Experiences of oral pre-exposure prophylaxis use among heterosexual men accessing sexual and reproductive health services in South Africa: a qualitative study

INTRODUCTION

South African men face a substantial burden of HIV and are less likely to test for HIV and initiate antiretroviral therapy if tested positive and more likely to die from AIDS-related causes than women. In addition to condoms and circumcision, guidelines provide for the use of daily oral pre-exposure prophylaxis (PrEP) as an HIV prevention intervention for any men who recognize their need and request PrEP. However, heterosexual men have not been a focus of PrEP programmes, and since its introduction, there is limited literature on PrEP use among men in South Africa. This study explores the experiences, motivators and barriers to oral PrEP use among heterosexual men accessing primary healthcare services in South Africa.

METHODS

This study forms part of a mixed-methods implementation science study aimed at generating evidence for oral PrEP introduction and conducted in primary healthcare clinics in South Africa since 2018. Men aged ≥15 years who initiated oral PrEP and enrolled in a parent cohort study were purposefully invited to participate in an in-depth interview (IDI). Between March 2020 and May 2022, 30 men participated in IDIs exploring their motivators for PrEP use, and experiences with accessing health services. Interviews were audio recorded, transcribed and analysed thematically.

RESULTS

The final analysis included 28 heterosexual men (18-56 years old). Motivations to initiate PrEP included fear of acquiring HIV, self-perceived vulnerability to HIV and mistrust in relationships; health systems factors which motivated PrEP use included the influence of healthcare providers, educational materials and mobile services. Perceived reduction in HIV vulnerability and changing proximity to partners were reasons for PrEP discontinuation. Side effects, daily-pill burden and stigma were noted as challenges to PrEP use. Health system barriers to PrEP use included limited PrEP availability, school and work demands, and inconsistent mobile clinic schedules.

CONCLUSIONS

Our study reports on the experiences of heterosexual men accessing oral PrEP in real-world settings and contributes to the limited literature among this population. We highlight multiple levels which could be strengthened to improve men's PrEP use, including individual support, education among partners and communities, and addressing health system barriers to access.

Key programmatic and policy considerations for introducing multipurpose prevention (MPT) methods: reflections from healthcare providers and key stakeholders in South Africa

Introduction

Multipurpose prevention technologies (MPTs) simultaneously prevent HIV, other sexually transmitted infections, and/or unintended pregnancy. Key gatekeepers, [healthcare providers (HCPs) and key stakeholders] require proactive engagement before product implementation. This manuscript identifies HCP demand creation strategies, key stakeholder considerations for the adoption of MPTs in South Africa.

Methods

Formative research was conducted in three districts in three South African provinces (July to November 2022). Nurses initiating oral PrEP at facility and mobile study sites participated in 4-hour participatory workshops, exploring HIV prevention, including MPTs, demand creation strategies, and preferred MPTs training packages. Activities were observed, transcribed, and thematically analysed. Five online in-depth interviews (IDIs) with Key informants (KIs) (National/district programme implementers and technical leads) and one in person, exploring key programmatic and policy considerations for MPT adoption. IDIs were approximately 40 min long, audio recorded, transcribed, and thematically analysed.

Results

Twenty-one Professional Nurses completed workshops: 19 female. Six IDIs were conducted with 4 Facility Managers, 1 NDoH representative and 1 DoH Provincial Deputy Director. All participants were females, aged 30-60+ years with >10 years' in SRH/HIV policy/advocacy/research. Community conversations and information at the clinic were the best MPT demand creation methods among HCPs. KIs identified five considerations for future MPT implementation: HCP training; demand creation and messaging; existing PrEP policy amendments; preparing users for additional choice; and sustaining MPT provision.

Conclusion

Contraceptive implant and oral PrEP implementation lessons learned should be proactively considered when preparing for MPT introduction. HCP training and demand creation are of particular importance before MPT introduction.

Learner experiences of safety at public high schools in three South African townships: Baseline findings from the National School Safety Framework learner surveys

Background

Despite progressive policies and frameworks on school safety by the Department of Basic Education, safety remains a concern in South African schools.

