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Tenza S, Mampuru L, Moji M, Zulu S, Begg L, Bruce IV, Reddy K, Friedland BA, Palanee-Phillips T, Mathur S. "Killing two birds with one stone" - a qualitative study on women's perspectives on the dual prevention pill in Johannesburg, South Africa. BMC Womens Health 2024; 24:462. [PMID: 39174929 PMCID: PMC11342472 DOI: 10.1186/s12905-024-03269-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 07/17/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND HIV incidence remains high in South Africa, with ~ 60% of all new HIV infections among adolescent girls and women (Country factsheets HIV and AIDS Estimates, 2022). Oral pre-exposure prophylaxis (PrEP), approved for HIV prevention in South Africa since 2015, is hampered by low uptake and adherence, particularly among adolescent girls and young women (AGYW). Combining oral PrEP with oral contraceptives could increase PrEP uptake, persistence and address unmet needs for contraception. We investigated the acceptability of a dual prevention pill (DPP), combining oral PrEP and a combined oral contraceptive (COC) for HIV and pregnancy prevention among women in Johannesburg, South Africa. METHODS Between March-July 2021, we conducted 12 focus group discussions (FGDs) with adolescent girls and women (n = 74) aged 16-40 stratified by ages (16-17, 18-24, 25-40), half of whom were COC users. We explored adolescent girls and women's opinions about the DPP concept, existing HIV and pregnancy prevention options, and input on perceived facilitators and barriers to DPP use. FGDs were conducted in English or isiZulu, using a standardized interview guide. FGDs were audio-recorded, transcribed to English and analyzed using ethnographic content analysis. RESULTS The majority viewed the DPP favorably as a multipurpose option preventing unplanned pregnancy and HIV. Most saw it as a convenient "two-in-one" solution, requiring one clinic visit for both PrEP and COCs. AGYW were viewed as the most likely to benefit from the DPP due to the likelihood of multiple partners and unplanned sex, possibly preventing school dropout from unplanned pregnancy or HIV acquisition. The DPP was perceived to be more reliable than condoms, especially when condom negotiation is limited. Benefits were also seen by participants in rape cases, protecting against pregnancy and HIV. DPP use barriers included side effect concerns, unsupportive partners and judgmental healthcare providers. CONCLUSIONS/SIGNIFICANCE The DPP was perceived as acceptable for HIV and pregnancy prevention to AGYW in Johannesburg and its dual indications helpful in supporting improved PrEP uptake and persistence. DPP implementation programs need to consider solutions to potential barriers, like education on DPP benefits, coupled with reliable side effect support and healthcare provider sensitization as part of routine sexual health services to encourage uptake and adherence.
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Affiliation(s)
- Siyanda Tenza
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Lydia Mampuru
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Mpho Moji
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Sihle Zulu
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Lorna Begg
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Irene V Bruce
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Krishnaveni Reddy
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Center for Biomedical Research, Population Council, New York, NY, USA
| | | | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology; School of Public Health, University of Washington, Seattle, USA
| | - Sanyukta Mathur
- Social and Behavioral Research, Population Council, Washington, DC, USA
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Fordjuoh J, Dolezal C, Bhengu N, Harrison AD, Exner TM, Hanass-Hancock J, Hoffman S. Peer-to-Peer Chain Recruitment for Enrolling Young South African Women into an HIV Pre-exposure Prophylaxis (PrEP) Intervention Study: How Did It Perform? AIDS Behav 2024; 28:1782-1794. [PMID: 38416275 DOI: 10.1007/s10461-023-04256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 02/29/2024]
Abstract
Peer-to-peer chain recruitment has been used for descriptive studies, but few intervention studies have employed it. We used this method to enroll sexually active women ages 18 to 25 into an online Pre-Exposure Prophylaxis (PrEP) information and motivation intervention pilot in eThekwini (Durban), South Africa. Seeds (N = 16) were recruited by study staff and randomized to Masibambane, Ladies Chat, a Gender-Enhanced group-based WhatsApp Workshop (GE), or Individual-Access (IA), a control condition that provided participants with online information/motivation materials only. Each seed could recruit up to three women to participate in the same study condition, with an incentive for each enrolled woman; participants in subsequent waves could choose to recruit or not. We evaluated if peer-to-peer recruitment was self-sustaining and resulted in enrolling women who, in subsequent waves, had less contact with the health care system and less knowledge about PrEP than the initial seeds. Over three recruitment waves beyond the seeds, 84 women were recruited. Almost 90% of women became recruiters, with each recruiting on average 1.90 women and 1.26 eligible enrolled women. The approach was successful at reaching women with less education but not women with less health system contact and PrEP knowledge across waves. IA participants had a slightly higher, though non-significantly different, percentage of individuals who became Peer Health Advocates (PHAs) than GE participants and, on average, they recruited slightly more women who enrolled. Our findings demonstrated that peer-to-peer recruitment is a feasible and self-sustaining way to recruit SA young women into a PrEP intervention study.
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Affiliation(s)
- Judy Fordjuoh
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Curtis Dolezal
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Nonhlonipho Bhengu
- South African Medical Research Council, Gender and Health Research Unit, Durban, South Africa
| | - Abigail D Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Theresa M Exner
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Jill Hanass-Hancock
- South African Medical Research Council, Gender and Health Research Unit, Durban, South Africa
| | - Susie Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, NY, USA
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Hlongwa M, Nicol E. Improving linkage to HIV care following a reactive HIV self-testing result among men in KwaZulu-Natal, South Africa. BMC Health Serv Res 2024; 24:552. [PMID: 38693539 PMCID: PMC11061974 DOI: 10.1186/s12913-024-10981-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/10/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite the many interventions that have been implemented in sub-Saharan Africa to improve the uptake of HIV testing and antiretroviral (ART) initiation services, the rates at which men are tested for HIV and initiated on ART have remained consistently lower compared to those for women. We aim to investigate barriers and facilitators for linkage to care following HIVST positive results among men aged between 18 and 49 years, and use these findings to design an intervention to improve linkage to care among men in a high-HIV prevalent district in KwaZulu-Natal province, South Africa. METHODS This multi-method study will be conducted over 24 months in eight purposively selected HIV testing and treatment facilities from December 2023 to November 2025. For the quantitative component, a sample of 197 HIV positive men aged 18-49 years old who link to care after HIV self-test (HIVST) will be recruited into the study. HIVST kits will be distributed to a minimum of 3000 men attending community services through mobile clinics that are supported by the Health Systems Trust, at different service delivery points, including schools, taxi ranks and other hotspots. The qualitative component will consist of in-depth interviews (IDIs) with 15 HIVST users and IDIs with 15 key informants. To design and develop acceptable, feasible, effective, and sustainable models for improving linkage to care, three groups of HIVST users (2*positive (N = 12) and 1*negative (N = 12)) will be purposively select to participate in a design workshop. Chi square tests will be used to identify social and demographic factors associated with linkage, while logistic regression will be used to identify independent factors. Kaplan Meier curves and cox proportional hazard models will be used to identify factors associated with time to event. Content and thematic approaches will be used to analyze the qualitative data. DISCUSSION There remains an urgent need for designing and implementing innovative intervention strategies that are convenient and tailored for addressing the needs of men for improving HIV testing and linkage to care at early stages in resource-limited settings, to improve individual health outcomes, reduce transmission from HIV and minimize HIV-related mortality rates. Our proposed study offers several important innovations aimed at improving linkage to care among men. Our study targets men, as they lag the HIV continuum but are also under-researched in public health studies.
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Affiliation(s)
- Mbuzeleni Hlongwa
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria, South Africa.
- School of Nursing and Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
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Hlongwa M, Basera W, Nicol E. Comparing PrEP initiation rates by service delivery models among high risk adolescent boys and young men in KwaZulu-Natal, South Africa: findings from a population-based prospective study. BMC Public Health 2024; 24:1151. [PMID: 38658900 PMCID: PMC11043044 DOI: 10.1186/s12889-024-18660-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 04/18/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is an HIV prevention strategy that can reduce the risk of HIV acquisition by more than 90% if taken consistently. Although South Africa has been implementing PrEP since 2016, initially for selected population groups before expanding access to more people, there is a dearth of research focused on PrEP among adolescent boys and young men (ABYM), despite them experiencing high rates of HIV infection. To address this gap, we compared PrEP initiation rates by service delivery points (SDPs) among ABYM in KwaZulu-Natal, South Africa. METHODS We conducted a population-based prospective study in 22 SDPs from July 2021 to July 2022 in KwaZulu-Natal, South Africa. Sexually active ABYM aged 15-35 years who tested HIV negative were recruited at purposively selected PrEP SDPs (i.e., healthcare facilities, secondary schools and Technical Vocational Education and Training (TVET) colleges, and community-based youth zones). We collected baseline quantitative data from each participant using self-administered electronic questionnaires built into REDCap, including demographic information such as age, sex, employment status and level of education, as well as PrEP initiation outcomes. We extracted data from REDCap and exported it to Stata version 17.0 for analysis, and then eliminated discrepancies and removed duplicates. We described baseline characteristics using summary and descriptive statistics (median, interquartile range [IQR] and proportions) and reported PrEP initiation proportions overall and by SDPs. RESULTS The study included 1104 ABYM, with a median age of 24 years (interquartile range (IQR): 21-28)). Almost all participants were black African (n = 1090, 99%), with more than half aged 15-24 years (n = 603, 55%) and 45% (n = 501) aged 25-35 years. The majority (n = 963; 87%) had attained a secondary level of education. Overall PREP initiation rate among adolescent boys and young men was low: among 1078 participants who were eligible for PrEP, 13% (n = 141) were started on PrEP. Among the participants who were initiated on PrEP, over three quarters (78%, n = 58) were initiated from high schools, compared with community-based youth zones (40%, n = 37), TVET colleges (26%, n = 16) and healthcare facilities (4%, n = 30). CONCLUSIONS This study provided evidence suggesting that expanding PrEP services to non-traditional settings, such as high schools, TVET colleges, and community-based organizations, may have a potential to increase PrEP access among ABYM in South Africa.
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Affiliation(s)
- Mbuzeleni Hlongwa
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria, South Africa.
