychological tests or batteries have been developed or adapted for, and normed on, South Africa’s linguistically, culturally, educationally, and economically diverse population. The purpose of this study was to explore the utility of the Montreal Cognitive Assessment to detect HIV-associated neurocognitive impairment among a sample of HIV+ and HIV-Black, Xhosa-speaking South Africans. HIV+ participants performed significantly worse overall and specifically in the domains of visuospatial, executive, attention, and language (confrontation naming). Regression analysis indicated that HIV status and education were the strongest predictors of total scores. Floor effects were observed on cube drawing, rhinoceros naming, serial 7’s, and one abstraction item, suggesting those items might not be useful in this population. While the Montreal Cognitive Assessment holds promise to help detect HAND in South Africa, it will likely need modification before it can be normed and validated for this population. Findings from this study may help neuropsychologists working with similar populations.
HIV; neuropsychology; screening; cross-cultural; South Africa; low-literacy; low-education
The emergence of barebacking (intentional unprotected anal intercourse in situations where there is risk of HIV infection) among men who have sex with men (MSM) has been partially attributed to a decrease in HIV-related concerns due to improved anti-retroviral treatment. It is important to understand the level of concern these men have regarding HIV infection because it can affect their interest in risk reduction behaviors as well as their possible engagement in risk reduction interventions. As part of a study on MSM who use the Internet to seek sexual partners, 89 ethnic and racially diverse men who reported never having an HIV-positive test result completed an in-depth qualitative interview and a computer-based quantitative assessment. Of the 82 men who were asked about concerns of HIV infection during the qualitative interviews, 30 expressed “significant concern” about acquiring HIV, while 42 expressed “moderate concern,” and 10 expressed “minimal concern. Themes that emerged across the different levels of concern were their perceptions of the severity of HIV infection, having friends who are HIV positive, and their own vulnerability to HIV infection. However, these themes differed depending on the level of concern. Among the most frequently mentioned approaches to decrease risk of HIV infection, participants mentioned avoiding HIV-positive sex partners, limiting the number of partners with whom they barebacked, and not allowing partners to ejaculate inside their rectum. Findings suggest that many MSM who bareback would be amenable to HIV prevention efforts that do not depend solely on condom use.
gay men; HIV prevention; HIV concerns; HIV optimism; raw sex
Venue-based characteristics (e.g., alcohol in bars, anonymous chat online, dark/quiet spaces in bathhouses) can impact how men who have sex with men (MSM) negotiate sex and HIV-associated risk behavior. We sought to determine the association between HIV-associated risk factors and the venues where MSM met their most recent new (first-time) male sex partner, using data from a 2004–2005 national online anonymous survey of MSM in the U.S (n = 2865). Most men (62%) met their partner through the Internet. Among those reporting anal sex during their last encounter (n = 1,550), half had not used a condom. In multivariate modeling, and among men reporting anal sex during their last encounter, venue where partner was met was not associated with unprotected anal intercourse (UAI). Nevertheless, venue was related to other factors that contextualized men’s sexual encounters. For example, HIV status disclosure was lowest among men who met their most recent partner in a park, outdoors, or other public place and highest among men who met their most recent partner online. Alcohol use prior to/during last sexual encounter was highest among men who met their most recent partner in a bathhouse or a bar/club/party/event. These data suggest it is possible to reach men online who seek sex in many different venues, thus potentially broadening the impact of prevention messages delivered in virtual environments. Although not associated with UAI, venues are connected to social-behavioral facets of corresponding sexual encounters, and may be important arenas for differential HIV and STI education, treatment, and prevention.
