Where have we come from and where are we going? The paediatric HIV programme in Johannesburg, South Africa, from 2004 to 2018: A retrospective analysis of programme trends

BACKGROUND

The paediatric HIV treatment programme in South Africa (SA) has grown since its inception in 2004. Despite this impressive scale-up of antiretroviral therapy (ART) in children, the proportion of children started on ART and retained in care remains unacceptably low, with only 47% of the 340 000 HIV-positive children in SA on ART in 2020. Johannesburg is one of the districts in SA with the largest number of children living with HIV who are not on ART, and is a priority district for paediatric case finding and retention.

OBJECTIVES

To describe the dynamics of the paediatric HIV programme in Johannesburg, SA.

METHODS

A secondary analysis was conducted on patient-level HIV treatment data from TIER.Net, the nationally mandated HIV/ART database. Children aged <15 years who received ART between January 2004 and June 2019 at public health facilities in Johannesburg were included. We reported the number of children on ART and the number who entered and exited the programme by age group over time, and analysed the trends of these indicators.

RESULTS

By December 2018, 7 630 children aged <15 years remained in Johannesburg's paediatric ART programme: 82.5% were aged 5 - <15 years, with 54.1% of these being 10 - <15 years old. During the study period, 19 850 children were newly initiated on ART. New initiations slowed from 2013, to range from 1 172 to 1 373 yearly. In 2018, 34.2% of initiators were aged <1 year, 24.2% 1 - <5 years and 41.6% 5 - <15 years. Despite these initiations, the number of children on ART only grew by 97 in 2018, owing to programme losses. In 2018, 924  children (12.1%) aged out, 35 (0.5%) died and 983 (12.9%) were lost to follow-up (LTFU), the latter having increased from 10.7% in 2017. Of children who aged out of the paediatric ART programme, 56.3% remained in care at the same facility.

CONCLUSION

Early in the SA ART roll-out, many children were found to be HIV infected and started on ART. This number started to slow in 2013, after which the growth rate of the paediatric HIV programme also began to slow. Scale-up of methods for identifying older children with HIV is needed. While ageing out of the paediatric programme is a consideration, the number of children LTFU remains unacceptably high. Further interrogation of barriers to paediatric retention is needed to help realise the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90:90:90 goals for children in SA.

Anti-retroviral Therapy Based HIV Prevention Among a Sample of Men Who Have Sex with Men in Cape Town, South Africa: Use of Post-exposure Prophylaxis and Knowledge on Pre-exposure Prophylaxis

Men who have Sex with Men (MSM) have been affected disproportionately by the global HIV pandemic. Rates of consistent condom-use are low and there is a need for further biomedical prevention interventions to prevent new HIV infections. Post exposure prophylaxis (PEP) can reduce the risk of HIV, but uptake among MSM is low. Pre-exposure prophylaxis (PrEP), an innovative anti-retroviral-based HIV prevention tool might be an appropriate intervention for MSM who have recently accessed PEP that involves HIV negative individuals taking daily tenofovir+emtricitabine for HIV prevention. 44 MSM, attending a primary health-care level MSM-focused sexual health clinic in Cape Town, South Africa, who had initiated PEP were enrolled in this study. Participants were followed up after 2, 4 and 12 weeks. Self-administered electronic surveys were completed at the initial, 4 and 12 week visit. Barriers and facilitators to accessing PEP and remaining adherent were examined, as was knowledge about PrEP. Thirty-two participants (80 %) were <40 years of age (range 20-65 years). 35 % of the participants reported their reason for requiring PEP as condomless receptive anal intercourse. A further 20 % required PEP following condomless penetrative anal intercourse; 27.5 % required PEP due to a broken condom during receptive anal sex and 2 participants during insertive anal sex. Three participants did not complete 28 days of PEP or were lost to follow up. Over half (58.5 %) of the participants reported being completely adherent to their regime; under a third (31.7 %) reported missing one PEP dose; and 9.8 % reported missing more than one dose. 36/40 (90 %) had heard of PrEP and 30/40 (75 %) indicated that they would use PrEP if it were accessible to them. That we enrolled 44 MSM who accessed PEP from a Department of Health affiliated clinic over 12 months, speaks to the low uptake by MSM of PEP services in South Africa. Adherence was high and demonstrates that adherence support is feasible from a state health clinic. Reported risk behaviors in some high-risk participants did not change over time, demonstrating the need for additional longer-term HIV preventions such as PrEP. PEP users could conceivably be transitioned from PEP to PrEP.

