Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments

Strikes and Gutters: Biomarkers and anthropometric measures for predicting diagnosed diabetes mellitus in adults in low- and middle-income countries

The management of diabetes necessitates the requirement of reliable health indices, specifically biomarkers and anthropometric measures, to detect the presence or absence of the disease. Nevertheless, limited robust empirical evidence exists regarding the optimal metrics for predicting diabetes in adults, particularly within low- and middle-income countries. This study investigates objective and subjective indices for screening diabetes in these countries.

METHODS

Data for this study was sourced from surveys conducted among adults (aged 18 years and above) in seventeen (17) countries. Self-reported diabetes status, fifty-four biomarkers, and twenty-six core and twenty-eight estimated anthropometric indices, including weight, waist circumference, body mass index, glycaemic triglycerides, and fasting blood glucose, were utilised to construct lasso regression models.

RESULTS

The study revealed variances in diabetes prediction outcomes across different countries. Central adiposity measures, fasting plasma glucose and glycaemic triglycerides demonstrated superior predictive capabilities for diabetes when compared to body mass index. Furthermore, fasting plasma or blood glucose, serving as a biomarker, emerged as the most accurate predictor of diabetes.

CONCLUSIONS

These findings offer critical insights into both general and context-specific tools for diabetes screening. The study proposes that fasting plasma glucose and central adiposity indices should be considered as routine screening tools for diabetes, both in policy interventions and clinical practice. By identifying adults with or at higher risk of developing diabetes and implementing appropriate interventions, these screening tools possess the potential to mitigate diabetes-related complications in low- and middle-income countries.

Use of hospital services by patients with chronic conditions in sub-Saharan Africa: a systematic review and meta-analysis

Objective

To estimate the prevalence of individual chronic conditions and multimorbidity among adults admitted to hospital in countries in sub-Saharan Africa.

Methods

We systematically searched MEDLINE®, Embase®, Global Index Medicus, Global Health and SciELO for publications reporting on patient cohorts recruited between 1 January 2010 and 12 May 2023. We included articles reporting prevalence of pre-specified chronic diseases within unselected acute care services (emergency departments or medical inpatient settings). No language restrictions were applied. We generated prevalence estimates using random-effects meta-analysis alongside 95% confidence intervals, 95% prediction intervals and I2 statistics for heterogeneity. To explore associations with age, sex, country-level income status, geographical region and risk of bias, we conducted pre-specified meta-regression, sub-group and sensitivity analyses.

Findings

Of 6976 identified studies, 61 met the inclusion criteria, comprising data from 20 countries and 376 676 people. None directly reported multimorbidity, but instead reported prevalence for individual conditions. Among medical admissions, the highest prevalence was human immunodeficiency virus infection (36.4%; 95% CI: 31.3-41.8); hypertension (24.4%; 95% CI: 16.7-34.2); diabetes (11.9%; 95% CI: 9.9-14.3); heart failure (8.2%; 95% CI: 5.6-11.9); chronic kidney disease (7.7%; 95% CI: 3.9-14.7); and stroke (6.8%; 95% CI: 4.7-9.6).

Conclusion

Among patients seeking hospital care in sub-Saharan Africa, multimorbidity remains poorly described despite high burdens of individual chronic diseases. Prospective public health studies of multimorbidity burden are needed to generate integrated and context-specific health system interventions that act to maximize patient survival and well-being.