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
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Moolla A, Galvin M, Mongwenyana C, Miot J, Magolego W, Leshabana P, Ngcobo N, Naidoo N, Coetzee L. Understanding HIV service preferences of South African women 30-49 years old missing from or linked to care: An exploratory study of Gauteng and Limpopo provinces. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241277080. [PMID: 39254147 PMCID: PMC11388305 DOI: 10.1177/17455057241277080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND The HIV epidemic in sub-Saharan Africa has a disproportionate gender impact, with women bearing the brunt of the epidemic. South Africa carries the largest share of the global HIV burden, with similar trends seen for women due to unequal socio-cultural and economic status. OBJECTIVES This study aims to understand 30-49 year-old women's barriers and facilitators to accessing HIV services in order to maximize health in resource limited settings and reach women missing from HIV care. DESIGN Employing a convenience sampling strategy, we recruited, informed, and consented participants at clinics and public areas. Interviews were conducted in respondent's preferred languages, transcribed verbatim, translated into English if needed, and thematically analyzed using grounded theory. METHODS We conducted 81 interviews with women aged 30-49 either missing from care (n = 21), having unknown HIV status (n = 30) or linked to care (n = 30) within two sites: City of Johannesburg district, Gauteng Province and Mopani district, Limpopo Province. RESULTS Participants missing from care reported negative staff attitudes, queues, family rejection, medication side effects, and painful blood tests as key deterrents. Participants with an unknown status were deterred by fear of being diagnosed as HIV positive and family rejection, which was similar to women missing from care who often dropped out from care due to actual family rejection. Participants linked to care reported that long queues and staff shortages were challenges but stayed in care due to a will to live for themselves and their children, in addition to counselling and feeling emotionally supported. Interestingly, participants missing from care often accessed medication from friends but, similarly to those with unknown status, noted that they would access care if attended to by supportive nurses and by having non-clinical HIV services. CONCLUSIONS The accounts of women in this research highlight significant improvements needed to address inequities in the fight against HIV in South Africa. Additionally, the healthcare service access preferences of women aged 30-49 need to be further explored quantitatively in order to design policy relevant interventions.
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Affiliation(s)
- Aneesa Moolla
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael Galvin
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Psychiatry, Boston Medical Center (BMC), Boston, MA, USA
- T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Constance Mongwenyana
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - William Magolego
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Patricia Leshabana
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nalini Naidoo
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lezanie Coetzee
- Health Economics and Epidemiology Research Office, Johannesburg, South Africa
- Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Schulz VE, Tuff JF, Tough RH, Lewis L, Chimukangara B, Garrett N, Abdool Karim Q, Abdool Karim SS, McKinnon LR, Kharsany ABM, McLaren PJ. Host genetic variation at a locus near CHD1L impacts HIV sequence diversity in a South African population. J Virol 2023; 97:e0095423. [PMID: 37747237 PMCID: PMC10617395 DOI: 10.1128/jvi.00954-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/04/2023] [Indexed: 09/26/2023] Open
Abstract
IMPORTANCE It has been previously shown that genetic variants near CHD1L on chromosome 1 are associated with reduced HIV VL in African populations. However, the impact of these variants on viral diversity and how they restrict viral replication are unknown. We report on a regional association analysis in a South African population and show evidence of selective pressure by variants near CHD1L on HIV RT and gag. Our findings provide further insight into how genetic variability at this locus contributes to host control of HIV in a South African population.
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Affiliation(s)
- Vanessa E. Schulz
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Sexually Transmitted and Bloodborne Infections Division, JC Wilt Infectious Diseases Research Centre, National Microbiology Laboratories, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Jeffrey F. Tuff
- Sexually Transmitted and Bloodborne Infections Division, JC Wilt Infectious Diseases Research Centre, National Microbiology Laboratories, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Riley H. Tough
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Sexually Transmitted and Bloodborne Infections Division, JC Wilt Infectious Diseases Research Centre, National Microbiology Laboratories, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Benjamin Chimukangara
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
- Department of Virology, University of KwaZulu-Natal, Durban, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Lyle R. McKinnon
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Science, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Paul J. McLaren
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
- Sexually Transmitted and Bloodborne Infections Division, JC Wilt Infectious Diseases Research Centre, National Microbiology Laboratories, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
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Mmotsa TM, Magasana V, Nsibande DF, Buthelezi M, Dassaye R, Rodriguez VJ, Jones DL, Goga AE, Ngandu NK. Mixed-methods cross-sectional study of the prevention of vertical HIV transmission program users unaware of male partner's HIV status, in six South African districts with a high antenatal HIV burden. BMC Public Health 2023; 23:1988. [PMID: 37828512 PMCID: PMC10571358 DOI: 10.1186/s12889-023-16921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 10/06/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Elimination of vertical HIV Transmission (VHT) and maternal deaths are global health priorities. Male involvement is one of the most important factors that influences women's decisions, including the uptake of Prevention of vertical HIV transmission (P-VHT). We sought to understand not knowing a male partner's HIV status (MPHIVs) amongst women using services to prevent vertical HIV transmission in six South African districts with high antenatal HIV burden. METHODS A mixed-methods cross-sectional study was conducted in six South African districts, and data collected through face-to-face interviews with women and focus group discussions (FGDs) with women or male partners. The quantitative data were analyzed using STATA SE-17.0 and an inductive approach was used for qualitative data analysis. RESULTS Overall, 28.7% of women were unaware of their MPHIVs, while 25.3% and 46.0% knew the MPHIVs was positive or negative, respectively. In multivariable logistic regression, single marital status and unplanned pregnancy increased the odds of not knowing a MPHIVs while a woman's disclosure of her HIV status to the male partner reduced the odds. FDGs highlighted complexities around MPHIVs disclosure, e.g., reluctance to test for HIV and potential interventions including healthcare worker (HCW) assisted HIV disclosure. CONCLUSION User-informed interventions to address MPHIVs non-disclosure amongst women of child-bearing age, particularly those at risk of unstable sexual partners and unplanned pregnancies, should be strengthened.
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Affiliation(s)
- Tshiamo M Mmotsa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Vuyolwethu Magasana
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Duduzile F Nsibande
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mbongeleni Buthelezi
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Reshmi Dassaye
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Psychology (Clinical/Community Division), University of Illinois at Urbana-Champaign, Champaign, IL, United States of America
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ameena E Goga
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Nobubelo K Ngandu
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
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Filiatreau LM, Edwards JK, Masilela N, Gómez-Olivé FX, Haberland N, Pence BW, Maselko J, Muessig KE, Kabudula CW, Dufour MSK, Lippman SA, Kahn K, Pettifor A. Understanding the effects of universal test and treat on longitudinal HIV care outcomes among South African youth: a retrospective cohort study. BMC Public Health 2023; 23:1724. [PMID: 37670262 PMCID: PMC10478421 DOI: 10.1186/s12889-023-16353-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 07/20/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION Little is known about the effects of universal test and treat (UTT) policies on HIV care outcomes among youth living with HIV (YLHIV). Moreover, there is a paucity of information regarding when YLHIV are most susceptible to disengagement from care under the newest treatment guidelines. The longitudinal HIV care continuum is an underutilized tool that can provide a holistic understanding of population-level HIV care trajectories and be used to compare treatment outcomes across groups. We aimed to explore effects of the UTT policy on longitudinal outcomes among South African YLHIV and identify temporally precise opportunities for re-engaging this priority population in the UTT era. METHODS Using medical record data, we conducted a retrospective cohort study among youth aged 18-24 diagnosed with HIV from August 2015-December 2018 in nine health care facilities in South Africa. We used Fine and Gray sub-distribution proportional hazards models to characterize longitudinal care continuum outcomes in the population overall and stratified by treatment era of diagnosis. We estimated the proportion of individuals in each stage of the continuum over time and the restricted mean time spent in each stage in the first year following diagnosis. Sub-group estimates were compared using differences. RESULTS A total of 420 YLHIV were included. By day 365 following diagnosis, just 23% of individuals had no 90-or-more-day lapse in care and were virally suppressed. Those diagnosed in the UTT era spent less time as ART-naïve (mean difference=-19.3 days; 95% CI: -27.7, -10.9) and more time virally suppressed (mean difference = 17.7; 95% CI: 1.0, 34.4) compared to those diagnosed pre-UTT. Most individuals who were diagnosed in the UTT era and experienced a 90-or-more-day lapse in care disengaged between diagnosis and linkage to care or ART initiation and viral suppression. CONCLUSIONS Implementation of UTT yielded modest improvements in time spent on ART and virally suppressed among South African YLHIV- however, meeting UNAIDS' 95-95-95 targets remains a challenge. Retention in care and re-engagement interventions that can be implemented between diagnosis and linkage to care and between ART initiation and viral suppression (e.g., longitudinal counseling) may be particularly important to improving care outcomes among South African YLHIV in the UTT era.
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Affiliation(s)
- Lindsey M Filiatreau
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, USA.
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nkosinathi Masilela
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joanna Maselko
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mi-Suk Kang Dufour
- Biostatistics Division, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Carolina Population Center, Chapel Hill, NC, USA
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Ndlovu SMS, Ross A, Ndirangu J. Knowledge of HIV and/or AIDS and HIV testing services among young men in South Africa. Afr J Prim Health Care Fam Med 2023; 15:e1-e10. [PMID: 37526557 PMCID: PMC10476458 DOI: 10.4102/phcfm.v15i1.3796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND The youth is at a heightened risk of immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV and/or AIDS) infection because of risk-taking behaviour. There remains a gap in understanding young men's knowledge of HIV and/or AIDS and HIV testing services (HTS) in hard-to-reach communities in South Africa. AIM This article aimed to explore young men's knowledge of HIV and/or AIDS, including HTS in Ladysmith, KwaZulu-Natal (KZN). SETTING Rural and peri-urban areas around the town of Ladysmith. METHODS Employing a qualitative descriptive research design, 17 young men aged between 18 and 30 years were purposively and conveniently sampled and interviewed using WhatsApp and landline audio calls to collect their data, which was thematically analysed. RESULTS Young men had good knowledge of HIV and/or AIDS but lacked knowledge about HTS and HIV self-testing (HIVST). They obtained their information about HIV and/or AIDS and HTS from various sources and were aware of where to access HTS. They were generally unaware and supportive of HIVST. CONCLUSION Male-targeted HIV and/or AIDS knowledge and testing interventions are needed to encourage and support young men to test for HIV. Human immunodeficiency virus self-testing should be explored as an alternative to clinic-based service to encourage young men to know their status, specifically those with limited access to or are reluctant to attend clinics. Strengthening HIV and/or AIDS education could facilitate better decision-making towards HIV testing among young men.Contribution: This study contributes to an understanding of young adult men's knowledge of HIV and/or AIDS and HTS in underserved settings in South Africa.