Sex venues; gay and bisexual men; Internet; HIV status disclosure; alcohol; condom use
Adherence to antiretroviral therapy (ART) is integral to the successful treatment of HIV infection. Research has indicated that HIV-infected Latinos may have difficulty adhering to ART. While studies have demonstrated strong relationships between numerous psychosocial factors and ART adherence, no research has examined if cultural factors are also involved in ART adherence among Latinos. Our study examined the relationship between acculturation to mainstream U.S. culture, bicultural self-efficacy, and ART adherence among HIV-infected Puerto Rican adults living in the United States. Participants with ≥ 95% adherence scored higher on U.S.- and Latino-involvement acculturation scales and on a measure of bicultural self-efficacy compared to those with suboptimal adherence. Among bicultural HIV-infected Puerto Ricans both acculturation and self-efficacy to navigate between cultures were positively related to adherence. Understanding the role of an individual’s sociocultural experience may help elucidate why HIV-infected Latinos have difficulties achieving optimal ART adherence and improve ART adherence interventions.
acculturation; adherence; antiretroviral; bicultural; Hispanic; HIV; Latino; Puerto Rican; self-efficacy
The integration of original data from multiple antiretroviral (ARV)
adherence studies offers a promising, but little used method to generate
evidence to advance the field. This paper provides an overview of the design and
implementation of MACH14, a collaborative, multi-site study in which a large
data system has been created for integrated analyses by pooling original data
from 16 longitudinal ARV adherence studies. Studies selected met specific
criteria including similar research design and data domains such as adherence
measured with medication event monitoring system, psychosocial factors related
to adherence behavior, and virologic and clinical outcomes. The data system
created contains individual data (collected between 1997 and 2009) from 2,860
HIV patients. Collaboration helped resolve the challenges inherent in pooling
data across multiple studies, yet produced a data system with strong statistical
power and potentially greater capacity to address key scientific questions than
possible with single-sample studies or even meta-analytic designs.
HIV/AIDS; Adherence; MEMS Multi-site Antiretroviral medication; Individual participant data
Adherence to antiretroviral therapies (ART) is the strongest predictor of viral suppression among individuals infected with HIV, however, limited data exists to understand the patterns of adherence that confer the greatest benefit across different ART regimens.
Longitudinal data pooled from 16 studies conducted between 1997 and 2009 across the United States.
Adherence was measured using Medication Event Monitoring System. Percentage of time with sufficient drug concentrations (covered time) and the length of the longest treatment interruption during the 28 days prior to plasma HIV-RNA measurements were calculated. Logistic regression with generalized estimating equations was used to estimate medication-specific adherence estimates on detectable HIV-RNA (>400 copies/ml).
One thousand and eighty-eight participants with 3795 HIV-RNA measures were studied. Both lower covered time and greater longest interruption showed dose– response relationships with the odds of detectable HIV-RNA; however, estimates did not vary by medication regimen. Compared with 93–100% coverage, periods of 0–25% covered time had a three-fold increased risk of detectable HIV-RNA [odds ratio (OR)=3.22, 95% confidence interval (CI): 2.48–4.19]. Similarly, compared to longest interruptions of 0–48 h, longest interruptions of 21–28 days had a nearly four-fold increased risk of detectable HIV-RNA (OR=3.65, 95% CI: 2.77, 4.81).
We found that adherence was consistently strongly associated with treatment response across ART regimens. Of the patterns of adherence, longer interruptions may have greater impact than covered time. Future research should investigate additional methods for examining adherence patterns, understanding the determinants of consecutive missed doses and the evaluation of interventions designed to address interruptions in treatment.
antiretroviral therapy; medication adherence; protease inhibitors; reverse transcriptase inhibitors; viral load
Acute/early HIV infection is a period of high HIV transmission. Consequently, early detection of HIV infection and targeted HIV prevention could prevent a significant proportion of new transmissions. As part of an NIMH-funded multisite study, we used in-depth interviews to explore understandings of acute HIV infection (AHI) among 34 individuals diagnosed with acute/early HIV infection in six U.S. cities. We found a marked lack of awareness of AHI-related acute retroviral symptoms and a lack of clarity about AHI testing methods. Most participants knew little about the meaning and/or consequences of AHI, particularly that it is a period of elevated infectiousness. Over time and after the acute stage of infection, many participants acquired understanding of AHI from varied sources, including the Internet, HIV-infected friends, and health clinic employees. There is a need to promote targeted education about AHI to reduce the rapid spread of HIV associated with acute/early infection within communities at risk for HIV.