The Effect of Cardiorespiratory Exercise in the Prevention and Treatment of Hypertension among HIV-Infected Individuals on Antiretroviral Therapy in Mthatha, South Africa

The prevalence of hypertension among people living with HIV (PLHIV) on antiretroviral therapy (ART) is concerning. Physical activity is a proposed approach for managing and avoiding hypertension in this population. While cardiorespiratory exercises (CET) have been efficacious in the general population, its effectiveness in PLHIV on ART, especially in the study setting, in Mthatha is unknown. Consequently, the purpose of this study was to see if CET improves cardiorespiratory fitness in HAART-treated PLHIV with blood flow restriction (BFR) in Mthatha, South Africa. A quasi-experimental study with 98 participants (49 of whom were cases) was carried out. Cases were participants assigned to the CET intervention group that comprised of concurrent training as it included both aerobic and resistance exercise, matched on age and gender. The relationship between CET and hypertension was assessed using logistic regression after adjusting for possible confounding variables. At baseline, there was no significant difference between the physical characteristics of the two groups, and after the intervention, there was a significant difference. Obesity and central adiposity were identified as strong risk factors for hypertension. The findings also indicated that a reduction in waist circumference and body mass index had a significant positive association with hypertension treatment amongst the intervention group (p < 0.05). According to the results of the study, CET has the potential to be an efficient and economical non-pharmacological intervention for the management and control of hypertension in PLHIV. However, further study is required to establish how long, how intense, and what kind of exercise is best for this population.

The state of kidney replacement therapy in Eastern Cape Province, South Africa: A call to action

Background. South Africa (SA) is one of the most financially unequal countries in the world. This situation is highlighted by disparateaccess to healthcare, particularly provision of kidney replacement therapy (KRT). Unlike the private sector, public sector access to KRT is highly rationed, and patient selection is based on suitability for transplantation and capacity.Objectives. To investigate the state of the KRT service in Eastern Cape Province, SA, by analysing access to and provision of KRT in theprovince for individuals with end-stage kidney disease, as well as disparities between the private and public healthcare systems.Methods. This was a retrospective descriptive study to examine KRT provision and temporal trends in the Eastern Cape. Data were obtained from the South African Renal Registry and the National Transplant Waiting List. KRT provision was compared between the three main referral centres, in Gqeberha (formerly Port Elizabeth), East London and Mthatha, and between the private and public healthcare systems.Results. There were 978 patients receiving KRT in the Eastern Cape, with an overall treatment rate of 146 per million population (pmp).The treatment rate for the private sector was 1 435 pmp, compared with 49 pmp in the public sector. Patients treated in the private sector were older at initiation of KRT (52 v. 34 years), and more likely to be male, to be HIV positive, and to receive haemodialysis as their KRT modality. Peritoneal dialysis was more commonly used in Gqeberha and East London as the first and subsequent KRT modality, compared with Mthatha. There were no patients from Mthatha on the transplant waiting list. There were no waitlisted HIV-positive patients in the public sector in East London, compared with 16% of the public sector patients in Gqeberha. The kidney transplant prevalence rate was 58 pmp in the private sector and 19 pmp in the public sector, with a combined prevalence of 22 pmp, constituting 14.9% of all patients on KRT. We estimated the shortfall of KRT provision in the public sector to be ~8 606 patients.Conclusion. Patients in the private sector were 29 times more likely to access KRT than their public sector counterparts, who were onaverage 18 years younger at initiation of KRT, probably reflecting selection bias in an overburdened public health system. Transplantation rates were low in both sectors, and lowest in Mthatha. A large public sector KRT provision gap exists in the Eastern Cape and needs to be addressed urgently.

Young people's access to sexual and reproductive health prevention services in South Africa during the COVID-19 pandemic: an online questionnaire

INTRODUCTION

The South African government responded swiftly to the first wave of novel coronavirus (SARS-CoV-2) with a nationwide lockdown. Initial restrictions from March-July 2020 required people to stay at home unless accessing essential, life-saving services. We sought to understand how the COVID-19 pandemic and resulting lockdowns affected young people's access to sexual and reproductive health services in a high-prevalence HIV setting.

METHODS

We analysed data from a cross-sectional web-based questionnaire conducted with 15-24 year-olds from September-December 2020 in Eastern Cape, South Africa. The questionnaire was promoted through social media platforms. Participants were asked whether and how the COVID-19 pandemic and related restrictions affected their access to sexual and reproductive health services, through closed-ended and open-ended questions. Descriptive statistics using proportions were used to summarise responses, and open text was analysed using thematic analysis.