Methods

A cross-sectional descriptive design was employed using the National School Safety Framework (NSSF) 152-question learner survey, exploring perceptions and experiences pertaining to eight safety domains: dangerous objects, drugs and alcohol, bullying, verbal abuse, physical violence, discrimination, sexual violence, and journey to and from school. Grade 9-11 learners from 15 government-funded high schools in the Girls Achieve Power trial in Khayelitsha, Soweto, and Thembisa townships were surveyed (March 2018 - April 2019), sampling 10% of the school population. Data analysis included Principal Component Analysis (PCA), reducing correlated variables into fewer questions, then analysis on a scree plot by calculating eigenvalues; repeated PCA with those that had a minimum eigenvalue of 1 and Cronbach Alpha test for internal reliability. Eleven composite variables were included in the final analysis.

Results

In total, 1034 learners completed the NSSF learner survey; 52.9% were female and the mean age was 16 years (SD=1.36). Results show statistically significant associations between four of the 11 composite variables in relation to sex. Over half (55%) of males have experienced peer provocation and relational aggression (p<0.001). Fifty-eight percent of females reported feeling unsafe on their way to and from school (p<0.003). Over half of males reported that their school was not effective in enforcing discipline (p=0.002) while 58% of females noted they could comfortably report any form of experienced or witnessed violence at school, to their educators (p<0.000).

Conclusions

Violence continues to be a concern in South African schools. Interventions should work across the ecological model to effectively prevent and reduce violence at school and community levels. Strengthened NSSF implementation is critical to achieving this. We recommend NSSF learner survey adaptations to increase utility and implementation.

Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment

OBJECTIVES

Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa.

METHODS

Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities.

RESULTS

We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12).

CONCLUSIONS

Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

Factors influencing the uptake of a mono-PrEP implant for the prevention of HIV: Males' perspectives from three South African provinces

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method; however, males over 15 years face challenges with its effective use. Long-acting prevention products could address barriers to effective PrEP use. This study aimed to estimate the potential uptake of a mono-PrEP implant and the factors influencing uptake among males in South Africa. The study also examined messaging and demand creation tactics that males perceive will improve HIV prevention uptake.

METHODS

We conducted a mixed methods study comprising participatory workshops and a self-administered survey among 142 PrEP-eligible males (18-40 years) in three provinces (Gauteng, Eastern Cape, and Kwa-Zulu Natal) in South Africa from July to November 2022. Logistic regression was used to assess the relationship between the potential uptake of a hypothetical, non-biodegradable mono-PrEP implant and socioeconomic and behavioural factors. Workshop data were analysed using content analysis.

RESULTS

The top three HIV prevention products that males would consider using were the monthly pill (74.6%), the mono-PrEP implant (62.7%), and event-driven oral PrEP (59.2%). If one prevention option was available, 31.7% of participants stated that they would use the monthly oral pill, 28.2% would use the six-monthly injection, and 19.7% the mono-PrEP implant. Four key themes were noted as influential to potential mono-PrEP uptake: "Health Over Everything", "Mono-PrEP Implant Concerns", "Potential Disclosure of Mono-PrEP Use", and "Information Distribution Channels". Participants preferred social and mainstream media as information distribution channels to receive information on HIV prevention services, including the mono-PrEP implant.

CONCLUSION

In this study among predominantly heterosexual men in South Africa, there was interest in long-acting HIV prevention methods but concerns about the mono-PrEP implant. A comprehensive and participatory introduction will be needed for the implant, to improve acceptability and address potential concerns. Demand-creation strategies utilising social media and health campaigns should be considered to engage and reach males.

Eita! Reaching Communities and Young People to Drive Demand for Oral Pre-Exposure Prophylaxis in South Africa

PURPOSE

This paper describes a holistic but flexible demand creation strategy for pre-exposure prophylaxis (PrEP) in national public health-care settings in low-income to middle-income countries.

METHODS

We describe the development and implementation of a model to drive demand for oral PrEP uptake and use as part of comprehensive sexual and reproductive health services in South Africa: The Eita!

MODEL

The project adapted two existing response hierarchy models (marketing models used to describe the stages individuals move through from being unaware to using a product), to formulate the Eita!

MODEL

Using the RE-AIM framework, we report on the reach, effectiveness, adoption, implementation, and maintenance of the Eita!