HIV/AIDS; Awareness; Acute HIV; HIV prevention
Efforts to scale-up HIV care and treatment have been successful at initiating large numbers of patients onto antiretroviral therapy (ART), although persistent challenges remain to optimizing scale-up effectiveness in both resource-rich and resource-limited settings. Among the most important are very high rates of ART initiation in the advanced stages of HIV disease, which in turn drive morbidity, mortality, and onward transmission of HIV. With a focus on sub-Saharan Africa, this review article presents a conceptual framework for a broader discussion of the persistent problem of late ART initiation, including a need for more focus on the upstream precursors (late HIV diagnosis and late enrollment into HIV care) and their determinants. Without additional research and identification of multilevel interventions that successfully promote earlier initiation of ART, the problem of late ART initiation will persist, significantly undermining the long-term impact of HIV care scale-up on reducing mortality and controlling the HIV epidemic.
Late ART initiation; sub-Saharan Africa; scale-up; conceptual framework; retention
Many men who have sex with men (MSM) are among those who increasingly use the internet to find sexual partners. Few studies have compared behavior by race/ethnicity in internet-based samples of MSM. We examined the association of race/ethnicity with HIV risk-related behavior among 10,979 Hispanic, black, and white MSM recruited online. Significant variations by race/ethnicity were found in: age, income level, sexual orientation, number of lifetime male and female sexual partners, and rates of unprotected anal intercourse (UAI). Black and Hispanic men were more likely to report anal intercourse during the last sexual encounter, but white men were more likely to report UAI. In multivariate analysis, UAI was associated with HIV infection and sex with a main partner. Significant risk behavior variations by race/ethnicity were found. Research is needed to better target online interventions to MSM who engage in UAI or have other risk factors for transmitting or acquiring HIV.
HIV; Men who have sex with men; Sexual behavior; Race; Ethnicity; Internet
Minority race/ethnicity is generally associated with antiretroviral therapy nonadherence in US-based studies. Limitations of the existing literature include small samples, subjective adherence measures, and inadequate control for potential confounders such as mental health and substance use, which have been consistently associated with poorer adherence.
Individual-level data were pooled from 13 US-based studies employing electronic drug monitoring to assess adherence. Adherence was operationalized as percent of prescribed doses taken from the first 12 (monthly) waves of data in each study. Depression symptoms were aggregated from several widely used assessments, and substance use was operationalized as any use of cocaine/stimulants, heroin/opiates, ecstasy, hallucinogens, or sedatives in the 30–365 days preceding baseline.
The final analytic sample of 1809 participants ranged in age from 18 to 72 years and was 67% male. Participants were 53% African American, 14% Latino, and 34% White. In a logistic regression adjusting for age, gender, income, education, and site, race/ethnicity was significantly associated with adherence (P < 0.001) and persisted in a model that also controlled for depression and substance use (P < 0.001), with African Americans having significantly lower adherence than Latinos [odds ratio (OR) = 0.72, P = 0.04] and whites (OR = 0.60, P < 0.001). Adherence did not differ between whites and Latinos (OR = 0.84, P = 0.27).
Racial/ethnic differences in demographics, depression, and substance abuse do not explain the lower level of antiretroviral therapy adherence in African Americans observed in our sample. Further research is needed to explain the persistent disparity and might examine factors such as mistrust of providers, health literacy, and inequities in the health care system.
HIV/AIDS; race/ethnicity; antiretroviral treatment; medication adherence
Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. We found that receipt of services to reduce HIV transmission-risk behaviors was low among 3787 HIV-infected individuals and that men who have sex with men were especially unlikely to receive these services even though they were more likely to report unprotected sexual intercourse with seronegative and unknown serostatus casual partners. Greater efforts should be made to ensure that prevention counseling is delivered to all HIV-infected persons, especially men who have sex with men.
In the era of anti-retroviral therapy (ART), depression and substance use predict hastened HIV disease progression but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.
Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.
Elevated affective symptoms of depression independently predicted ART discontinuation (Adjusted OR [AOR] = 1.39, 95% CI = 1.08 – 1.78), and use of stimulants at least weekly independently predicted intermittent ART utilization (AOR = 2.62, 95% CI = 1.45 – 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4+) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became non-significant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.
Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.
