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Dassaye R, Wand H, Reddy T, Tanser F, Sartorius B, Morris N, Ramjee G. Spatial variations in STIs among women enrolled in HIV prevention clinical trials in Durban, KwaZulu-Natal, South Africa. SAHARA J 2023; 20:2193238. [PMID: 36995287 PMCID: PMC10064823 DOI: 10.1080/17290376.2023.2193238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
South Africa is faced with a high HIV and STI prevalence and incidence, respectively, with pockets of high burden areas driving these diseases. Localised monitoring of the HIV epidemic and STI endemic would enable more effective targeted prevention strategies. We assessed spatial variations in curable STI incidence among a cohort of women enrolled in HIV prevention clinical trials between 2002 and 2012. STI incidence rates from 7557 South African women enrolled in five HIV prevention trials were geo-mapped using participant household GPS coordinates. Age and period standardised incidence rates were calculated for 43 recruitment areas and Bayesian conditional autoregressive areal spatial regression (CAR) was used to identify significant patterns and spatial patterns of STI infections in recruitment communities. Overall age and period standardised STI incidence rate were estimated as 15 per 100 PY and ranged from 6 to 24 per 100 PY. We identified five significant STI high risk areas with higher-than-expected incidence of STIs located centrally (three-locations) and southern neighbouring areas of Durban (two-locations). Younger age (<25), not married/cohabitating, parity <3 and poor education were all significant correlates of high STI communities. Findings demonstrate sustained STI incidence rates across the greater Durban area. The role of STI incidence in HIV acquisition in high HIV endemic areas need to be revisited as current highly effective PrEP interventions do not protect from STI acquisition. In these settings there is an urgent need for integrative HIV and STI prevention and treatment services.
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Affiliation(s)
- Reshmi Dassaye
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Handan Wand
- Kirby Institute, University of New South Wales, Kensington, Australia
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Frank Tanser
- University of Lincoln, Lincoln Institute for Health, Lincoln, UK
| | - Benn Sartorius
- Faculty of Infectious and Tropical Diseases (ITD), London School of Hygiene & Tropical Medicine, London, UK
| | - Natashia Morris
- Biostatistics Unit: GIS, South African Medical Research Council, Durban, South Africa
| | - Gita Ramjee
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
- London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK
- School of Medicine, Department of Global Health, University of Washington, Seattle, WA, USA
- The Aurum Institute, Johannesburg, South Africa
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ngandu NK, Mmotsa TM, Dassaye R, Thabetha A, Odendaal W, Langdown N, Ndwandwe D. Hospital acquired COVID-19 infections amongst patients before the rollout of COVID-19 vaccinations, a scoping review. BMC Infect Dis 2022; 22:140. [PMID: 35144556 PMCID: PMC8830001 DOI: 10.1186/s12879-022-07128-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/04/2022] [Indexed: 01/16/2023] Open
Abstract
Background Hospital settings are at increased risk of spreading Coronavirus Disease 2019 (COVID-19) infections, hence non-pharmaceutical prevention interventions (NPPIs) and prioritized vaccination of healthcare workers and resident patients are critical. The status of COVID-19 hospital acquired infections (HAIs) in low-income settings is unclear. We aimed to identify and summarize the existing evidence on COVID-19 HAIs amongst patients, prior to the rollout of vaccines in countries worldwide. Methods We conducted a scoping review of English peer-reviewed literature in PubMed, Web of Science and Scopus using a combination of selected search terms. Full texts articles presenting results on COVID-19 HAIs in hospitalised patients before the rollout of vaccines in countries worldwide were eligible. Data extracted from eligible articles included estimates of COVID-19 HAIs, country, and type of hospital setting, and was summarized narratively. Quality assessment of included articles was not possible. Results Literature searches generated a total of 5920 articles, and 45 were eligible for analysis. Eligible articles were from Europe, North America, Asia, and Brazil and none were from low-income countries. The proportion of COVID-19 HAIs ranged from 0% when strict NPPIs were applied, to 65% otherwise. The estimates of COVID-19 HAIs did not differ by country but were lower in studies conducted after implementation of NPPIs and in specialized hospital settings for operative surgery. Studies conducted before the implementation of NPPIs or in long-term care and psychiatric wards often reported high estimates of HAI. Although there was no clear trend in general wards, those situated in academic hospitals managed to reduce HAI rates under strict NPPI protocols. Operative surgery settings, unlike psychiatric settings, effectively prevented COVID-19 HAI using tailored NPPIs. Conclusion The available evidence shows a high risk of COVID-19 HAIs, the feasibility of preventing HAIs in different healthcare settings and the importance of appropriately tailored NPPIs. There were no data from low-income settings, therefore, it is unclear whether the reported NPPI approaches could be equally effective elsewhere. We recommend routine monitoring of COVID-19 HAIs in countries with low vaccination coverage, to identify and close gaps in NPPIs and understand gains made from vaccinating healthcare workers and hospitalized patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07128-5.