RESULTS

Of 3431 respondents, the proportions reporting 'more difficulty' accessing HIV testing services, HIV self-screening kits, condoms, pre-exposure prophylaxis and antiretroviral treatment since the COVID-19 pandemic were 16.8%, 13.7%, 13.9%, 11% and 7%, respectively. In 796 open-text responses, participants described challenges accessing HIV services due to clinics being overwhelmed and prioritising patients with COVID-19, resulting in young people being turned away. Some were afraid of contracting COVID-19 at or en route to clinics. Others were unable to reach clinics because of restricted transport or financial insecurity.

DISCUSSION

Young people in Eastern Cape rely on local clinics for services, and large proportions of young males and females faced difficulties or fears accessing clinics during the COVID-19 lockdown. Clinics became overwhelmed or inaccessible, limiting young people's access to sexual and reproductive health services. In high HIV risk contexts, prevention services and tools must be more accessible to young people, outside of clinics and within the communities and spaces that young people can access without fear or cost.

Progress towards unique patient identification and case-based surveillance within the Southern African development community

Population mobility makes patient-tracking and care linkage in the South African Development Community (SADC) challenging. Case-based surveillance (CBS) through individual-level clinical data linked with a unique patient-identifier (UPI) is recommended. We conducted a mixed-methods landscape analysis of UPI and CBS implementation within selected SADC countries, this included: (1) SADC UPI implementation literature review; (2) assessment of UPI and CBS implementation for high HIV-prevalence SADC countries; (3) UPI implementation case-study in selected South African primary healthcare (PHC) facilities. Research into CBS and UPI implementation for the SADC region is lacking. Existing patient-identification methods often fail and limit patient-tracking. Paper-based records and poor integration between health-information systems further restrict patient-tracking. Most countries were in the early-middle stages of CBS and faced UPI challenges. Our South African case-study found that the UPI often goes uncaptured. Difficulties tracking patients across prevention and care cascades will continue until a functional and reliable UPI is available.

Cochleovestibular findings linked to COVID-19: A scoping review for clinical care planning in South Africa

Background

On 30 January 2020, the World Health Organization (WHO) officially declared an outbreak of the coronavirus disease 2019 (COVID-19) to be a global health emergency. Research has focused on the impact and response to life-threatening symptoms of COVID-19 across the lifespan; however, there is a need to investigate the effects of COVID-19 on the cochleovestibular system, as viral infections are known to impact this system. This is particularly important for contexts where resources are limited and prioritisation of resources requires strong risk versus benefit evaluations.

Objective

Therefore, the purpose of this scoping review was to investigate published evidence on the impact of COVID-19 on the cochleovestibular system across the lifespan in order to allow for strategic clinical care planning in South Africa, where capacity versus demand challenges exist.

Methods

Electronic bibliographic databases such as CINAHL, EBSCOHost, MEDLINE, ProQuest, PubMed, Scopus and ScienceDirect were searched for peer-reviewed publications between January 2020 and January 2022. These had to be published in English and related to the impact of COVID-19 on the cochleovestibular system, where the question was: ‘what evidence has been published on the impact of COVID-19 on the cochleovestibular system?’ Review selection and characterisation was performed by the researcher with an independent review by a colleague using pretested forms.

Results

Of a total of 24 studies that met the inclusion criteria, the current scoping review revealed limited conclusive published evidence linking COVID-19 to permanent hearing function symptoms. Current evidence supports the possibility of COVID-19, similar to other viral infections in adults, impacting the cochleovestibular system and causing tinnitus, vertigo and sudden sensorineural hearing loss (SSNHL), with the symptoms being generally temporary and resolving either partially or completely following therapy with steroids, with very inconclusive findings in the paediatric population.