Access; Adherence; Antiretroviral; Cocaine; Depression; Disease Progression; Highly Active; HIV/AIDS; HIV Viral Load; Methamphetamine; Substance Use; Utilization
Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one's ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self administered and interviewer administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying inter-relationships among provider interactions, adherence self-efficacy, and medication adherence are supported.
HIV/AIDS; Provider Relations; Adherence/Compliance
Opiate substitution treatment has been associated with better adherence to lifesaving antiretroviral medications, but the impact of other substance abuse treatment on adherence is unknown.
In this study, 215 patients who had been in adherence-focused research studies provided electronically-measured adherence data and a measure of whether the patient had recently been in substance abuse treatment. Recent engagement in substance abuse treatment was independently associated with significantly higher adherence, after covarying for recent substance use and other factors potentially affecting adherence.
The findings suggest that substance abuse treatment is associated with better adherence. Potential mechanisms by which substance abuse treatment improves adherence, such as more stability or more future-orientation, require further study.
Medication adherence; AIDS; Substance abuse; Treatment
As HIV infection continues unabated, there is a need for effective interventions targeting at-risk men who have sex with men (MSM). Engaging MSM online where they meet sexual partners is critical for HIV prevention efforts.
A randomized controlled trial (RCT) conducted online among U.S. MSM recruited from several gay sexual networking websites assessed the impact of 2 HIV prevention videos and an HIV prevention webpage compared to a control condition for the study outcomes HIV testing, serostatus disclosure, and unprotected anal intercourse (UAI) at 60-day follow-up. Video conditions were pooled due to reduced power from low retention (53%, n = 1,631). No participant incentives were provided.
Follow-up was completed by 1,631 (53%) of 3,092 eligible men. In the 60 days after the intervention, men in the pooled video condition were significantly more likely than men in the control to report full serostatus disclosure (‘asked and told’) with their last sexual partner (OR 1.32, 95% CI 1.01–1.74). Comparing baseline to follow-up, HIV-negative men in the pooled video (OR 0.70, 95% CI 0.54–0.91) and webpage condition (OR 0.43, 95% CI 0.25–0.72) significantly reduced UAI at follow-up. HIV-positive men in the pooled video condition significantly reduced UAI (OR 0.38, 95% CI 0.20–0.67) and serodiscordant UAI (OR 0.53, 95% CI 0.28–0.96) at follow-up.
Findings from this online RCT of MSM recruited from sexual networking websites suggest that a low cost, brief digital media intervention designed to engage critical thinking can increase HIV disclosure to sexual partners and decrease sexual risk. Effective, brief HIV prevention interventions featuring digital media that are made widely available may serve as a complementary part of an overall behavioral and biomedical strategy for reducing sexual risk by addressing the specific needs and circumstances of the target population, and by changing individual knowledge, motivations, and community norms.
There is an urgent need for valid, reliable, and simple-to-use screening tools for HIV-associated dementia (HAD) in South Africa, as little is known about its impact on South Africa's 5.5 million people living with HIV (PLWH). Screening for HAD in South Africa involves several challenges, including few culturally appropriate and validated screening tools, and a shortage of trained personnel to conduct screening. This study examined rates of positive HAD screens as determined by the cutoff score on the International HIV Dementia Scale (IHDS) administered by nonspecialist community health workers (CHWs) in South Africa and examined associations between positive HAD screens and common risk factors for HAD. Sixty-five Xhosa-speaking HIV-positive individuals on antiretroviral therapy (ART) with low CD4 counts and documented ART adherence problems were administered a battery of demographic, psychiatric and neurocognitive screening measures. Positive HAD screens were present in 80% of the sample. Presence of a current alcohol dependence disorder and CD4 counts of 200 or lower were significantly associated with positive HAD screens. HIV-positive South Africans on ART with low CD4 counts and ART adherence problems may be at a very high risk for HAD, highlighting the need for more routine screening and monitoring of neurocognitive functions among South Africa's millions of PLWH on ART. Future research is needed to: (1) validate IHDS performance against a gold standard neurocognitive battery for the detection of HAD among larger samples of Xhosa-speaking South Africans with ART adherence difficulties and (2) compare performance of CHW to expert health care personnel in administering the IHDS.