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Affiliation(s)
- Nobubelo K Ngandu
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Tshiamo M Mmotsa
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Reshmi Dassaye
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Alice Thabetha
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Willem Odendaal
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Natasha Langdown
- Knowledge and Information Management Services, South African Medical Research Council, Cape Town, South Africa
| | - Duduzile Ndwandwe
- Cochrane, South African Medical Research Council, Cape Town, South Africa
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Wand H, Reddy T, Dassaye R, Moodley J, Naidoo S, Ramjee G. Contraceptives and sexual behaviours in predicting pregnancy rates in HIV prevention trials in South Africa: Past, present and future implications. Sex Reprod Healthc 2020; 26:100531. [PMID: 32615376 PMCID: PMC8032504 DOI: 10.1016/j.srhc.2020.100531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/08/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Despite all efforts, high pregnancy rates are often reported in HIV biomedical intervention trials conducted in African countries. We therefore aimed to develop a pregnancy risk scoring algorithm for targeted recruitment and screening strategies among a cohort of women in South Africa. METHODS The study population was ~ 10,000 women who enrolled in one of the six biomedical intervention trials conducted in KwaZulu Natal, South Africa. Cox regression models were used to create a pregnancy risk scoring algorithm which was internally validated using standard statistical measures. RESULTS Five factors were identified as significant predictors of pregnancy incidence:<25 years old, not using injectable contraceptives, parity (<3), being single/not cohabiting and having ≥ 2 sexual partners in the past three months. Women with total scores of 21-24, 25-35 and 36+ were classified as being at "moderate", "high", "severe" risk of pregnancy. Sensitivity of the development and validation models were reasonably high (sensitivity 76% and 74% respectively). CONCLUSION Our risk scoring algorithm can identify and alert researchers to women who need additional non-routine pregnancy assessment and counselling, with statistically acceptable accuracy and robustness.
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Affiliation(s)
- Handan Wand
- Kirby Institute, University of New South Wales, Kensington 2052, New South Wales, Australia.
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, Kwazulu-Natal, South Africa.
| | - Reshmi Dassaye
- South African Medical Research Council, HIV Prevention Research Unit, Durban, Kwazulu-Natal, South Africa
| | - Jothi Moodley
- South African Medical Research Council, HIV Prevention Research Unit, Durban, Kwazulu-Natal, South Africa
| | - Sarita Naidoo
- South African Medical Research Council, HIV Prevention Research Unit, Durban, Kwazulu-Natal, South Africa
| | - Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, Kwazulu-Natal, South Africa; Aurum Global Department: Health Research, Durban, Kwazulu-Natal, South Africa
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Wand H, Reddy T, Dassaye R, Moodley J, Naidoo S, Ramjee G. Estimating prevalence and incidence of sexually transmitted infections among South African women: Implications of combined impacts of risk factors. Int J STD AIDS 2020; 31:1093-1101. [PMID: 32883173 DOI: 10.1177/0956462420915388] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In addition to being the epicentre of the HIV epidemic, South Africa also has the highest burden of sexually transmitted infections (STIs) in the world. Therefore, understanding the most influential risk factors of STIs is a research priority. Using the data from 9948 women who resided in KwaZulu Natal, South Africa, we estimated the population attributable risk to quantify the combined impacts of the most influential factors on STI diagnosis. Overall STI prevalence was 20%, and STI incidence was 15 per 100 person-years. Four factors: age at sexual debut, single/not cohabiting, two or more sex partners and parity <3 were identified as the most influential risk factors for STI prevalence and incidence rates. However, these factors collectively associated with only 51% and 53% of the excess STI prevalence and incidence rates, respectively. These relatively modest impacts provide empirical evidence for the significant impacts of unmeasured factors on STIs. Culturally and socially appropriate prevention programs may be more effective to target those at highest risk of STIs.