Conclusion

These findings raise global implications for properly designed studies, which include longitudinal follow-up of cases across the lifespan, examining this link with some focus on establishing the pathophysiologic mechanisms at play as well. In the meanwhile, current findings raise the value of polymerase chain reaction (PCR) testing for all patients presenting with unexplained cochleovestibular symptoms during the pandemic, as these may be the only presenting symptoms indicating COVID-19, thus requiring careful treatment and management.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis

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.

Cost-Effectiveness of Bivalent, Quadrivalent, and Nonavalent HPV Vaccination in South Africa

BACKGROUND AND OBJECTIVES

In South Africa, the prevalence of human papillomavirus (HPV) and associated diseases, such as cervical cancer and genital warts, is among the highest in the world. This study evaluates the cost-effectiveness of bivalent, quadrivalent, and nonavalent HPV vaccination for 9- to 14-year-old girls from the South African healthcare system perspective.

METHODS

A Markov model portraying the natural HPV disease progression from high-risk infection to cervical intraepithelial neoplasia (CIN) I, CIN II/III, or cervical cancer and from low-risk infection to genital warts was built. Transition probability, utility, and efficacy data were sourced from peer-reviewed literature. Vaccination costs were calculated based on the World Health Organization (WHO) guidelines. The model was populated with a cohort of 520,000 9-year-old girls to calculate incremental cost-effectiveness ratios (ICER) in South African Rand (R) per quality-adjusted life-years (QALYs) gained for each vaccination strategy.

RESULTS

All HPV vaccination strategies dominate the no vaccine strategy. Compared with the bivalent vaccine, the nonavalent strategy increases QALYs by 0.14 and costs by R1793 (ICER: R13,013 per QALY) per person, while the quadrivalent vaccination provides -0.02 incremental QALYs and R1748 costs (ICER: -R116,397 per QALY). Consequently, at the South African willingness-to-pay threshold of R23,630 per QALY, nonavalent vaccination is the preferred strategy, with a probability of 90.2%. Scenario analysis demonstrated that results are influenced by vaccine coverage, efficacy, and duration of efficacy.

CONCLUSIONS

The introduction of nonavalent for bivalent HPV vaccination is a cost-effective intervention in South Africa. HPV vaccination should be part of a multifaceted public health strategy entailing screening, condoms, and education of all stakeholders to reduce the significant burden of sexual transmitted diseases in South Africa. Sex-neutral and catch-up vaccinations are subjects for further research.

Correlates and cascade of HIV care in patients with psychiatric disorders in the Eastern Cape province, South Africa

Background

The cascade of human immunodeficiency virus (HIV) care in patients with psychiatric disorders is poorly understood.

Aim

This study determined the prevalence of HIV and described its cascade of care among patients with psychiatric disorders in the Eastern Cape province, South Africa. The study also examined the correlates of HIV comorbidity with psychiatric disorders in the cohort.

Methods

In this cross-sectional study, a total of 368 individuals attending the Psychiatric Outpatients’ Department of Cecilia Makiwane Hospital in Eastern Cape were interviewed with a structured questionnaire. Relevant items on demographics and clinical information were extracted from the medical records. Virologic suppression was defined as viral load < 1000 RNA copies/mL.

Results

The HIV prevalence after the intervention was 18.8% and a significant proportion of participants already knew their status (n = 320; 87.0%). Linkage to care and antiretroviral therapy initiation occurred in 61 participants, of those diagnosed with HIV (88.4%), with 84.1% being eligible for viral load monitoring (n = 58) and 53.4% having achieved virologic suppression. Being female (AOR = 5.48; 95% CI 2.61–11.51) and black (adjusted odds ratio [AOR] = 3.85; 95% confidence interval [CI] 1.06–14.03) were independent predictors of HIV comorbidity in individuals living with psychiatric disorders.

Conclusion

This study found a moderately high prevalence (close to 19%) of HIV in individuals with psychiatric disorders, with a significant correlation with being female and being black people. This study also found a significant gap in the linkage to antiretroviral therapy (ART) initiation and a low rate of virologic suppression of 53.4%. Clinicians, therefore, should monitor and provide interventions for patients with concomitant HIV infection along this cascade of care.