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Affiliation(s)
- Sithembiso M S Ndlovu
- Department of Family Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; and Office of the Dean of Health Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein.
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10
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Dubé K, Mthimkhulu D, Ngcobo W, Mindry D, Maphalala L, Pillay V, Tran W, Korolkova A, Ndung’u T, Dong K. 'With this study, we have hope that something is coming': community members' perceptions of HIV cure-related research in Durban, South Africa - a qualitative focus group study. HIV Res Clin Pract 2023; 24:2243046. [PMID: 37555592 PMCID: PMC10433450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
BACKGROUND Developing a cure for HIV remains a global scientific priority. In 2022, the Females Rising through Education, Support and Health (FRESH) cohort launched an HIV cure-related trial involving an analytical treatment interruption (ATI) in Durban, South Africa. OBJECTIVES To explore community perspectives about HIV cure-related research. METHODS Between July-August 2022, we conducted three focus groups with community members. We transcribed audio recordings verbatim and used content analysis to analyze the data. RESULTS Twenty community members (13 women and 7 men) participated in three focus groups (HIV status not included). Participants viewed HIV cure-related research as a way to address the issue of defaulting on (not taking) HIV treatment. Participants expressed hesitancy around ATIs, since these contradict longstanding treatment adherence messages. Participants shared concerns around the risk of side effects from experimental interventions balanced against potential efficacy. They advocated for trial participants to have the right to decide whether to inform their sex partners about their HIV status and ATI participation, rather than research teams making disclosure mandatory. Focus group participants also emphasized the importance of using simple language to explain HIV cure-related research. CONCLUSIONS With HIV cure trials set to launch across Africa in the future, there is a critical need to better understand and respond to local community needs and preferences and to adopt this as standard practice prior to regional trial implementation.
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Affiliation(s)
- Karine Dubé
- University of California San Diego (UCSD) School of Medicine, Division of Infectious Diseases and Global Public Health (IDGPH), La Jolla, CA, USA
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Deli Mthimkhulu
- Integration of Tuberculosis in Education and Care for HIV/AIDS (ITEACH), Durban, South Africa
| | - Wiseman Ngcobo
- Integration of Tuberculosis in Education and Care for HIV/AIDS (ITEACH), Durban, South Africa
| | - Deborah Mindry
- Center for Gender and Health Justice, University of California Global Health Institute, Los Angeles, CA, USA
| | - Luyanda Maphalala
- Females Rising through Education, Support and Health (FRESH), Durban, South Africa
| | - Vanessa Pillay
- Females Rising through Education, Support and Health (FRESH), Durban, South Africa
| | - Whitney Tran
- University of California San Diego (UCSD) School of Medicine, Division of Infectious Diseases and Global Public Health (IDGPH), La Jolla, CA, USA
| | - Ana Korolkova
- University of California San Diego (UCSD) School of Medicine, Division of Infectious Diseases and Global Public Health (IDGPH), La Jolla, CA, USA
| | - Thumbi Ndung’u
- HIV Pathogenesis Programme (HPP), The Doris Duke Medical Research Institute, University of KwaZulu-Natal (UKZN), Durban, South Africa
- Africa Health Research Institute (AHRI), Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
- Ragon Institute of Massachusetts General Hospital (MGH), Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, USA
| | - Krista Dong
- Ragon Institute of Massachusetts General Hospital (MGH), Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Cambridge, MA, USA
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11
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Nyirenda M, Sukazi S, Buthelezi C, Hanass-Hancock J. “A frightening experience, especially at our age”: Examining the neglect and abuse of older persons in HIV prevention and care programs. Front Public Health 2023; 11:1061339. [PMID: 36992889 PMCID: PMC10040649 DOI: 10.3389/fpubh.2023.1061339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/10/2023] [Indexed: 03/14/2023] Open
Abstract
BackgroundAs the global population ages and the HIV pandemic matures, a growing number of older persons aged ≥50 years are becoming increasingly vulnerable to acquiring HIV. Unfortunately, older persons are often neglected and left out of sexual health programs and services. This study explored the experiences of older persons living with and without HIV in accessing prevention and care services and how those experiences translate into the neglect and abuse of older persons. The study also explored older people's perspectives on community responses to HIV in older people.MethodsThis qualitative analysis used data from 37 individuals who participated in focus group discussions conducted in 2017/2018 across two communities in Durban, South Africa. Using an interview guide and thematic content analysis, salient themes regarding attitudes to HIV in older persons and factors of access to HIV prevention and cares services for older persons were analyzed.ResultsThe study participant's mean age was 59.6 years. Major themes emerging from the data included factors impacting HIV prevention and transmission in older people; community responses to HIV contributing to the abuse of older people, and structural drivers of abuse in older people living with HIV (OPLHIV). Knowledge about HIV and how to protect themselves from HIV was limited among participants. Older persons were frightened to acquire HIV at an older age as they feared judgment and discrimination for getting HIV at that age. OPLHIV reported frequently experiencing community stigma and poor staff attitudes and practices at health facilities, such as a triage health delivery system that fueled community stigma. Participants also experienced neglect, verbal and emotional abuse at healthcare facilities.ConclusionAlthough there were no reports of physical and sexual abuse of older persons in this study, this study shows that despite decades of HIV programs in the country, HIV-related stigma, discrimination, and disrespect of older persons remain pervasive in the community and at health facilities. As an increasing number of people age and live longer with HIV, the neglect and outright abuse of older persons need urgent policy and program interventions.
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Affiliation(s)
- Makandwe Nyirenda
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- College of Health Sciences, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- *Correspondence: Makandwe Nyirenda
| | - Sizakele Sukazi
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Cebo Buthelezi
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Jill Hanass-Hancock
- Gender and Health Research Unit, South African Medical Research Council, Durban, South Africa
- College of Health Sciences, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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12
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Kriel Y, Milford C, Cordero JP, Suleman F, Steyn PS, Smit JA. Access to public sector family planning services and modern contraceptive methods in South Africa: A qualitative evaluation from community and health care provider perspectives. PLoS One 2023; 18:e0282996. [PMID: 36930610 PMCID: PMC10022780 DOI: 10.1371/journal.pone.0282996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/28/2023] [Indexed: 03/18/2023] Open
Abstract
Progress has been made to improve access to family planning services and contraceptive methods, yet many women still struggle to access contraception, increasing their risk for unintended pregnancy. This is also true for South Africa, where over fifty per cent of pregnancies are reported as unintended, even though contraception is freely available. There is also stagnation in the fertility rate indicators and contraceptive use data, indicating that there may be challenges to accessing contraception. This paper explores the evaluation of access to contraception from community and health care provider perspectives. This qualitative study explored factors affecting the uptake and use of contraception through focus group discussions (n = 14), in-depth interviews (n = 8), and drawings. Participants included male and female community members (n = 103) between 15 and 49 years of age, health care providers (n = 16), and key stakeholder informants (n = 8), with a total number of 127 participants. Thematic content analysis was used to explore the data using NVivo 10. Emergent themes were elucidated and thematically categorised. The results were categorised according to a priori access components. Overall, the results showed that the greatest obstacle to accessing contraception was the accommodation component. This included the effects of integrated care, long waiting times, and limited operational hours-all of which contributed to the discontinuation of contraception. Community members reported being satisfied with the accessibility and affordability components but less satisfied with the availability of trained providers and a variety of contraceptive methods. The accessibility and affordability themes also revealed the important role that individual agency and choice in service provider plays in accessing contraception. Data from the illustrations showed that adolescent males experienced the most geographic barriers. This study illustrated the importance of examining access as a holistic concept and to assess each component's influence on contraceptive uptake and use.
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Affiliation(s)
- Yolandie Kriel
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- School of Public Health and Nursing, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- * E-mail:
| | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Joanna Paula Cordero
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Fatima Suleman
- Discipline of Pharmaceutical Science, College of Health Sciences, University of KwaZulu-Natal, Westville, South Africa
| | - Petrus S. Steyn
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Jennifer Ann Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
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13
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Lewis L, Kharsany ABM, Humphries H, Maughan-Brown B, Beckett S, Govender K, Cawood C, Khanyile D, George G. HIV incidence and associated risk factors in adolescent girls and young women in South Africa: A population-based cohort study. PLoS One 2022; 17:e0279289. [PMID: 36542645 PMCID: PMC9770356 DOI: 10.1371/journal.pone.0279289] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, high HIV incidence rates in adolescent girls and young women (AGYW) persist despite extensive HIV prevention efforts. METHODS A prospective cohort of 2,710 HIV-negative AGYW (15-24 years) in KwaZulu-Natal, South Africa were interviewed at baseline and followed-up approximately 18 months later (2014-2017). Associations between HIV seroconversion and socio-demographic and behavioural variables measured at baseline and follow-up were examined using Cox regression and a proximate determinants framework. Inter-relationships between determinants were measured using logistic regression. Separate models were built for 15-19 and 20-24-year-olds. RESULTS Weighted HIV incidence was 3.92 per 100 person-years (95% confidence interval: 3.27-4.69; 163 seroconversions over 4,016 person-years). Among 15-19-year-olds, absence of family support (adjusted hazards ratio (aHR): 3.82 (1.89-7.72)), having a circumcised partner (aHR: 0.5 (0.27-0.94)) or one who was HIV-positive and not on antiretroviral therapy (ART) (aHR: 6.21 (2.56-15.06)) were associated with HIV incidence. Those reporting an absence of family support were also more likely to report >1 partner during follow-up (odds ratio (OR): 2.7(1.11-6.57)). Among 20-24-year-olds, failure to complete secondary school (aHR: 1.89 (1.11-3.21)), inconsistent condom use (aHR: 3.01 (1.14-7.96)) and reporting partner(s) who were HIV-positive and not on ART (aHR: 7.75 (3.06-19.66)) were associated with HIV incidence. Failure to complete secondary school among 20-24-year-olds was associated with inconsistent condom use (OR: 1.82 (1.20-2.77)) and reporting an HIV-positive partner not on ART (OR: 3.53(1.59-7.82)) or an uncircumcised partner (OR: 1.39 (1.08-1.82). CONCLUSION Absence of family support and incomplete schooling are associated with risky sexual behaviours and HIV acquisition in AGYW. In addition, partner-level prevention-condom use, medical circumcision, and viral suppression-continue to play an important role in reducing HIV risk in AGYW. These findings support the use of combination HIV prevention programs that consider structural as well as biological and behavioural HIV risk factors in their design.