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Affiliation(s)
- Handan Wand
- Kirby Institute, University of New South Wales, Kensington, Australia
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Reshmi Dassaye
- HIV Prevention Unit, South African Medical Research Council, Durban, South Africa
| | - Jothi Moodley
- HIV Prevention Unit, South African Medical Research Council, Durban, South Africa
| | - Sarita Naidoo
- HIV Prevention Unit, South African Medical Research Council, Durban, South Africa
| | - Gita Ramjee
- HIV Prevention Unit, South African Medical Research Council, Durban, South Africa
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Wand H, Morris N, Dassaye R, Reddy T, Ramjee G. Correlates of Sexually Transmitted Infections Among South African Women Using Individual- and Community-Level Factors: Results from Generalized Additive Mixed Models. Arch Sex Behav 2020; 49:1875-1886. [PMID: 30767180 PMCID: PMC6944771 DOI: 10.1007/s10508-018-1315-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 06/29/2018] [Accepted: 09/21/2018] [Indexed: 06/09/2023]
Abstract
South Africa has the highest burden of human immunodeficiency virus (HIV) infections in the world. There is also growing evidence that an individual's risk of contracting HIV is increased by the presence of other sexually transmitted infections (STIs). The primary objective of this study was to examine the association between the prevalence of STIs in a cohort of South African women who enrolled in HIV prevention trials (2002-2012). The current study linked the individual factors with the community-level characteristics using geo-referencing. These multi-level data were analyzed in generalized additive mixed models settings. In the multivariate logistic regression model, younger age (odds ratio [OR] 4.30, 95% CI 3.20, 5.77 and OR 2.72, 95% CI 2.02, 3.66 for age < 25 and 25-29, respectively); being single/not cohabiting (OR 4.57, 95% CI 3.18, 6.53), two + sex partners (OR 1.46, 95% CI 1.18,1.80); parity < 2 (OR 2.04, 95% CI 1.53, 2.72), parity = 2 (OR 1.85, 95% CI 1.37, 2.48), and using injectables (contraceptive) (OR 1.53, 95% CI 1.13, 2.06) were all significantly associated with increased prevalence of STIs. Women who resided in the communities with high proportions of female headed-households were also significantly at higher risk for STIs (OR 1.20, p = .0025). Because these factors may reflect characteristics of the larger groups who share similar cultural norms and social environments, they can provide considerable insight into the spread of STIs. Prevention strategies based on individual and community-level drivers of STIs are likely to be the most effective means of targeting and reaching those at greatest risk of infection. This strategy has the potential to play a significant role in the epidemic's trajectory.
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Affiliation(s)
- Handan Wand
- Kirby Institute, University of New South Wales, Kensington, NSW, 2052, Australia.
| | - Natashia Morris
- Biostatistics Unit, South African Medical Research Council, Durban, Kwazulu-Natal, South Africa
| | - Reshmi Dassaye
- HIV Prevention Research Unit, South African Medical Research Council, Westville, KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, Kwazulu-Natal, South Africa
| | - Gita Ramjee
- Biostatistics Unit, South African Medical Research Council, Durban, Kwazulu-Natal, South Africa
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Ramjee G, Dassaye R, Reddy T, Wand H. Targeted Pregnancy and Human Immunodeficiency Virus Prevention Risk-Reduction Counseling for Young Women: Lessons Learned from Biomedical Prevention Trials. J Infect Dis 2019; 218:1759-1766. [PMID: 29947802 DOI: 10.1093/infdis/jiy388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/23/2018] [Indexed: 01/17/2023] Open
Abstract
Background Women enrolled in human immunodeficiency virus (HIV) prevention efficacy trials receive counseling on prevention of HIV, sexually transmitted infections (STIs), and pregnancy during every visit. Incident pregnancy has an impact on efficacy outcomes. Incidence rates of pregnancy and HIV/STIs among women who became pregnant and associated risk factors were assessed. Methods Data from 9165 women participating in HIV prevention trials in KwaZulu-Natal, South Africa from 2002-2012 were combined. Demographic and behavioral predictors of incidence pregnancy and incidence HIV and STIs were determined using Cox regression models. Results Overall pregnancy incidence was 9.6 per 100 person-year (py) (95% confidence interval [Cl], 9.1-10.3). Human immunodeficiency virus incidence among pregnant women was 5.93 per 100 py (95% Cl, 4.73-7.44). Incidence of STIs among pregnant women for Chlamydia trachomatis, Trichomonas vaginalis, Neisseria gonorrhoeae, and Treponema pallidum (syphilis) were 10.87, 7.42, 3.92, and 1.43 per 100 py, respectively. In the adjusted analyses, we observed overlapping risk factors for HIV acquisition during pregnancy, ie, young age, not married/not cohabitating, and low parity. The risk of pregnancy and HIV acquisition is more than 3 times higher among young women (<20 years of age). Conclusions We identified overlapping risk factors for pregnancy and HIV incidence, suggesting an urgent need for appropriate, targeted, individual-centred counseling for women participating in HIV prevention trials.