Knowledge, Attitudes and Beliefs regarding Post Exposure Prophylaxis among South African Men who have Sex with Men

The Soweto Men's Study (2008), demonstrated an overall HIV prevalence rate of 13.2 %, with 10.1 % among straight-identified Men-who-have-sex-with-men (MSM), 6.4 % among bisexual-identified MSM and 33.9 % among gay-identified MSM. Behavioral interventions are imperative, but insufficient to prevent new HIV infections. Biomedical prevention of HIV offers a variety of combination prevention tools, including Post-exposure prophylaxis (PEP). PEP studies amongst MSM have been conducted in Amsterdam, Brazil and San Francisco, but never before in Africa. A cross-sectional, Internet-based survey was initiated to measure knowledge, attitudes and beliefs regarding PEP among South African MSM. Recruitment commenced in June 2014 and ran until October 2015. Participants were recruited through banner advertisements on Facebook.com and mambaonline.com, advertisements in the local gay media and at Health4Men (H4M) MSM-targeted clinics. Outreach workers distributed flyers advertising the study in their local communities. The survey was also made available on a computer at the H4M clinics in Cape Town and Johannesburg to reach MSM who may not have Internet access. A total of 408 men completed the survey. The majority of these men were under the age of 40, identified as gay/homosexual and were employed; 51 % (208/408) self-identified as black or of mixed race. In multivariate analysis participants who identified as gay had greater odds of having previously heard of PEP (AOR 1.91, 95 % CI 1.04, 3.51; p = 0.036), as did those who reported their HIV status as positive (AOR 2.59, 95 % CI 1.47, 4.45; p = 0.001). Participants with medical insurance had greater odds of having used PEP previously (AOR 2.67, 95 % CI 1.11, 6.43; p = 0.029). Bivariate analysis showed that condomless sex in the past 6 months was not significantly associated with PEP knowledge (p = 0.75) or uptake (p = 0.56) of PEP. Our findings suggest a lack of PEP knowledge and uptake among non-gay identified, HIV negative and un-insured MSM. Focusing PEP programs on these men may potentially increase uptake. Increased knowledge needs to be provided to MSM who engage in risky sexual behaviors.

Remote sensing of aerosols in the Arctic for an evaluation of global climate model simulations

In this study Moderate Resolution Imaging Spectroradiometer (MODIS) Aqua retrievals of aerosol optical thickness (AOT) at 555 nm are compared to Sun photometer measurements from Svalbard for a period of 9 years. For the 642 daily coincident measurements that were obtained, MODIS AOT generally varies within the predicted uncertainty of the retrieval over ocean (ΔAOT = ±0.03 ± 0.05 · AOT). The results from the remote sensing have been used to examine the accuracy in estimates of aerosol optical properties in the Arctic, generated by global climate models and from in situ measurements at the Zeppelin station, Svalbard. AOT simulated with the Norwegian Earth System Model/Community Atmosphere Model version 4 Oslo global climate model does not reproduce the observed seasonal variability of the Arctic aerosol. The model overestimates clear-sky AOT by nearly a factor of 2 for the background summer season, while tending to underestimate the values in the spring season. Furthermore, large differences in all-sky AOT of up to 1 order of magnitude are found for the Coupled Model Intercomparison Project phase 5 model ensemble for the spring and summer seasons. Large differences between satellite/ground-based remote sensing of AOT and AOT estimated from dry and humidified scattering coefficients are found for the subarctic marine boundary layer in summer.

KEY POINTS

Remote sensing of AOT is very useful in validation of climate models.

Global emissions of terpenoid VOCs from terrestrial vegetation in the last millennium

We investigated the millennial variability (1000 A.D.-2000 A.D.) of global biogenic volatile organic compound (BVOC) emissions by using two independent numerical models: The Model of Emissions of Gases and Aerosols from Nature (MEGAN), for isoprene, monoterpene, and sesquiterpene, and Lund-Potsdam-Jena-General Ecosystem Simulator (LPJ-GUESS), for isoprene and monoterpenes. We found the millennial trends of global isoprene emissions to be mostly affected by land cover and atmospheric carbon dioxide changes, whereas monoterpene and sesquiterpene emission trends were dominated by temperature change. Isoprene emissions declined substantially in regions with large and rapid land cover change. In addition, isoprene emission sensitivity to drought proved to have significant short-term global effects. By the end of the past millennium MEGAN isoprene emissions were 634 TgC yr^-1 (13% and 19% less than during 1750-1850 and 1000-1200, respectively), and LPJ-GUESS emissions were 323 TgC yr^-1(15% and 20% less than during 1750-1850 and 1000-1200, respectively). Monoterpene emissions were 89 TgC yr^-1(10% and 6% higher than during 1750-1850 and 1000-1200, respectively) in MEGAN, and 24 TgC yr^-1 (2% higher and 5% less than during 1750-1850 and 1000-1200, respectively) in LPJ-GUESS. MEGAN sesquiterpene emissions were 36 TgC yr^-1(10% and 4% higher than during 1750-1850 and 1000-1200, respectively). Although both models capture similar emission trends, the magnitude of the emissions are different. This highlights the importance of building better constraints on VOC emissions from terrestrial vegetation.