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Affiliation(s)
- Lara Lewis
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu–Natal, Durban, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu–Natal, Durban, South Africa
- School of Laboratory Medicine and Medical Science, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Hilton Humphries
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu–Natal, Durban, South Africa
- Department of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, Cape Town, South Africa
| | - Sean Beckett
- HIV Economics and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Kaymarlin Govender
- HIV Economics and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDs Risk Management, Cape Town, South Africa
| | | | - Gavin George
- HIV Economics and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
- Division of Social Medicine and Global Health, Lund University, Lund, Sweden
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14
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Karim QA, Archary D, Barré-Sinoussi F, Broliden K, Cabrera C, Chiodi F, Fidler SJ, Gengiah TN, Herrera C, Kharsany ABM, Liebenberg LJP, Mahomed S, Menu E, Moog C, Scarlatti G, Seddiki N, Sivro A, Cavarelli M. Women for science and science for women: Gaps, challenges and opportunities towards optimizing pre-exposure prophylaxis for HIV-1 prevention. Front Immunol 2022; 13:1055042. [PMID: 36561760 PMCID: PMC9763292 DOI: 10.3389/fimmu.2022.1055042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Preventing new HIV infections remains a global challenge. Young women continue to bear a disproportionate burden of infection. Oral pre-exposure prophylaxis (PrEP), offers a novel women-initiated prevention technology and PrEP trials completed to date underscore the importance of their inclusion early in trials evaluating new HIV PrEP technologies. Data from completed topical and systemic PrEP trials highlight the role of gender specific physiological and social factors that impact PrEP uptake, adherence and efficacy. Here we review the past and current developments of HIV-1 prevention options for women with special focus on PrEP considering the diverse factors that can impact PrEP efficacy. Furthermore, we highlight the importance of inclusion of female scientists, clinicians, and community advocates in scientific efforts to further improve HIV prevention strategies.
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Affiliation(s)
- Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Derseree Archary
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Kristina Broliden
- Department of Medicine Solna, Division of Infectious Diseases, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Center for Molecular Medicine, Stockholm, Sweden
| | - Cecilia Cabrera
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesca Chiodi
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Sarah J. Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London UK and Imperial College NIHR BRC, London, United Kingdom
| | - Tanuja N. Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Carolina Herrera
- Department of Infectious Disease, Section of Virology, Faculty of Medicine, Imperial College London, London, United Kingdom,*Correspondence: Carolina Herrera,
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Lenine J. P. Liebenberg
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sharana Mahomed
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Elisabeth Menu
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France,MISTIC Group, Department of Virology, Institut Pasteur, Paris, France
| | - Christiane Moog
- Laboratoire d’ImmunoRhumatologie Moléculaire, Institut national de la santé et de la recherche médicale (INSERM) UMR_S 1109, Institut thématique interdisciplinaire (ITI) de Médecine de Précision de Strasbourg, Transplantex NG, Faculté de Médecine, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nabila Seddiki
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa,JC Wilt Infectious Disease Research Centre, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Mariangela Cavarelli
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France
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Bergam S, Sibaya T, Ndlela N, Kuzwayo M, Fomo M, Goldstein MH, Marconi VC, Haberer JE, Archary M, Zanoni BC. "I am not shy anymore": A qualitative study of the role of an interactive mHealth intervention on sexual health knowledge, attitudes, and behaviors of South African adolescents with perinatal HIV. Reprod Health 2022; 19:217. [PMID: 36457044 PMCID: PMC9713189 DOI: 10.1186/s12978-022-01519-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND South Africa has one of the highest burdens of adolescents with perinatally-acquired HIV (APHIV) in the world. APHIV in South Africa have limited access to sexual and reproductive health (SRH) education and services specific to their HIV status. When lacking comprehensive SRH education, APHIV are prone to sexual risk behaviors that can lead to unintended pregnancy, sexually transmitted infections, and HIV transmission. The use of mHealth interventions has been shown to deliver information, foster social support, and improve decision-making skills. In this study, we evaluate how an mHealth intervention influences sexual health knowledge and behaviors in APHIV. METHODS We purposively enrolled adolescents from the intervention arm of a randomized clinical trial assessing a multi-module, moderated WhatsApp-based intervention-Interactive Transition Support for Adolescents Living with HIV (InTSHA)-within a government supported clinic in KwaMashu, an urban township of KwaZulu-Natal, South Africa. We conducted in-depth interviews based on World Health Organization guidelines for asking adolescents about SRH. We thematically analyzed data through an iterative, team-based coding approach combining deductive and inductive elements to contextualize SRH attitudes, knowledge, and behaviors before and after receiving the InTSHA intervention. RESULTS Of the 21 participants, 13 (61.9%) were female and the mean age was 16.6 years. Most participants reported first learning about SRH as young teenagers in school through non-targeted and negative ways, seeking clarification through peers and the internet rather than clinicians or caregivers. Participants reported that InTSHA provided a holistic perspective on relationships, gender, and sexuality specific to growing up with HIV in South Africa. They praised the ability to give and receive information from peers in a moderated setting through the mHealth intervention, building their confidence, decision-making skills, and communication with partners and caregivers throughout their everyday lives. Despite reporting some technological challenges, adolescents agreed that InTSHA was convenient, confidential, and user-friendly. CONCLUSIONS South African APHIV receive incomplete and conflicting sexual education from peers, caregivers, teachers, and technology that can be supplemented by mHealth curricula targeted for the unique needs of APHIV. Future, scaled-up mHealth interventions can lower SRH stigma by expanding access to sexual education and peer support, supplementing adolescents' existing SRH education.
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Affiliation(s)
- Scarlett Bergam
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa ,George Washington School of Medicine and Health Sciences, Washington, DC USA
| | - Thobekile Sibaya
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Nompumelelo Ndlela
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Mpume Kuzwayo
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Messaline Fomo
- grid.189967.80000 0001 0941 6502Department of Global Health, Emory University’s Rollins School of Public Health, Atlanta, GA USA
| | | | - Vincent C. Marconi
- grid.189967.80000 0001 0941 6502Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502Department of Global Health, Emory University’s Rollins School of Public Health, Atlanta, GA USA
| | - Jessica E. Haberer
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Moherndran Archary
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Brian C. Zanoni
- grid.189967.80000 0001 0941 6502Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502Department of Global Health, Emory University’s Rollins School of Public Health, Atlanta, GA USA ,grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
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16
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Soogun AO, Kharsany ABM, Zewotir T, North D, Ogunsakin E, Rakgoale P. Spatiotemporal Variation and Predictors of Unsuppressed Viral Load among HIV-Positive Men and Women in Rural and Peri-Urban KwaZulu-Natal, South Africa. Trop Med Infect Dis 2022; 7:232. [PMID: 36136643 PMCID: PMC9502339 DOI: 10.3390/tropicalmed7090232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 02/05/2023] Open
Abstract
Unsuppressed HIV viral load is an important marker of sustained HIV transmission. We investigated the prevalence, predictors, and high-risk areas of unsuppressed HIV viral load among HIV-positive men and women. Unsuppressed HIV viral load was defined as viral load of ≥400 copies/mL. Data from the HIV Incidence District Surveillance System (HIPSS), a longitudinal study undertaken between June 2014 to June 2016 among men and women aged 15−49 years in rural and peri-urban KwaZulu-Natal, South Africa, were analysed. A Bayesian geoadditive regression model which includes a spatial effect for a small enumeration area was applied using an integrated nested Laplace approximation (INLA) function while accounting for unobserved factors, non-linear effects of selected continuous variables, and spatial autocorrelation. The prevalence of unsuppressed HIV viral load was 46.1% [95% CI: 44.3−47.8]. Predictors of unsuppressed HIV viral load were incomplete high school education, being away from home for more than a month, alcohol consumption, no prior knowledge of HIV status, not ever tested for HIV, not on antiretroviral therapy (ART), on tuberculosis (TB) medication, having two or more sexual partners in the last 12 months, and having a CD4 cell count of <350 cells/μL. A positive non-linear effect of age, household size, and the number of lifetime HIV tests was identified. The higher-risk pattern of unsuppressed HIV viral load occurred in the northwest and northeast of the study area. Identifying predictors of unsuppressed viral load in a localized geographic area and information from spatial risk maps are important for targeted prevention and treatment programs to reduce the transmission of HIV.
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Affiliation(s)
- Adenike O. Soogun
- Department of Statistics, School of Mathematics, Statistics and Computer Science, College of Agriculture Engineering and Science, University of KwaZulu-Natal, Durban 4001, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban 4001, South Africa
- School of Laboratory Medicine & Medical Science, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Temesgen Zewotir
- Department of Statistics, School of Mathematics, Statistics and Computer Science, College of Agriculture Engineering and Science, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Delia North
- Department of Statistics, School of Mathematics, Statistics and Computer Science, College of Agriculture Engineering and Science, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Ebenezer Ogunsakin
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Perry Rakgoale
- Department of Geography, School of Agriculture, Earth, and Environmental Science, University of KwaZulu-Natal, Durban 4001, South Africa
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Significant Associations between Chlamydia trachomatis and Neisseria gonorrhoeae Infections in Human Immunodeficiency Virus-Infected Pregnant Women. Infect Dis Obstet Gynecol 2022; 2022:7930567. [PMID: 35754526 PMCID: PMC9232329 DOI: 10.1155/2022/7930567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
There is a lack of data on the burden of Chlamydia trachomatis and Neisseria gonorrhoeae among human immunodeficiency virus- (HIV-) infected pregnant women in South Africa. We conducted a cross-sectional study which included 385 HIV-infected pregnant women attending antenatal clinic at the King Edward VIII Hospital in Durban, South Africa. The women provided vaginal swabs which were tested for C. trachomatis and N. gonorrhoeae. The prevalence of the individual STIs was as follows: C. trachomatis (47/385, 12.2%) and N. gonorrhoeae (16/385, 4.1%). Having a circumcised partner, testing positive for N. gonorrhoeae, and perceiving themselves of being at risk for infection were shown to increase the risk for C. trachomatis infection. Without controlling for the other factors, testing positive for N. gonorrhoeae increased the risk for C. trachomatis infection by 10-fold (OR: 10.17, 95% CI: 3.39-29.66, p < 0.001). Similarly, adjusting for the other factors, the risk for C. trachomatis infection in women who tested positive for N. gonorrhoeae was 9-fold (OR: 9.16, 95% CI: 2.19-40.18, p = 0.003). The following factors were associated with the increased risk of N. gonorrhoeae infection: not knowing their partner's HIV status, partner having other partners, and C. trachomatis infection status. Without controlling for the other factors, testing positive for C. trachomatis increased the risk for N. gonorrhoeae infection by 6-fold (OR: 6.52, 95% CI: 2.22-18.49, p < 0.001). Similarly, adjusting for the other factors, the risk for N. gonorrhoeae infection in women who tested positive for C. trachomatis was 6-fold (OR: 6.09, 95% CI: 1.73-22.03, p = 0.005). We found a significant association between C. trachomatis and N. gonorrhoeae in the pregnant women and the risk factors associated with these pathogens. Future studies are urgently required to investigate the impact of C. trachomatis/N. gonorrhoeae coinfections in HIV pregnant women since this data is lacking in our setting. In addition, etiological screening of C. trachomatis and N. gonorrhoeae during antenatal clinic is urgently required to prevent adverse pregnancy and birth outcomes associated with these infections.