MODEL

RESULTS

More than 34 million connections were made from December 2018 to 2021 through a variety of channels: social media and websites, at events and mobile clinic outreach, and radio and community dialogs. There were 42,447 adolescent girls and young women reached in-person during this time, 16,823 adolescent girls and young women presented for sexual and reproductive health services, and of those 14,637 (87%) initiated on PrEP. The model was implemented in eight health-care facilities and four mobile clinics in three provinces in South Africa. A total of 26 trainings were delivered to project staff implementing the strategy. Various demand creation resources, such as materials and online platforms, have since been adopted by the National Department of Health as national tools.

DISCUSSION

The Eita! model was successfully implemented to support the uptake of HIV prevention services and rollout of biomedical prevention products, and can be adapted by other low-income to middle-income countries.

Mental Health Needs of Adolescent and Young Adult PrEP Users in South Africa: Implications for Sexual and Reproductive Health Programming

PURPOSE

Poor mental health is associated with sexual and reproductive health (SRH) risks, including human immunodeficiency virus (HIV) and pre-exposure prophylaxis discontinuation. Adolescents and young people (AYP) are vulnerable to HIV and depression. This paper describes the prevalence and severity of depression and associated factors in AYP accessing SRH services in South Africa.

METHODS

A cross-sectional analysis of enrollment data (January 2019 to December 2021) from a cohort of individuals receiving pre-exposure prophylaxis services at eight clinics in three provinces in South Africa was conducted. Females (n = 1,074) and males (n = 231) aged 15-24 years were included. Interviewer-administered questionnaires were conducted, and the prevalence and severity of depression assessed using the Patient Health Questionnaire-9. Multivariate analysis was used to identify factors associated with depression.

RESULTS

Over 40% of participants had experienced any depression symptoms (43.7% of females, 38.5% of males). For males, experiencing intimate partner violence was the only predictor of depression symptoms (adjusted odds ratio (AOR) 8.81, 95% confidence intervals (CI) 1.03-75.44). For females, living with both parents (AOR 1.70, 95% CI 1.15-2.51), having transactional sex (AOR 1.63, 95% CI 1.00-2.65), experiencing any intimate partner violence (AOR 1.96, 95% CI 1.34-2.89), and using drugs (AOR 1.78, 95% CI 1.03-3.11) were all positively associated with depression symptoms. Resilience was a protective factor against depression symptoms for both sexes (males: AOR 0.96, 95% CI 0.93-0.98; females: AOR 0.96, 95% CI 0.95-0.97).

DISCUSSION

There is a high burden of depression among AYP accessing SRH services in South Africa. Mental health screening should be integrated into SRH and HIV prevention programs for AYP.

Patterns of HIV Pre-exposure Prophylaxis use Among Adolescent Girls and Young Women Accessing Routine Sexual and Reproductive Health services in South Africa

PURPOSE

This study describes the patterns of pre-exposure prophylaxis (PrEP) use among adolescent girls and young women (AGYW) initiated on daily oral PrEP for the prevention of HIV, within routine sexual and reproductive health services in South Africa.

METHODS

We analysed clinical and survey data from a nested cohort of 967 AGYW initiated on oral PrEP between January 2019 and December 2021 in four geographical clusters in South Africa. We describe the periods of PrEP use, and the proportion who discontinued and subsequently restarted PrEP. Logistic regression analyses were conducted to determine factors associated with early PrEP discontinuation, PrEP use for ≥4 months and PrEP restart.

RESULTS

PrEP use for ≤1 month was high (68.6%), although 27% returned and restarted PrEP; and 9% restarted more than once. Initiating PrEP at a mobile clinic (AOR 2.10, 95% CI 1.51 - 2.93) and having a partner known to be HIV negative or whose HIV status was unknown (AOR 7.11, 95% CI 1.45 - 34.23; AOR 6.90, 95% CI 1.44 - 33.09) were associated with PrEP use for ≤1 month. AGYW receiving injectable contraceptives were more likely to restart PrEP (AOR 1.61, 95% CI 1.10 - 2.35). Compared to those aged 15-17 years, participants 18 - 20 and 21 - 24 years were less likely to restart PrEP (AOR 0.51, 95% CI 0.35 - 0.74; AOR 0.60, 95%, CI 0.41 - 0.87), as were those initiating PrEP at a mobile clinic compared to a fixed facility (AOR 0.66, 95% CI 0.47 - 0.92).