Timing of antenatal care and ART initiation in HIV-infected pregnant women before and after introduction of NIMART

In this review of routinely collected data from five community health centres in the Johannesburg Health District, we assess timing of antenatal care and antiretroviral therapy (ART) initiation in HIV-infected pregnant women before and after the introduction of nurse-initiated management of ART in antenatal clinics. There are important lessons to be learnt as we reflect on the South African prevention of mother-to-child transmission of HIV programme.

‘Feedback: Where data finally get thrilling’ – tools for facility managers to use data for improved health outcomes in the prevention of mother-to-child transmission of HIV and antiretroviral therapy

Data use and data quality continue to be a challenge for government sector health facilities and districts across South Africa. Led by the National Department of Health, key stakeholders, such as the Anova Health Institute and district health management teams, are aligning efforts to address these gaps. Coverage and correct implementation of existing tools – including TIER.net, routine data collection forms and the South African District Health Information System – must be ensured. This conference report provides an overview of such tools and summarises suggestions for quality improvement, data use and systematic evaluation of data-related interventions.

Top2btm symposium on health care for men who have sex with men (MSM)

Men who have sex with men (MSM) are at high risk of HIV acquisition and transmission, and country-specific HIV prevalence rates are always higher in MSM than among heterosexual men. South African data confirm this, with reported HIV prevalences of 10.4 - 33.9% across various studies. Donors and government health planners have recognised the need for targeted programmes that address the high burden of HIV transmission and disease in stigmatised populations such as MSM, as well as other ‘most at risk populations’ (MARPS) such as commercial sex workers, drug users and displaced refugees. Specific programmes targeting MSM and other MARPS have been included in the South African government’s current National Strategic Plan for health care and will feature in the new plan under development.

Hopes, fears, knowledge and misunderstandings: responses of HIV-positive mothers to early knowledge of the status of their baby

Little is known about how HIV-positive mothers experience and react to knowing the HIV status of their baby as diagnosed by the polymerase chain reaction (PCR) test at 4-6 weeks. This qualitative study drew on interviews with 20 mothers of HIV-negative and 18 mothers of HIV-positive babies after receiving their baby's PCR results. Thematic analysis combined exploration of themes that appeared significant to the participants and those relevant to health care. Amongst the themes identified were the following: The period before getting the results involved active mental preparation and was emotionally stressful. Most women accepted the results, but some had doubts about their reliability. Mothers of HIV-negative babies were relieved, but mothers of HIV-positive babies were generally very distressed and expressed a sense of responsibility and guilt. Both groups of mothers had similar hopes for the future of their babies, but the timelines of mothers of HIV-positive babies tended to be shorter. Most women experienced significant levels of stress, but were able to call on support networks and use various individual coping mechanisms to manage their stress. Most women were formula feeding their babies, but regretted not being able to breastfeed. Many women had not planned their current baby and most did not intend to have more children, but many of the latter had not taken active steps to prevent further pregnancy. The findings provide pointers to shortcomings in health worker communication and suggest that more effective communication should take account of normative community views and be more closely attuned to the changing needs and experiences of HIV-positive mothers.

"They see you as a different thing": the experiences of men who have sex with men with healthcare workers in South African township communities

OBJECTIVES

To describe interactions between men who have sex with men (MSM) and healthcare workers (HCW) in peri-urban township communities in South Africa.

METHOD

Qualitative study using semistructured in-depth interviews and focus group discussions in the Gauteng province townships of Soweto and Mamelodi. 32 MSM were purposively sampled for in-depth interviews and 15 for focus group discussions. Topics explored included identity, sexuality, community life, use of health services and experiences of stigma and discrimination.

RESULTS

MSM felt their options for non-stigmatising sexual healthcare services were limited by homophobic verbal harassment by HCW. Gay-identified men sought out clinics with reputations for employing HCW who respected their privacy and their sexuality and challenged those HCW who mistreated them. Non-gay-identified MSM presented masculine, heterosexual identities when presenting for sexual health problems and avoided discussing their sexuality with HCW.

CONCLUSIONS

The strategies MSM employ to confront or avoid homophobia from HCW may not be conducive to sexual health promotion in this population. Interventions that increase the capacity of public sector HCW to provide appropriate sexual health services to MSM are urgently needed.