The geography of emergency department-based HIV testing in South Africa: Can patients link to care?

BACKGROUND

Emergency Departments (EDs) can serve as clinical sites for identification of new HIV infections and their entry into care. We examined if HIV-positive patients who present to EDs in South Africa are able to successfully link to care.

METHODS

We conducted a one-year longitudinal prospective cohort study in four hospitals across the Eastern Cape, South Africa, with participants followed between July 2016 and July 2018. All adult, non-critical patients presenting to the ED were systematically approached, asked about their HIV status, and, if unknown, offered a point-of-care (POC) HIV test. All HIV-positive patients were further consented to participate in a follow-up study to assess subsequent linkage to care and distance from "home" to ED. Linkage to care was defined as self-reported linkage (telephonic) or evidence of repeated CD4/viral load testing in the National Health Laboratory System (NHLS) at either the 6- or 12-months post index ED visit.

FINDINGS

A total of 983 HIV-positive patients consented to participate in the study. In the 12 months following their ED visit, 34·1% of patients demonstrated linkage to care (335/983), 23·8% did not link to care (234/983), and 42·1% (414/983) were lost to follow-up. Though not statistically significant, a high percentage of young men (27/50, 54%) and those presenting with a trauma-related complaints (100/205, 48.8%) did not link to care. A considerable proportion of patients (105/454, 23·2%,) resided 50 or more kilometers from their index ED sites, though there was not a significant difference in linkage to care rate between those who lived closer or further from the ED.

INTERPRETATION

We have shown that strategies to improve linkage to care from the ED should consider the high rates of poor linkage among young men and those presenting to the ED with trauma. Furthermore, innovative linkage to care solutions will need to account for the unique geographical consideration of this population, given that many ED patients will need to continue care at a site distant from the diagnosis site.

FUNDING

This research was supported by the South African Medical Research Council, the Division of Intramural Research, the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Johns Hopkins Center for Global Health.

Barriers to the Implementation of the HIV Universal Test and Treat Strategy in Selected Primary Care Facilities in South Africa's Eastern Cape Province

Background:

The South African government implemented the Universal Test and Treat (UTT) approach to treating HIV in the second half of 2016. As part of a contribution to the successful implementation of UTT, this study looked at barriers to implementation of UTT emanating from weaknesses of the health system in 2 Community Health Centers in South Africa’s Eastern Cape Province.

Methods:

This was a quantitative cross-sectional design which had both descriptive and analytical components. Convenience sampling was used to select and recruit 2 primary care facilities and 30 nurses. Self-administered questionnaires were used to solicit data from facility managers and nurses. In addition, a record review was used to access 6 months’ data for the period 1 October 2017 to 31 March 2018. Data were analyzed using Stata 14.1. Categorical data were presented using frequency and contingency tables. The 95% confidence interval (95% CI) is used for the precision of estimates and the P-value of statistical significance is P < .05.

Results:

Facilities were found to have poor leadership and governance; human resource challenges that include shortages, lack of skills and lack of developmental support; poorly resourced service delivery platforms and poor information management. Of the three 90-90-90 targets, health facilities only satisfactorily achieved the second 90 of initiating all who test positive for HIV within a week (93.1% or n = 288/307).

Conclusions:

This study has been able to identify potential barriers to the implementation of the UTT strategy at the selected facilities including the lack of structured programs in place to monitor performance of healthcare staff, knowledge gaps, and a lack of good clinical governance practices as evidenced by the lack of customized protocols and Standard Operating Procedures.

Frequent Detection of Undiagnosed HIV Within Emergency Departments in Botswana

ABSTRACT

Among 130,161 HIV testing records from unique individuals at 149 programmatic sites in Botswana, frequency of detecting undiagnosed HIV infection within emergency departments (EDs) was 4.7% (455/9695), 2-fold higher than other clinic-based HIV counseling and testing. Men and noncitizens less frequently initiated same-day antiretroviral therapy after testing HIV positive within emergency departments.