DISCUSSION

Although early PrEP discontinuation was high, it appears that PrEP use is frequently cyclical in nature. Further research is needed to determine if these cycles of PrEP correlate to periods of perceived or actual vulnerability to HIV, which may also be cyclical. PrEP delivery presents a unique opportunity to address multiple unmet health needs of young people.

Implementing Differentiated and Integrated HIV Prevention Services for Adolescent Girls and Young Women: Experiences From Oral PrEP Rollout in Primary Care Services in South Africa

PURPOSE

In South Africa, adolescent girls and young women (AGYW, aged 15-24 years) are disproportionately affected by human immunodeficiency viruses (HIV). Oral pre-exposure prophylaxis (PrEP) has been available in South Africa since 2016; however, there is limited evidence on oral PrEP implementation and integration in real-world settings, particularly among AGYW. Project PrEP is an implementation science project that sought to inform the introduction and integration of oral PrEP as part of combination HIV prevention and sexual and reproductive health services (SRH) in South Africa. The project focused on AGYW, as a priority population in need of HIV prevention. This paper presents strategies Project PrEP employed to increase oral PrEP and SRH service access and utilization.

METHODS

We present strategies employed to increase oral PrEP and SRH services uptake. Using routine monitoring data, facility assessments, stakeholder engagement, training and progress reports, and observations, we share implementation lessons learned and describe how strategies can be adapted by HIV prevention programs in different contexts.

RESULTS

Approximately 22, 000 people initiated on oral PrEP (December 2018-December 2021) across eight facilities and four mobile clinics. Two-thirds (67%) of initiated clients were AGYW.

DISCUSSION

Lessons are to be learned from the introduction of oral PrEP as implementers prepare for the introduction of new PrEP methods. Stakeholders must be continuously engaged to ensure buy-in, and social mobilization and demand creation should be contextual, focused, and innovative. Continuous staff training is needed to reinforce knowledge, and AGYW service delivery models must be local context relevant.

Comparing the Integration of Syndromic versus Etiological Management of Sexually Transmitted Infections Into HIV Pre-Exposure Prophylaxis Services for Adolescent Girls and Young Women, in South Africa

South Africa has a high incidence of human immunodeficiency virus and sexually transmitted infections (STIs), particularly among adolescent girls and young women. National and global guidelines recommend varied strategies for integrating STI and pre-exposure prophylaxis (PrEP) services.

PURPOSE

This paper describes the implementation of a syndromic compared to an etiological approach to STI integration within PrEP services in South Africa.

METHODS

We analysed program data from eight fixed and four mobile clinics to describe a cascade of STI care and integration of syndromic management among clients accessing PrEP services. Diagnostic testing was conducted in a subset of clients to determine the prevalence of STIs and estimate the burden of disease missed using a syndromic approach.

RESULTS

Between December 2018 and December 2021, 22,505 clients sought services and a high proportion (92.9%) was screened for STI symptoms. Of these, 9% of females and 3% of males had symptoms and 89.5% had recorded treatment. In a subset of PrEP clients (406 females, 70 males) screened through laboratory testing, chlamydia was identified in 25.7% of female and 20.0% of male samples, gonorrhea in 14.1% of female and 18.6% of male samples, and syphilis in 2.3% of female and 1.4% of male samples. Highest prevalence was found among females aged 18-20 years.

DISCUSSION

Syndromic STI screening and management can be integrated into routine PrEP service delivery and can identify symptomatic STIs, but misses asymptomatic infections. PrEP clients have a high prevalence of treatable STIs. Etiologic approaches can identify more infections than syndromic screening, but cheap point-of-care tests are needed.

The Use of HIV Pre-exposure Prophylaxis Among Men Accessing Routine Sexual and Reproductive Health Services in South Africa

PURPOSE

This study describes a cohort of men seeking oral pre-exposure prophylaxis (PrEP) services and explores their patterns of PrEP use within an implementation project seeking to integrate PrEP provision within sexual and reproductive health services in public health clinics in South Africa.

METHODS

Routine program and survey data from 364 males initiated on oral PrEP between July 2020 and May 2022 were analyzed. PrEP use was examined, including time to first discontinuation and restart patterns. Factors associated with early PrEP discontinuation and PrEP restart were analyzed.