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O. Soogun A, B.M. Kharsany A, Zewotir T, North D. Spatial Variation and Factors Associated with Unsuppressed HIV Viral Load among Women in an HIV Hyperendemic Area of KwaZulu-Natal, South Africa. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.105547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
New HIV infections among young women remains exceptionally high and to prevent onward transmission, UNAIDS set ambitious treatment targets. This study aimed to determine the prevalence, spatial variation and factors associated with unsuppressed HIV viral load at ≥400 copies per mL. This study analysed data from women aged 15–49 years from the HIV Incidence Provincial Surveillance System (HIPSS) enrolled in two sequential cross-sectional studies undertaken in 2014 and 2015 in rural and peri-urban KwaZulu-Natal, South Africa. Bayesian geoadditive model with spatial effect for a small enumeration area was adopted using Integrated Nested Laplace Approximation (INLA) function to analyze the findings. The overall prevalence of unsuppressed HIV viral load was 45.2% in 2014 and 38.1% in 2015. Factors associated with unsuppressed viral load were no prior knowledge of HIV status, had a moderate-to-low perception of acquiring HIV, not on antiretroviral therapy (ART), and having a low CD4 cell count. In 2014, women who ever consumed alcohol and in 2015, ever ran out of money, had two or more lifetime sexual partners, ever tested for tuberculosis, and ever diagnosed with sexually transmitted infection were at higher risk of being virally unsuppressed. The nonlinear effect showed that women aged 15 to 29 years, from smaller households and had fewer number of lifetime HIV tests, were more likely to be virally unsuppressed. High viral load risk areas were the north-east and south-west in 2014, with north and west in 2015. The findings provide guidance on identifying key populations and areas for targeted interventions.
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Soogun AO, Kharsany ABM, Zewotir T, North D, Ogunsakin RE. Identifying Potential Factors Associated with High HIV viral load in KwaZulu-Natal, South Africa using Multiple Correspondence Analysis and Random Forest Analysis. BMC Med Res Methodol 2022; 22:174. [PMID: 35715730 PMCID: PMC9206247 DOI: 10.1186/s12874-022-01625-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Sustainable Human Immunodeficiency Virus (HIV) virological suppression is crucial to achieving the Joint United Nations Programme of HIV/AIDS (UNAIDS) 95–95-95 treatment targets to reduce the risk of onward HIV transmission. Exploratory data analysis is an integral part of statistical analysis which aids variable selection from complex survey data for further confirmatory analysis. Methods In this study, we divulge participants’ epidemiological and biological factors with high HIV RNA viral load (HHVL) from an HIV Incidence Provincial Surveillance System (HIPSS) sequential cross-sectional survey between 2014 and 2015 KwaZulu-Natal, South Africa. Using multiple correspondence analysis (MCA) and random forest analysis (RFA), we analyzed the linkage between socio-demographic, behavioral, psycho-social, and biological factors associated with HHVL, defined as ≥400 copies per m/L. Results Out of 3956 in 2014 and 3868 in 2015, 50.1% and 41% of participants, respectively, had HHVL. MCA and RFA revealed that knowledge of HIV status, ART use, ARV dosage, current CD4 cell count, perceived risk of contracting HIV, number of lifetime HIV tests, number of lifetime sex partners, and ever diagnosed with TB were consistent potential factors identified to be associated with high HIV viral load in the 2014 and 2015 surveys. Based on MCA findings, diverse categories of variables identified with HHVL were, did not know HIV status, not on ART, on multiple dosages of ARV, with less likely perceived risk of contracting HIV and having two or more lifetime sexual partners. Conclusion The high proportion of individuals with HHVL suggests that the UNAIDS 95–95-95 goal of HIV viral suppression is less likely to be achieved. Based on performance and visualization evaluation, MCA was selected as the best and essential exploration tool for identifying and understanding categorical variables’ significant associations and interactions to enhance individual epidemiological understanding of high HIV viral load. When faced with complex survey data and challenges of variables selection in research, exploratory data analysis with robust graphical visualization and reliability that can reveal divers’ structures should be considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01625-6.
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Affiliation(s)
- Adenike O Soogun
- School of Mathematics, Statistics and Computer Science, College of Agriculture Engineering and Science, University of KwaZulu-Natal, Westville Campus, Durban, South Africa. .,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
| | - Ayesha B M Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Temesgen Zewotir
- School of Mathematics, Statistics and Computer Science, College of Agriculture Engineering and Science, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Delia North
- School of Mathematics, Statistics and Computer Science, College of Agriculture Engineering and Science, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Ropo Ebenezer Ogunsakin
- Biostatistics Unit, Discipline of Public Health Medicine, School of Nursing & Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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20
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Ntombela NP, Kharsany ABM, Soogun A, Yende-Zuma N, Baxter C, Kohler HP, McKinnon LR. Viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa: a cross sectional study to assess progress towards UNAIDS indicators and Implications for HIV Epidemic Control. Reprod Health 2022; 19:116. [PMID: 35550580 PMCID: PMC9097174 DOI: 10.1186/s12978-022-01419-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/18/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND South Africa has made significant progress in scaling up antiretroviral therapy (ART) to achieve the aspirational goal of HIV epidemic control. The aim of this study was to determine the prevalence of HIV, assess progress towards each of the Joint United Nations Programme on HIV/AIDS (UNAIDS) indicators and determine factors associated with achieving viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa. METHODS Pregnant adolescents and women, 12 years and older seeking antenatal care at six primary health care clinics were enrolled in a cross-sectional study. Following written informed consent, structured questionnaires were administered, and finger-prick blood samples were collected for HIV antibody testing and viral load measurement. Viral suppression was defined as HIV viral load of < 400 copies per mL. RESULTS Between Dec 2016 and March 2017, among the 546 enrolled participants, data for 545 were analysed. The overall HIV prevalence was 40.2% [95% Confidence Interval (CI) 36.1-44.3]. Age-stratified prevalence increased from 22.1% (95% CI, 15.9-30.0) in the 14-19 year age group to 63.9% (95% CI, 55.1-71.9) among women ≥ 30 years (Χ2 trend P < 0.0001). Of the HIV positive participants, 84.5% (95% CI, 79.0-88.8) knew their HIV positive status, 98.3% (95% CI 95.1-99.4) who knew their status were on ART, and of those on ART, 95.9% (95% CI 91.8-98.0) were virally suppressed. Among all HIV-positives 90.8% (95% CI, 86.3-94.0) had achieved viral suppression, whilst those in the 14-19 year age group were least likely to be virally suppressed at 82.8% (95% CI 65.5-92.4) compared to those in the older age groups. Married women compared to those unmarried were more likely to have achieved viral suppression (PRR) of 1.11 (95% CI 1.05-1.18), P < 0.001. CONCLUSIONS The proportion of HIV positive pregnant women achieving viral suppression was encouraging though far short of the target towards achieving epidemic control. Importantly, adolescent pregnant women were less likely to know their HIV status and to achieve viral suppression, underscoring the public health implications of sustained risk of HIV transmission. Thus, greater effort and strong social support are essential to improve HIV knowledge of status and care continuum towards the goal to achieving HIV epidemic control. To "fast-track" the response to achieve HIV epidemic control and end the AIDS epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set ambitious HIV testing and treatment targets for people living with HIV. Meeting these targets through scaling up testing for HIV, initiating and sustaining antiretroviral therapy (ART) to maintain viral suppression provides both therapeutic and preventive benefits with the potential to reduce HIV transmission. Viral suppression among pregnant adolescents and women living with HIV is crucial for the prevention of mother-to-child transmission of HIV including onward transmission to sexual partners. As a public health approach, in South Africa all pregnant women are offered routine HIV testing and immediate initiation of lifelong ART irrespective of CD4 cell count. It is, therefore, important to ascertain progress towards reaching the targets. The proportion of HIV positive pregnant adolescents and women achieving viral suppression was encouraging though far short of the target towards achieving epidemic control. Importantly, pregnant adolescents were less likely to know their HIV status and to achieve viral suppression, underscoring the public health implications of sustained risk of HIV transmission. Thus, greater effort and strong social support are essential to improve HIV knowledge of status and care continuum towards the goal to achieving HIV epidemic control.
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Affiliation(s)
- Nonzwakazi P Ntombela
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Congella, South Africa
| | - Ayesha B M Kharsany
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Congella, South Africa.
- 2nd Floor, Doris Duke Medical Research Institute, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, CAPRISA, University of KwaZulu-Natal, Private Bag 7, Congella, 4013, Durban, South Africa.
| | - Adenike Soogun
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Congella, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Congella, South Africa
| | - Cheryl Baxter
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Congella, South Africa
- Current Affiliation for Dr Cheryl Baxter, Centre for Epidemic Response and Innovation (CERI), School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Hans-Peter Kohler
- Population Studies Center, University of Pennsylvania, New York, USA
| | - Lyle R McKinnon
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Congella, South Africa
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
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Castor D, Burgess EK, Yende-Zuma N, Heck CJ, Abdool Karim Q. Age-Restriction of a Validated Risk Scoring Tool Better Predicts HIV Acquisition in South African Women: CAPRISA 004. AIDS Behav 2022; 26:3300-3310. [PMID: 35419667 PMCID: PMC9474358 DOI: 10.1007/s10461-022-03664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
We examined the predictive ability of the VOICE risk screening tool among adolescent girls and young women at heightened HIV risk in urban and peri-urban Kwa-Zulu-Natal, South Africa. Using participant data from CAPRISA 004’s control arm (N = 444), we applied the initial VOICE risk screening score (IRS), a modified risk score (MRS) based on predictive and non-predictive variables in our data, and age-restricted (AIRS and AMRS, respectively). We estimated incidence rates, 95% confidence bounds, sensitivity, specificity, negative and positive predictive values and area under the curve (AUC). The sample’s HIV incidence rate was 9.1/100 Person-Years [95% CI 6.9–11.7], resulting from 60 seroconversions (60/660.7 Person-Years). The IRS’ ≥ 8 cutpoint produced moderate discrimination [AUC = 0.66 (0.54–0.74), sensitivity = 63%, specificity = 57%]. Restricting to age < 25 years improved the score’s predictive ability (AIRS: AUC = 0.69, AMRS: AUC = 0.70), owing mainly to male partner having other partners and HSV-2. The risk tool predicted HIV acquisition at a higher cutpoint in this sample than in the initial VOICE analysis. After age-stratification, fewer variables were needed for maintaining score’s predictiveness. In this high incidence setting, risk screening may still improve the efficiency or effectiveness of prevention counseling services. However, PrEP should be offered to all prevention-seeking individuals, regardless of risk ascertainment.