The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions

INTRODUCTION

The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade.

METHODS

We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero.

RESULTS AND DISCUSSION

Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care.

CONCLUSIONS

The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.

Assessing attitudes to ED-based HIV testing: Development of a short-structured survey instrument

INTRODUCTION

Emergency Department (ED)-based HIV counseling and testing (HCT) has had a significant impact on improving rates of HIV diagnosis and linkage to care. Unfortunately, expansion of this strategy to low- and middle-income countries has been limited. Successful implementation of ED-based HCT is dependent on patient and provider acceptance of the intervention, and their attitudes and pre-existing biases towards the disease. This study sought to develop validated survey instruments to assess attitudes towards ED-based HCT.

METHODS

This cross-sectional study surveyed patients and providers in three EDs in the Eastern Cape province, South Africa. A convenience sample of patients and providers in the ED were surveyed. Exploratory factor analysis was conducted using questions on attitudes to HIV testing to develop validated survey instruments. An ANOVA test assessed variance in attitudes towards HCT based on demographic variables collected.

RESULTS

A total of 104 patient and 132 provider surveys were completed. Exploratory factor analysis resulted in a 17- and 7-question attitudes survey for patients and providers, respectively. Overall, 92.3% of patients and 70.7% of providers supported ED-based HCT, however, both groups displayed only mildly positive attitudes. Questions representing 'confidentiality' and 'stigma around HIV testing' had the least positive influence on patients' overall attitudes. Questions representing 'comfort with HIV testing' had the least positive influence on providers' overall attitudes.

CONCLUSION

Our study demonstrated ED patients and providers are generally supportive of ED-based HCT. A validated survey instrument was able to provide a standardized approach to identify barriers to HCT implementation in an ED setting, across contexts. For successful implementation, behavioral interventions must focus on strengthening patient beliefs around confidentiality and the consent process, and providers' comfort levels with providing HIV testing services in the ED.

An open-label, randomized crossover study to evaluate the acceptability and preference for contraceptive options in female adolescents, 15 to 19 years of age in Cape Town, as a proxy for HIV prevention methods (UChoose)

Introduction

Young women in Southern Africa have extremely high HIV incidence rates necessitating the availability of female‐controlled prevention methods. Understanding adolescent preference for seeking contraception would improve our understanding of acceptability, feasibility and adherence to similar modes of delivery for HIV prevention.

Methods

UChoose was an open‐label randomized crossover study over 32 weeks which aimed to evaluate the acceptability and preference for contraceptive options in healthy, HIV‐uninfected, female adolescents aged 15 to 19 years, as a proxy for similar HIV prevention methods. Participants were assigned to a contraceptive method for a period of 16 weeks in the form of a bi‐monthly injectable contraceptive, monthly vaginal Nuvaring^® or daily combined oral contraceptive (COC) and then asked to state their preference. At 16 weeks, participants crossed over to another contraceptive method, to ensure that all participants tried the Nuvaring^® (least familiar modality) and additionally, either the injection or COC. Primary outcomes were contraceptive acceptability and preference. At the end of the 32 weeks they were also asked to imagine their preference for an HIV prevention modality. Secondary endpoints included changes in sexual behaviour, contraceptive adherence and preference for biomedical and behavioural HIV prevention methods.

Results

Of the 180 participants screened, 130 were enrolled and randomized to the Nuvaring^® (n = 45), injection (n = 45) or COC (n = 40). Significantly more Nuvaring^® users (24/116; 20.7%) requested to change to another contraceptive option compared to injection (1/73; 1.4% p = 0.0002) and COC users (4/49; 8% p = 0.074). Of those that remained on the Nuvaring^®, adherence was significantly higher than to COC (p < 0.0001). Significantly more injection users (77/80; 96.3%) thought this delivery mode was convenient to use compared to Nuvaring^® (74/89; 83.1%; p = 0.0409) or COC (38/50; 76.0%; p = 0.0034). Overall, the preferred contraceptive choice was injection, followed by the ring and lastly the pill.

