A longitudinal population-based analysis of relationship status and mortality in KwaZulu-Natal, South Africa 2001-2011

Predictors of migration in an HIV hyper-endemic rural South African community: evidence from a population-based cohort (2005-2017)

Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15-49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20-24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19-3.57), and 2.9-times higher among young men aged 20-24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69-3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 - 0.99) and men (aHR = 0.73, 95% CI 0.66 - 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.

Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014

BACKGROUND

In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014.

METHODS

Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age.

RESULTS

The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively.

CONCLUSIONS

The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.

HIV seroconcordance among heterosexual couples in rural KwaZulu-Natal, South Africa: a population-based analysis

INTRODUCTION

High levels of HIV seroconcordance at the population level reduce the potential for effective HIV transmission. However, the level of HIV seroconcordance is largely unknown among heterosexual couples in sub-Saharan Africa. We aimed to quantify the population level HIV seroconcordance in stable heterosexual couples in rural South Africa.

METHODS

We followed adults (≥15 years old) using a population-based, longitudinal and open surveillance system in KwaZulu-Natal, South Africa, from 2003 to 2016. Sexual partnerships and HIV status were confirmed via household surveys and annual HIV surveillance. We calculated the proportions of HIV seroconcordance and serodiscordance in stable sexual partnerships and compared them to the expected proportions under the assumption of random mixing using individual-based microsimulation models. Among unpartnered individuals, we estimated the incidence rates and hazard of sexual partnership formation with HIV-positive or HIV-negative partners by participants' own time-varying HIV status. Competing risks survival regressions were fitted adjusting for sociodemographic and clinical factors. We also calculated Newman's assortativity coefficients.

RESULTS

A total of 18,341 HIV-negative and 11,361 HIV-positive individuals contributed 154,469 person-years (PY) of follow-up. Overall, 28% of the participants were in stable sexual partnerships. Of the 677 newly formed stable sexual partnerships, 7.7% (95% CI: 5.8 to 10.0) were HIV-positive seroconcordant (i.e. both individuals in the partnership were HIV-positive), which was three times higher than the expected proportion (2.3%) in microsimulation models based on random mixing. The incidence rates of sexual partnership formation were 0.54/1000PY with HIV-positive, 1.12/1000PY with HIV-negative and 2.65/1000PY with unknown serostatus partners. HIV-positive individuals had 2.39 (95% CI: 1.43 to 3.99) times higher hazard of forming a sexual partnership with an HIV-positive partner than did HIV-negative individuals after adjusting for age, opposite-sex HIV prevalence (by 5-years age groups), HIV prevalence in the surrounding community, ART coverage and other sociodemographic factors. Similarly, forming a sexual partnership with an HIV-negative partner was 1.47 (95% CI: 1.01 to 2.14) times higher in HIV-negative individuals in the adjusted model. Newman's coefficient also showed that assortativity by participant and partner HIV status was moderate (r = 0.35).

CONCLUSIONS

A high degree of population level HIV seroconcordance (both positive and negative) was observed at the time of forming new sexual partnerships. Understanding factors driving these patterns may help the development of strategies to bring the HIV epidemic under control.

Talking about sex in pregnancy: reflections from the field in urban South Africa

Qualitative research with close engagement in the field allows researchers and participants to build relationships and establish trust, enabling researchers to collect meaningful and sensitive information. Drawing on findings from a study conducted in an urban setting in South Africa, we discuss the challenges faced when interviewing pregnant women with HIV infection, retaining them in the study, and extending the study to include their partners. We discuss the dynamics of pregnancy and draw lessons from interviews concerned with personal, sensitive issues. The study on which we draw was conducted in Johannesburg, South Africa, and was nested in a larger prospective cohort study of women and their infants, which in turn was part of a case control study. Sensitive topics are difficult and complex, but to ignore these and stay in safe territory is to ignore some of the most pressing questions of our time. It is important that those who conduct interviews are well trained and able to engage empathetically with participants, and that some form of counselling is available for both participants and researchers.

Does antiretroviral therapy change partnership dynamics and HIV risk behaviours among HIV-infected adults

Objective:

We explore the impact of antiretroviral therapy (ART) on partnership acquisition and dissolution rates and changes in sexual behaviours among HIV-infected adults.

Design:

Using detailed longitudinal data from a prospective cohort of HIV-infected adults with CD4⁺ cell count below 200 cells/μl (ART-eligible) or CD4⁺ cell count above 500 cells/μl (pre-ART) conducted in rural KwaZulu-Natal, South Africa, from 2009 to 2012.

Methods:

Partnership acquisition and dissolution are explored through survival analysis methods, whereas generalized linear models were fitted for the sexual behaviour outcomes with interaction terms to allow the association with ART to vary over time. Throughout, the primary comparison of interest for each outcome is differences between the two ART groups.

Results:

ART is not associated with partner acquisition or relationship dissolution. During follow-up, the two ART groups do not differ in the odds of being sexually active nor the number of sex acts, whereas the odds of unprotected sex are significantly lower for partnerships of ART-eligible participants (adjusted odds ratio 0.26, 95% confidence interval 0.15, 0.43). Relationship-level characteristics including cohabitation status and wanting more children with that partner are associated with higher odds and increased frequency of sexual activity, and increased odds of unprotected sex, whereas living with partner, higher relationship quality and longer relationship duration are associated with lower risk of partnership dissolution.

Conclusion:

Being on ART was not associated with increased sexual risk behaviours, a reassuring finding given the WHO recommends ART initiation upon HIV diagnosis. The importance of relationship-level characteristics provides evidence that HIV care services should offer routine support for HIV disclosure and sexual risk reduction, and promotion of couples-testing and positive couple relationships.