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Affiliation(s)
- Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, KwaZulu-Natal, South Africa.,Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, United Kingdom.,Department of Global Health, School of Medicine, University of Washington, Seattle
| | - Reshmi Dassaye
- HIV Prevention Research Unit, South African Medical Research Council, KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Kensington, Australia
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Wand H, Dassaye R, Reddy T, Yssel J, Ramjee G. Geographical-level contributions of risk factors for HIV infections using generalized additive models: results from a cohort of South African women. AIDS Care 2018; 31:714-722. [PMID: 30537858 DOI: 10.1080/09540121.2018.1556382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
South Africa has the highest burden of human immunodeficiency virus (HIV) infections in the world with significant geographical variations. We identified the predictors of HIV infections and their sub-geographical-level contributions to the epidemic using a decade long data (2002-2012) from 6484 South African women. Generalized additive models were used to uncover the most significant features of these estimates across the region. In the overall analysis, younger age, not married or cohabiting with a partner, partner has another partner(s) and null/prim parity, using injectable contraceptives and presence of other sexually transmitted infections (STIs) were identified as independent predictors of HIV seroconversions. Overall, the top three highest contributors to infections were women's marital status (PAR% = 73%, 95% CI: 68%, 77%), parity (PAR% = 47%, 95% CI: 42%, 53%) and partnership factors (PAR% = 37%, 95% CI: 30%, 44%). However, their contributions varied remarkably at sub-geographical level. This was mainly due to the substantial localized variations in their prevalence and hazard ratios across the region. Our results will guide policy makers to develop tailored prevention strategies in order to allocate scarce resources by targeting the most significant contributors of HIV infection at sub-geographical level.
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Affiliation(s)
- Handan Wand
- a Kirby Institute , University of New South Wales , Kensington , Australia
| | - Reshmi Dassaye
- b HIV Prevention Research Unit , South African Medical Research Council , Westville , South Africa
| | - Tarylee Reddy
- c Biostatistics Unit , South African Medical Research Council , Durban , South Africa
| | - Justin Yssel
- b HIV Prevention Research Unit , South African Medical Research Council , Westville , South Africa
| | - Gita Ramjee
- b HIV Prevention Research Unit , South African Medical Research Council , Westville , South Africa
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Abstract
Lineage tracing studies have revealed that transcription factors play a cardinal role in pancreatic development, differentiation and function. Three transitions define pancreatic organogenesis, differentiation and maturation. In the primary transition, when pancreatic organogenesis is initiated, there is active proliferation of pancreatic progenitor cells. During the secondary transition, defined by differentiation, there is growth, branching, differentiation and pancreatic cell lineage allocation. The tertiary transition is characterized by differentiated pancreatic cells that undergo further remodeling, including apoptosis, replication and neogenesis thereby establishing a mature organ. Transcription factors function at multiple levels and may regulate one another and auto-regulate. The interaction between extrinsic signals from non-pancreatic tissues and intrinsic transcription factors form a complex gene regulatory network ultimately culminating in the different cell lineages and tissue types in the developing pancreas. Mutations in these transcription factors clinically manifest as subtypes of diabetes mellitus. Current treatment for diabetes is not curative and thus, developmental biologists and stem cell researchers are utilizing knowledge of normal pancreatic development to explore novel therapeutic alternatives. This review summarizes current knowledge of transcription factors involved in pancreatic development and β-cell differentiation in rodents.
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Affiliation(s)
- Reshmi Dassaye
- a Discipline of Pharmaceutical Sciences; Nelson R. Mandela School of Medicine, University of KwaZulu-Natal , Durban , South Africa
| | - Strini Naidoo
- a Discipline of Pharmaceutical Sciences; Nelson R. Mandela School of Medicine, University of KwaZulu-Natal , Durban , South Africa
| | - Marlon E Cerf
- b Diabetes Discovery Platform, South African Medical Research Council , Cape Town , South Africa
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