Conclusions

Adherence to daily COC was difficult for adolescents in this cohort and the least favoured potential HIV prevention option. While some preferred vaginal ring use, these data suggest that long‐acting injectables would be the preferred prevention method for adolescent girls and young women. This study highlights the need for additional options for HIV prevention in youth.

HIV testing and self-testing coverage among men and women in South Africa: an exploration of related factors

OBJECTIVES

Uptake of HIV testing is critical to halting the spread of HIV. Our study aimed to examine the coverage of HIV testing and self-testing and the individual-level, household-level and community-level factors associated with HIV testing and self-testing awareness.

METHODS

We analysed data of 12 312 men and women from 2016 SADHS and used multilevel mixed-effects models to examine the factors associated with uptake of HIV testing and self-testing awareness.

RESULTS

About 80% of participants had ever tested for HIV, and 64% had tested in the past year. Only 49% of adolescents aged 15-19 years had ever tested for HIV compared with over 80% of adults. Self-testing awareness was low (22%), and only 2.9% of respondents had ever self-tested for HIV. The odds of having ever tested for HIV were significantly higher among respondents who were aged 25-29 (AOR: 4.02; 95% CI: 3.27-4.95), had a higher level of education (AOR: 3.18; 95% CI: 2.19-4.61), were married (AOR: 1.63; 95% CI: 1.36-1.94), had high media exposure (AOR: 1.23; 95% CI: 1.06-1.44) and had ever had sex (AOR: 5.57; 95% CI: 4.67-6.64), but lower among men (AOR: 0.39; 95% CI: 0.35-0.44).

CONCLUSION

In conclusion, HIV testing coverage is high in South Africa relative to most countries in sub-Saharan Africa, but falls short of the UNAIDS first 95. We found no evidence of socioeconomic and geographic inequalities in access to HIV testing. However, adolescents had a lower level of HIV testing uptake, suggesting a need for interventions to expand testing in this age group.

Low awareness and use of post-exposure prophylaxis among adolescents and young adults in South Africa: implications for the prevention of new HIV infections

The vulnerability of adolescents and young adults in South Africa to HIV and sexual violence is well documented. Post-exposure prophylaxis (PEP) is available for victims of sexual abuse in the country but awareness of this measure is required to maximise its HIV-prevention benefits. This study examined levels of PEP awareness and its correlates and the uptake of PEP among 772 students (16-24 years) in a South African university using stratified random sampling. Overall, we included more females (477) than males (295), reflecting the male-female ratio at the university. Adjusted and unadjusted logistic regression models were used to determine correlates of PEP awareness, which was low (24.1%), particularly among those who experienced sexual violence in the past year (19.8%) compared those who had not (24.8%). Only 2.6% of participants had used PEP, while 7.5% had seen it, and 14.6% knew where to get it. In the adjusted model, adequate family support (AOR: 2.22; CI: 1.54-3.20) and prior HIV testing (AOR: 2.65; CI: 1.59-4.42) were associated with a higher likelihood of PEP awareness. The study concluded that awareness of PEP was low in the study setting and especially among those who need it. Social marketing of PEP is needed in the study settings to realise the maximum benefits of PEP in preventing new HIV infections.

Safeguarding gains in the sexual and reproductive health and AIDS response amidst COVID-19: The role of African civil society

This article outlines the role of African civil society in safeguarding gains registered to date in sexual and reproductive health and the response to HIV. The case is made for why civil society organizations (CSOs) must be engaged vigilantly in the COVID-19 response in Africa. Lockdown disruptions and the rerouting of health funds to the pandemic have impeded access to essential sexual and reproductive health (SRH) and social protection services. Compounded by pre-existing inequalities faced by vulnerable populations, the poor SRH outcomes amid COVID-19 call for CSOs to intensify demand for the accountability of governments. CSOs should also continue to persevere in their aim to rapidly close community-health facility gaps and provide safety nets to mitigate the gendered impact of COVID-19.