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Affiliation(s)
- Delivette Castor
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Private Bag X7, Congella, Durban, 4013, South Africa
| | - Craig J Heck
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Private Bag X7, Congella, Durban, 4013, South Africa.
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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Govender K, Beckett S, Reddy T, Cowden RG, Cawood C, Khanyile D, Kharsany ABM, George G, Puren A. Association of HIV Intervention Uptake With HIV Prevalence in Adolescent Girls and Young Women in South Africa. JAMA Netw Open 2022; 5:e228640. [PMID: 35452103 PMCID: PMC9034400 DOI: 10.1001/jamanetworkopen.2022.8640] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE In South Africa, adolescent girls and young women aged 15 to 24 years are among the most high-risk groups for acquiring HIV. Progress in reducing HIV incidence in this population has been slow. OBJECTIVE To describe HIV prevalence and HIV risk behaviors among a sample of adolescent girls and young women and to model the association between exposure to multiple or layered interventions and key HIV biological and behavioral outcomes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey was conducted between March 13, 2017, and June 22, 2018, in 2 districts in Gauteng province and in 2 districts in KwaZulu-Natal province in South Africa. A stratified cluster random sampling method was used. Participants included adolescent girls and young women aged 12 to 24 years who lived in each sampled household. Overall, 10 384 participants were enrolled in Gauteng province and 7912 in KwaZulu-Natal province. One parent or caregiver was interviewed in each household. Data analysis was performed from March 12, 2021, to March 1, 2022. EXPOSURES DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe)-like interventions. MAIN OUTCOMES AND MEASURES The primary outcome was HIV prevalence. HIV status was obtained from laboratory-based testing of peripheral blood samples. Secondary outcomes included HIV testing and antiretroviral therapy uptake as well as numerous HIV risk variables that the DREAMS program sought to improve, such as pregnancy, sexually transmitted infection, intimate partner violence, and age-disparate sex. RESULTS The final sample included 18 296 adolescent girls and young women (median [IQR] age, 19 [15-21] years) in 10 642 households. Approximately half of participants (49.9%; n = 8414) reported engaging in sexual activity, and 48.1% (n = 3946) reported condom use at the most recent sexual encounter. KwaZulu-Natal province had a higher HIV prevalence than Gauteng province (15.1% vs 7.8%; P < .001). Approximately one-fifth of participants (17.6%; n = 3291) were not exposed to any interventions, whereas 43.7% (n = 8144) were exposed to 3 or more interventions. There was no association between exposure to DREAMS-like interventions and HIV status. Adolescent girls and young women who accessed 3 or more interventions were more likely to have undergone HIV testing (adjusted odds ratio, 2.39; 95% CI, 2.11-2.71; P < .001) and to have used condoms consistently in the previous 12 months (adjusted odds ratio, 1.68; 95% CI, 1.33-2.12; P < .001) than those who were not exposed to any interventions. CONCLUSIONS AND RELEVANCE Results of this study suggest that self-reported exposures to multiple or layered DREAMS-like interventions were associated with favorable behavioral outcomes. The beneficial aspects of layering HIV interventions warrant further research to support the sexual and reproductive health of adolescent girls and young women.
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Affiliation(s)
- Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Richard G. Cowden
- Human Flourishing Program, Harvard University, Cambridge, Massachusetts
| | - Cherie Cawood
- Epicentre AIDS Risk Management Limited, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDS Risk Management Limited, Cape Town, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases, Johannesburg, South Africa
- National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa
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Khumalo GE, Ntuli S, Lutge E, Mashamba-Thompson TP. Geo-analysis: the distribution of community health workers in relation to the HIV prevalence in KwaZulu-Natal province, South Africa. BMC Health Serv Res 2022; 22:326. [PMID: 35277152 PMCID: PMC8915516 DOI: 10.1186/s12913-022-07707-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The South African Ward Based Primary Health Care Outreach Team (WBPHCOT) policy framework states that the distribution of community health workers (CHWs) should be proportional to levels of poverty and disease within the population. We aimed to describe the spatial distribution of CHWs in relation to the prevalence of the Human Immunodeficiency Virus (HIV) which has itself been associated with poverty in previous studies. METHODS This was a descriptive, cross-sectional study in which secondary data was used for geospatial analysis. Based on the extrapolation from the norm of one WBPHCOT per 6000 individuals, we utilized geographic information system (GIS) methods to visualize the distribution of CHWs in relation to the prevalence of HIV in KwaZulu-Natal (KZN). Dot density mapping was used to visualize the random distribution of CHWs in relation to HIV prevalence and population in the districts. The districts' HIV prevalence, number of PLWH, ratio of CHW: people living with HIV (PLWH), ratio of CHW: population and poverty scores were mapped using choropleth mapping. MapInfo Pro 17.0 was used to map geospatial presentation of the data. RESULTS Overall, KZN province showed under allocation of CHWs with a CHW: people ratio of 1: 1156 compared to the estimated norm of 1: 600-1000. At district level, only two of 11 districts met the suggested norm of CHW: PLWH (1: 109-181). This indicates shortages and misallocation of CHWs in the nine remaining districts. Furthermore, our findings showed extensive geospatial heterogeneity with no clear pattern in the distribution of CHWs. There was no relationship between CHW distribution and HIV prevalence or poverty scores in the districts. CONCLUSION This study shows inequality in the distribution of CHWs which may be associated with inequalities in the provision of HIV related services. It is critical to strengthen the response to the HIV epidemic through the appropriate distribution of CHWs especially in those districts with high levels of HIV prevalence and poverty.
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Affiliation(s)
- G E Khumalo
- University of KwaZulu-Natal, Discipline of Public Health Medicine, School of Nursing & Public Health, Howard College Campus, Durban, South Africa.
- Health Research & Knowledge Management Unit; KwaZulu-Natal Department of Health, 330 Langalibalele Street, Pietermaritzburg, South Africa.
| | - S Ntuli
- Geographical Information System Unit, African Health Research Institute, Somkhele, Mtubatuba, South Africa
| | - E Lutge
- University of KwaZulu-Natal, Discipline of Public Health Medicine, School of Nursing & Public Health, Howard College Campus, Durban, South Africa
- Health Research & Knowledge Management Unit; KwaZulu-Natal Department of Health, 330 Langalibalele Street, Pietermaritzburg, South Africa
| | - T P Mashamba-Thompson
- University of KwaZulu-Natal, Discipline of Public Health Medicine, School of Nursing & Public Health, Howard College Campus, Durban, South Africa
- Faculty of Health Sciences, University of Pretoria, Prinshof Campus, Bophelo Rd, Prinshof 349-Jr, Pretoria, 0084a, South Africa
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Psaki SR, Pulerwitz J, Zieman B, Hewett PC, Beksinska M. What are we learning about HIV testing in informal settlements in KwaZulu-Natal, South Africa? Results from a randomized controlled trial. PLoS One 2022; 17:e0257033. [PMID: 35259151 PMCID: PMC8903271 DOI: 10.1371/journal.pone.0257033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent evidence highlighting high HIV incidence and prevalence in informal settlements suggests that they are environments that foster HIV risk. Given growing urbanization in sub-Saharan Africa, there is a critical need to assess the successes and challenges of implementing HIV testing, prevention and treatment interventions in these contexts. METHODS We randomly selected a household-based sample of 1528 adult men (18-35) and women (18-24) living in 18 randomly selected communities in KZN, South Africa. After the baseline interview, communities were randomized to one of three intervention rollout arms in a stepped wedge design. At approximately 8-month intervals, the Asibonisane Community Responses Program (and in particular the implementation of Stepping Stones, a participatory HIV prevention program focused on strengthening relationships and communication) was rolled at by intervention phase. Using data from this evaluation, we describe levels and trends in HIV testing and treatment during follow-up, and we use fixed effects models to estimate the effects of participation in the program on testing. RESULTS Study respondents reported high levels of economic insecurity and mobility, and men report various HIV risk behaviors including about 50% reporting multiple partnerships. About two-thirds of respondents (73% of women, 63% of men) had been tested for HIV in the last six months. Among those living with HIV, treatment levels were high at baseline, and almost universal by endline in 2019. Program participation led to a 17% increase in the probability of testing for women (p<0.05) but had no effect on testing for men due, in part, to the fact that the program did not reach men who were least likely to be tested, including those who had migrated recently, and those who had never been tested at baseline. CONCLUSIONS Near universal HIV treatment use demonstrates positive trends in access to some HIV services (including treatment as prevention) in these communities. Stepping Stones had positive effects on HIV testing for women, yet barriers to HIV testing remain, especially for men. Redoubled efforts to reach men with testing are vital for improving HIV outcomes for both men and their partners.
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Affiliation(s)
- Stephanie R. Psaki
- Population Council/Project SOAR, New York, New York, United States of America
| | - Julie Pulerwitz
- Population Council/Project SOAR, Washington, DC, United States of America
| | - Brady Zieman
- Population Council/Project SOAR, Blantyre, Malawi
| | - Paul C. Hewett
- Population Council/Project SOAR, Washington, DC, United States of America
| | - Mags Beksinska
- MatCH Research Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. METHODS We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis. RESULTS AND DISCUSSION We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. CONCLUSIONS Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Global Health Institute, Cambridge, Massachusetts, USA
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Ngobese B, Abbai NS. Sexually transmitted infections in pregnant women from sub-Saharan Africa. S Afr J Infect Dis 2021; 36:312. [PMID: 34917679 PMCID: PMC8664065 DOI: 10.4102/sajid.v36i1.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/06/2021] [Indexed: 11/05/2022] Open
Abstract
Background Sexually transmitted infections (STIs) are a major health problem in most countries of the world, particularly in developing countries where the resources and technology to diagnose and treat them are limited. Currently, there is limited data on STIs and risk factors for these infections in pregnant women living with human immunodeficiency virus (HIV), especially in sub-Saharan Africa (SSA). This review provides data on the prevalence and risk factors for STIs in pregnant women living with HIV from SSA. This review also describes the association between STIs and HIV on pregnancy and birth outcomes as well as highlights the importance of laboratory-based diagnosis of STIs. Method An electronic search of online databases was used to find and collect relevant research articles connected to the prevalence, adverse pregnancy and birth outcomes, health complications and risk factors associated with STIs and HIV in pregnant women from SSA. The search was limited to articles published in English. Relevant studies were identified by searching literature from January 2001 to date. The search yielded 4709 results. Results In SSA, STIs are highly prevalent in pregnant women and are widely known to be linked with an increased risk of poor maternal and neonatal outcomes. These infections are often asymptomatic and highly prevalent in pregnant women. The screening of STIs in pregnant women living with HIV can reduce the risk of mother-to-child transmission (MTCT) and screening and treatment for STIs can also prevent adverse perinatal outcomes. It is important to recognise regional and national STI epidemics in order to promote STI prevention and control interventions considering the test and treat approach as opposed to syndromic management. Conclusion This review highlights the need to use diagnostic screening methods instead of syndromic STI management in SSA. Moreover, more research into effective prevention and treatment measures for STIs in pregnant women is urgently required.
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Affiliation(s)
- Bongekile Ngobese
- Department of Clinical Medicine Laboratory, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Nathlee S Abbai
- Department of Clinical Medicine Laboratory, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Prevalence and Risk Factors for HIV Infection Among Heterosexual Men Recruited from Socializing Venues in Rural KwaZulu-Natal, South Africa. AIDS Behav 2021; 25:3528-3537. [PMID: 33575900 DOI: 10.1007/s10461-021-03182-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 02/07/2023]
Abstract
Young heterosexual men have low uptake of HIV prevention and treatment services and represent an important key population that may require novel strategies. We recruited 1271 heterosexual men, 12 years and older from socializing venues such as "shebeens", transport hubs, "spaza" shops, and community centers in rural KwaZulu-Natal, South Africa. Participants completed a questionnaire and were tested for HIV serostatus. Generalized estimating equations (GEE) with exchangeable covariance structure estimated factors independently associated with prevalent HIV infection. Median age was 25 years [Interquartile range (IQR) 21-29]. HIV prevalence was 15.5% [95% confidence interval (CI) 11.0-21.9] and increased significantly by age. Factors associated with higher odds of HIV infection were being 25 years and older [adjusted odds ratio (aOR) 4.82, 95% CI 3.47-6.69; p < 0.001), not completing high school (aOR 1.60, 95% CI 1.39-1.85; p < 0.001), not using condoms at first sex (aOR 1.43, 95% CI 1.20-1.70; p < 0.001), consuming alcohol (aOR 1.63, 95% CI 1.15-2.31; p = 0.006) or substances (aOR 1.37, 95% CI 1.31-1.44; p < 0.001), and absence of medical circumcision (aOR 2.05, 95% CI 1.71-2.44; p < 0.001). Risk was lower among those testing for HIV in last 12 months (aOR 0.54, 95% CI 0.36-0.80; p = 0.002). Greater effort is needed to implement innovative programs within settings that are easily accessible and where heterosexual men are likely to be.
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Hale N, Manalew WS, Leinaar E, Smith M, Sen B, Sharma P, Khoury A. Contraceptive Use and Pregnancy Outcomes Among Women Enrolled in South Carolina Medicaid Programs. Matern Child Health J 2021; 25:1960-1971. [PMID: 34637063 DOI: 10.1007/s10995-021-03260-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE State medicaid programs provide access to effective contraception for people with lower incomes. This study examined contraception use and pregnancy among reproductive-age women enrolled in the South Carolina Medicaid, by eligibility program and socio-demographic sub-groups. METHODS A retrospective cohort of women aged 15-45 who were newly eligible for South Carolina Medicaid from 2012 to 2016 was examined. Log-binomial regression and average marginal effects assessed relationships between contraception use and pregnancies ending in live and non-live births. Contraception was categorized as permanent, long acting reversible contraception (LARC), short-acting hormonal contraception (SAC), or no contraceptive claims. Women with family planning or full-benefit medicaid coverage were included. RESULTS Approximately 11% of women used LARC methods, 41% used SAC methods, and 46% had no evidence of contraceptive claims. Method utilization varied by eligibility program, race/ethnicity and age. The likelihood of pregnancy was lower among SAC users and lowest among LARC users compared to women with no evidence of contraception across all three programs (family planning APR = 0.44; 95% CI 0.41-0.49 and APR = 0.13, 95% CI 0.10-0.17; Low income families APR = 0.82; 95% CI 0.77-0.88 and APR = 0.33, 95% CI 0.28-0.38; Partners for Healthy Children APR = 0.72; 95% CI 0.68-0.77 and APR = 0.35, 95% CI 0.30-0.43, respectively). Non-Hispanic Black and Hispanic teens were less likely to experience a pregnancy than non-Hispanic white teens. CONCLUSIONS FOR PRACTICE The likelihood of pregnancy was lower among women using SAC methods and markedly lower among women using LARC. Variation in contraceptive use among racial/ethnic groups was noted despite Medicaid coverage. As new policies and initiatives emerge, these findings provide important context for understanding the role of Medicaid programs in reducing financial barriers to contraceptive services and ensuring access to effective contraception, while fostering reproductive health autonomy among women.
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Affiliation(s)
- Nathan Hale
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA.
| | - Wondimu S Manalew
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
| | - Edward Leinaar
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
| | - Michael Smith
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
| | - Bisakha Sen
- Department of Health Care Organization and Policy, The University of Alabama at Birmingham School of Public Health, 1665 University Blvd, RPHB 330F, Birmingham, AL, 35294, USA
| | - Pradeep Sharma
- Department of Health Care Organization and Policy, The University of Alabama at Birmingham School of Public Health, 1665 University Blvd, RPHB 320C, Birmingham, AL, 35294, USA
| | - Amal Khoury
- Department of Health Services Management & Policy, College of Public Health, Center for Applied Research & Evaluation in Women's Health, East Tennessee State University, PO Box 70264, Johnson, TN, 37614, USA
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Filiatreau LM, Pettifor A, Edwards JK, Masilela N, Twine R, Xavier Gómez-Olivé F, Haberland N, Kabudula CW, Lippman SA, Kahn K. Associations Between Key Psychosocial Stressors and Viral Suppression and Retention in Care Among Youth with HIV in Rural South Africa. AIDS Behav 2021; 25:2358-2368. [PMID: 33624194 PMCID: PMC8222008 DOI: 10.1007/s10461-021-03198-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 12/20/2022]
Abstract
Despite improvements in access to antiretroviral treatment over the past decade, sub-optimal HIV care outcomes persist among youth with HIV (YWH) in rural South Africa. Psychosocial stressors could impede improved HIV treatment outcomes within this population. We linked self-reported psychosocial health and demographic data from a cross-sectional survey conducted among YWH aged 12-24 in rural South Africa to individual medical record data, including facility visit history and viral load measurements. Poisson regression with robust standard errors was used to estimate the associations between five psychosocial stressors- heightened depressive symptoms (Center for Epidemiological Studies-Depression scale scores ≥ 16), lower social support (Medical Outcomes Social Support Scale scores ≤ 38), lower resilience (Conner-Davidson Resilience Scale scores ≤ 73), lower self-esteem (Rosenberg Self-Esteem Scale scores ≤ 21), and higher perceived stress (Sheldon Cohen Perceived Stress Scale scores ≥ 10)- and viral non-suppression (viral load ≥ 400 copies/mL) and loss to care (no documented clinic visits within the 90 days prior to survey), separately. A total of 359 YWH were included in this analysis. The median age of study participants was 21 (interquartile range: 16-23), and most were female (70.2%), single (82.4%), and attending school (54.7%). Over a quarter of participants (28.1%) had heightened depressive symptoms. Just 16.2% of all participants (n = 58) were lost to care at the time of survey, while 32.4% (n = 73) of the 225 participants with viral load data were non-suppressed. The prevalence of non-suppression in individuals with lower self-esteem was 1.71 (95% confidence interval: 1.12, 2.61) times the prevalence of non-suppression in those with higher self-esteem after adjustment. No meaningful association was observed between heightened depressive symptoms, lower social support, lower resilience, and higher perceived stress and viral non-suppression or loss to care in adjusted analyses. Retention in care and viral suppression among YWH in rural South Africa are below global targets. Interventions aimed at improving viral suppression among YWH should incorporate modules to improve participant's self-esteem as low self-esteem is associated with viral non-suppression in this setting. Future studies should longitudinally explore the joint effects of co-occurring psychosocial stressors on HIV care outcomes in YWH and assess meaningful differences in these effects by age, gender, and route of transmission.
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Affiliation(s)
- Lindsey M Filiatreau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, USA.
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, USA
| | - Nkosinathi Masilela
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
HIV incidence has recently been in decline across some of the most intense epidemics in sub-Saharan Africa due to the scale-up of prevention and transmission-blocking treatments. Understanding whether declines in incidence are being felt equally across age and gender can help prioritize demographic groups where more effort is needed to lower transmission. We found that HIV incidence has declined disproportionately in the youngest men and women in a population with the highest HIV prevalence in the world. Shifts in the age distribution of risk may be the consequence of aging prevalence, prioritized prevention to younger individuals, and delays in age at infection from reduced overall force of infection. Our results highlight the need to expand age targets for HIV prevention. Recent declines in adult HIV-1 incidence have followed the large-scale expansion of antiretroviral therapy and primary HIV prevention across high-burden communities of sub-Saharan Africa. Mathematical modeling suggests that HIV risk will decline disproportionately in younger adult age-groups as interventions scale, concentrating new HIV infections in those >age 25 over time. Yet, no empirical data exist to support these projections. We conducted a population-based cohort study over a 16-y period (2004 to 2019), spanning the early scale-up of antiretroviral therapy and voluntary medical male circumcision, to estimate changes in the age distribution of HIV incidence in a hyperepidemic region of KwaZulu-Natal, South Africa, where adult HIV incidence has recently declined. Median age of HIV seroconversion increased by 5.5 y in men and 3.0 y in women, and the age of peak HIV incidence increased by 5.0 y in men and 2.0 y in women. Incidence declined disproportionately among young men (64% in men 15 to 19, 68% in men 20 to 24, and 46% in men 25 to 29) and young women (44% in women 15 to 19, 24% in women 20 to 24) comparing periods pre- versus post-universal test and treat. Incidence was stable (<20% change) in women aged 30 to 39 and men aged 30 to 34. Age shifts in incidence occurred after 2012 and were observed earlier in men than in women. These results provide direct epidemiological evidence of the changing demographics of HIV risk in sub-Saharan Africa in the era of large-scale treatment and prevention. More attention is needed to address lagging incidence decline among older individuals.