Quantifying early COVID-19 outbreak transmission in South Africa and exploring vaccine efficacy scenarios

The emergence and fast global spread of COVID-19 has presented one of the greatest public health challenges in modern times with no proven cure or vaccine. Africa is still early in this epidemic, therefore the extent of disease severity is not yet clear. We used a mathematical model to fit to the observed cases of COVID-19 in South Africa to estimate the basic reproductive number and critical vaccination coverage to control the disease for different hypothetical vaccine efficacy scenarios. We also estimated the percentage reduction in effective contacts due to the social distancing measures implemented. Early model estimates show that COVID-19 outbreak in South Africa had a basic reproductive number of 2.95 (95% credible interval [CrI] 2.83-3.33). A vaccine with 70% efficacy had the capacity to contain COVID-19 outbreak but at very higher vaccination coverage 94.44% (95% Crl 92.44-99.92%) with a vaccine of 100% efficacy requiring 66.10% (95% Crl 64.72-69.95%) coverage. Social distancing measures put in place have so far reduced the number of social contacts by 80.31% (95% Crl 79.76-80.85%). These findings suggest that a highly efficacious vaccine would have been required to contain COVID-19 in South Africa. Therefore, the current social distancing measures to reduce contacts will remain key in controlling the infection in the absence of vaccines and other therapeutics.

The recent application of 3D-QSAR and docking studies to novel HIV-protease inhibitor drug discovery

INTRODUCTION

Despite the availability of FDA approved inhibitors of HIV protease, numerous efforts are still ongoing to achieve 'near-perfect' drugs devoid of characteristic adverse side effects, toxicities, and mutational resistance. While experimental methods have been plagued with huge consumption of time and resources, there has been an incessant shift towards the use of computational simulations in HIV protease inhibitor drug discovery.

AREAS COVERED

Herein, the authors review the numerous applications of 3D-QSAR modeling methods over recent years relative to the design of new HIV protease inhibitors from a series of experimentally derived compounds. Also, the augmentative contributions of molecular docking are discussed.

EXPERT OPINION

Efforts to optimize 3D QSAR and molecular docking for HIV-1 drug discovery are ongoing, which could further incorporate inhibitor motions at the active site using molecular dynamics parameters. Also, highly predictive machine learning algorithms such as random forest, K-means, decision trees, linear regression, hierarchical clustering, and Bayesian classifiers could be employed.

Framework for the implementation of advanced HIV disease diagnostics in sub-Saharan Africa: programmatic perspectives

Patients with advanced HIV disease have a high risk of mortality, mainly from tuberculosis and cryptococcal meningitis. The advanced HIV disease management package recommended by WHO, which includes diagnostics, therapeutics, and patient psychosocial support, is barely implemented in many different countries. Here, we present a framework for the implementation of advanced HIV disease diagnostics. Laboratory and point-of-care-based reflex testing, coupled with provider-initiated requested testing, for cryptococcal antigen and urinary Mycobacterium tuberculosis lipoarabinomannan antigen, should be done for all patients with CD4⁺ cell counts of 200 cells per μL or less. Implementation of the advanced HIV disease package should be encouraged within primary health-care facilities and task shifting of testing to lay cadres could facilitate access to rapid results. Implementation of differentiated antiretroviral therapy delivery models can allow clinicians enough time to focus on the management of patients with advanced HIV disease. Efficient up-referral and post-discharge systems, including the development of patient-centric advanced HIV disease literacy, are also crucial. Implementation of the advanced HIV disease package is feasible at all health-care levels, and it should be part of the core of the global response towards ending AIDS as a public health threat.