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Kharsany ABM, McKinnon LR, Lewis L, Cawood C, Khanyile D, Maseko DV, Goodman TC, Beckett S, Govender K, George G, Ayalew KA, Toledo C. Population prevalence of sexually transmitted infections in a high HIV burden district in KwaZulu-Natal, South Africa: Implications for HIV epidemic control. Int J Infect Dis 2020; 98:130-137. [PMID: 32562845 PMCID: PMC7484252 DOI: 10.1016/j.ijid.2020.06.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sexually transmitted infections (STIs) and Human immunodeficiency virus (HIV) share a complex bidirectional relationship, however, population prevalence and the association between the presence of STIs and HIV in a high HIV burden district in KwaZulu-Natal, South Africa is not known. METHODS A total of 9812 participants aged 15-49 years were enrolled in a cross-sectional population-based household survey. Participants completed a structured questionnaire and provided first-pass urine (males) or self-collected vulvo-vaginal swabs (females) for the detection of STIs. RESULTS Prevalence of herpes simplex virus type-2 (HSV-2) was 57.8%, syphilis was 1.6%, Neisseria gonorrhoeae was 2.8%, Chlamydia trachomatis was 7.1%, Trichomonas vaginalis was 9.0%, Mycoplasma genitalium was 5.5% and HIV was 36.3%. HIV positive status was associated with an increased probability of having M. genitalium (aPR = 1.49, 95% CI 1.02-2.19) among males and syphilis (aPR = 2.54, 95% CI 1.32-4.86), N. gonorrhoeae (aPR = 2.39, 95% CI 1.62-3.52), T. vaginalis (aPR = 1.70, 95% CI 1.43-2.01) and M. genitalium (aPR = 1.60, 95% CI 1.15-2.22) among females. HIV viral load ≥400 copies per mL was associated with an increased probability of N. gonorrhoeae (aPR = 1.91, 95% CI 1.36-2.70), C. trachomatis (aPR = 1.52, 95% CI 1.12-2.05) and M. genitalium (aPR = 1.83, 95% CI 1.27-2.63). CONCLUSIONS The high prevalence of STIs and the association between STIs and HIV, and HIV viral load underscores the public health implications of sustained transmission risk of STIs and HIV. These findings highlight the urgent need for expanding STI surveillance and implementing interventions to monitor and reduce the STI burden.
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Affiliation(s)
- Ayesha B M Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; School of Laboratory Medicine & Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa.
| | - Lyle R McKinnon
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDS Risk Management (Pty) Limited, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDS Risk Management (Pty) Limited, Cape Town, South Africa
| | - Domiciled Venessa Maseko
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service (NICD/NHLS), Johannesburg, South Africa
| | - Tawni C Goodman
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | | | - Carlos Toledo
- Centers for Disease Control and Prevention (CDC), Atlanta, United States
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Vandormael A, Cuadros D, Dobra A, Bärnighausen T, Tanser F. HIV incidence declines in a rural South African population: a G-imputation approach for inference. BMC Public Health 2020; 20:1205. [PMID: 32762668 PMCID: PMC7409400 DOI: 10.1186/s12889-020-09193-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 07/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ad hoc assumptions about the unobserved infection event, which is known only to occur between the latest-negative and earliest-positive test dates, can lead to biased HIV incidence rate estimates. Using a G-imputation approach, we infer the infection dates from covariate data to estimate the HIV incidence rate in a hyper-endemic South African setting. METHODS A large demographic surveillance system has annually tested a cohort of HIV-uninfected participants living in the KwaZulu-Natal province. Using this data, we estimated a cumulative baseline hazard function and the effects of time-dependent covariates on the interval censored infection dates. For each HIV-positive participant in the cohort, we derived a cumulative distribution function and sampled multiple infection dates conditional on the unique covariate values. We right censored the data at the imputed dates, calculated the annual HIV incidence rate per 100 person-years, and used Rubin's rules to obtain the 95% confidence intervals. RESULTS A total of 20,011 uninfected individuals with a repeat HIV test participated in the incidence cohort between 2005 and 2018. We observed 2,603 infections per 58,769 person-years of follow-up among women and 845 infections per 41,178 person-years of follow-up among men. Conditional on age and circumcision status (men only), the female HIV incidence rate declined by 25%, from 5.0 to 3.7 infections per 100 person-years between 2014 and 2018. During this period, the HIV incidence rate among men declined from 2.1 to 1.1 infections per 100 person-years-a reduction of 49%. We observed similar reductions in male and female HIV incidence conditional on condom-use, marital status, urban residential status, migration history, and the HIV prevalence in the surrounding community. CONCLUSION We have followed participants in one of the world's largest and longest running HIV cohorts to estimate long-term trends in the population-wide incidence of infection. Using a G-imputation approach, we present further evidence for HIV incidence rate declines in this hyper-endemic South African setting.
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Affiliation(s)
- Alain Vandormael
- Africa Health Research Institute (AHRI), Durban, South Africa. .,Heidelberg Institute of Global Health, University of Heidelberg, 130.3 Im Neuenheimer Feld, Heidelberg, 69115, Germany. .,KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal (UKZN), Durban, South Africa.
| | - Diego Cuadros
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, USA
| | - Adrian Dobra
- Department of Statistics, Center for Statistics and the Social Sciences, and Center for Studies in Demography and Ecology, University of Washington, Seattle, USA
| | - Till Bärnighausen
- Africa Health Research Institute (AHRI), Durban, South Africa.,Heidelberg Institute of Global Health, University of Heidelberg, 130.3 Im Neuenheimer Feld, Heidelberg, 69115, Germany.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Frank Tanser
- Africa Health Research Institute (AHRI), Durban, South Africa.,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK.,School of Nursing and Public Health, UKZN, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
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George G, Cawood C, Puren A, Khanyile D, Gerritsen A, Govender K, Beckett S, Glenshaw M, Diallo K, Ayalew K, Gibbs A, Reddy T, Madurai L, Kufa-Chakezha T, Kharsany ABM. Evaluating DREAMS HIV prevention interventions targeting adolescent girls and young women in high HIV prevalence districts in South Africa: protocol for a cross-sectional study. BMC Womens Health 2020; 20:7. [PMID: 31948429 PMCID: PMC6966796 DOI: 10.1186/s12905-019-0875-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Young women in sub-Saharan Africa remain at the epicentre of the HIV epidemic, with surveillance data indicating persistent high levels of HIV incidence. In South Africa, adolescent girls and young women (AGYW) account for a quarter of all new HIV infections. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is a strategy introduced by the United States President's Emergency Plan for AIDS Relief (PEPFAR) aimed at reducing HIV incidence among AGYW in 10 countries in sub-Saharan Africa by 25% in the programme's first year, and by 40% in the second year. This study will assess the change in HIV incidence and reduction in risk associated behaviours that can be attributed to the DREAMS initiative in South Africa, using a population-based cross-sectional survey. METHODS Data will be collected from a household-based representative sample of AGYW (between the ages 12-24 years) in four high prevalence districts (more than 10% of the population have HIV in these districts) in South Africa in which DREAMS has been implemented. A stratified cluster-based sampling approach will be used to select eligible participants for a cross-sectional survey with 18,500, to be conducted over 2017/2018. A questionnaire will be administered containing questions on sexual risk behaviour, selected academic and developmental milestones, prevalence of gender based violence, whilst examining exposure to DREAMS programmes. Biological samples, including two micro-containers of blood and self-collected vulvovaginal swab samples, are collected in each survey to test for HIV infection, HIV incidence, sexually transmitted infections (STIs) and pregnancy. This study will measure trends in population level HIV incidence using the Limiting antigen (LAg) Avidity Enzyme Immuno-Assay (EIA) and monitor changes in HIV incidence. DISCUSSION Ending the HIV/AIDS pandemic by 2030 requires the continual monitoring and evaluation of prevention programmes, with the aim of optimising efforts and ensuring the achievement of epidemic control. This study will determine the impact DREAMS interventions have had on HIV incidence among AGYW in a 'real world, non-trial setting'.
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Affiliation(s)
- Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), 4th Floor, J Block, Westville Campus, University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDs Risk Management (Pty) Limited, Paarl, South Africa
| | - Adrian Puren
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service (NICD/NHLS), Johannesburg, South Africa
| | - David Khanyile
- Epicentre AIDs Risk Management (Pty) Limited, Paarl, South Africa
| | | | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division (HEARD), 4th Floor, J Block, Westville Campus, University of KwaZulu-Natal, Durban, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division (HEARD), 4th Floor, J Block, Westville Campus, University of KwaZulu-Natal, Durban, South Africa
| | - Mary Glenshaw
- U.S. Centers for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Karidia Diallo
- U.S. Centers for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Kassahun Ayalew
- U.S. Centers for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Andrew Gibbs
- Health Economics and HIV and AIDS Research Division (HEARD), 4th Floor, J Block, Westville Campus, University of KwaZulu-Natal, Durban, South Africa
- Gender and Health Research Unit, South African Medical Research Council (SAMRC), Pretoria, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council (SAMRC), Durban, South Africa
| | - Lorna Madurai
- Global Clinical and Virology Laboratory, Amanzimtoti, Durban, South Africa
| | - Tendesayi Kufa-Chakezha
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service (NICD/NHLS), Johannesburg, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal South Africa
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Kong X. HIV Prevention and Treatment Scale-up and Community HIV Incidence in KwaZulu-Natal, South Africa. JAMA Netw Open 2019; 2:e1914408. [PMID: 31675077 DOI: 10.1001/jamanetworkopen.2019.14408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Xiangrong Kong
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Biostatistics, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland
- Department of Health, Behavior and Society, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland
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