RESULTS

Despite primarily focusing on access for adolescent girls and young women, PrEP services reached males with HIV prevention needs. PrEP use for ≤1 month (early discontinuation) was high at 58%; however, 18% restarted on PrEP, with 4% restarting repeatedly. Having depression symptoms was associated with early PrEP discontinuation (adjusted odds ratio [AOR]: 1.71, 95% CI [confidence interval]: 1.06-2.78). Those ≥25 years were less likely to discontinue early, as were those with a partner treated for a sexually transmitted infection in the preceding three months (AOR: 0.33, 95% CI: 0.13-0.84) and those who had been circumcised (AOR: 0.59, 95% CI: 0.36-0.96). Those 18-20 years old were less likely to restart PrEP than those ≥25 years (AOR: 0.43, 95% CI: 0.19-0.97), as were those whose partner's HIV status was unknown (AOR: 0.33, 95% CI: 0.12-0.88).

DISCUSSION

This study identified interest and uptake of oral PrEP among an underrepresented population of predominantly heterosexual males seeking sexual and reproductive health services. It found high rates of early PrEP discontinuation, with a subset returning to restart PrEP. Further research is needed to determine whether these periods of PrEP use are associated with periods of HIV risk.

Preferences, educational messaging, and demand creation channels for multipurpose-prevention technologies (MPTs) among women in South Africa

BACKGROUND

South African women, including female sex workers (FSWs), are disproportionately affected by HIV, experience a high unmet need for contraception and high rates of sexually transmitted infections (STIs). Products that address the interlinked risk between HIV, unplanned pregnancy, and other STIs are needed. There are several multipurpose-prevention technologies (MPTs) in development, aimed at preventing both HIV and pregnancy. This study aimed to explore educational messaging and demand creation channels to improve the potential uptake of a hypothetical MPT implant, using participatory action research. It also aimed to look at product and service provision attributes preferred by potential end users.

METHODS

Between July and August 2022, 303 PrEP-eligible adolescent girls and young women (AGYW) (18-24 years), women > 24 years, and FSW's (≥ 18 years) participated in 4-hour workshops, where they were asked about their ideal messaging and demand creation channels and their preferences for different attributes of an MPT implant. Quantitative descriptive analysis was conducted to determine the frequency and ranking for each demand creation message, channel, and each product and service provision attribute, by population group. A chi-square test was used to assess MPT implant characteristics associated with age. Qualitative data were analysed using deductive and thematic analysis.

RESULTS

A total of 104 AGYW, 157 women > 24 years, and 42 FSWs participated in the PAR workshops. Participants preferred demand creation messages that were empowering, motivational and encouraged body autonomy. The use of slang was popular. Community radio stations and newspapers, social media, and information at hospitals and clinics were participants' preferred MPT demand creation channels because they were easily accessible. Providing long-term and dual HIV and pregnancy protection, receiving implant services at the local clinic, manageable side effects, discreet and private implant, and numbing the area before insertion and removal, were the most preferred product and service provision attributes.

CONCLUSION

Early considerations for women's product preferences are key to product development. Educational messaging around the MPT implant should be empowering and in local languages, this may motivate women to learn more about it and use it. Multiple demand creation channels should be used to engage both young and older populations, which may ensure better reach.

Safety surveillance for PrEP in pregnant and breastfeeding women

The risk of HIV acquisition is higher during pregnancy and postpartum than other times. Newly acquired maternal HIV infection associated with high primary viraemia, substantially increases the risk of vertical HIV transmission. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition. Currently available products include oral tenofovir/emtricitabine (TDF/FTC) and tenofovir alafenamide (TAF)/FTC), long-acting cabotegravir (CAB-LA) and the dapivirine ring (DVR). All except oral TDF/FTC have limited safety data available for use in pregnant and breastfeeding women. The safety of new PrEP agents for pregnant women and the fetus, infant and child, either exposed in utero or during breastfeeding is an ongoing concern for health care workers and pregnant and breastfeeding women, particularly as the safety risk appetite for antiretroviral (ARV) agents used as PrEP is lower in pregnant and breastfeeding women who are HIV-uninfected, compared to women living with HIV taking ARVs as treatment. With the widespread rollout of TDF/FTC among pregnant women in South Africa and other low-middle income countries (LMIC) and the potential introduction of new PrEP agents for pregnant women, there is a need for safety surveillance systems to identify potential signals of risk to either the mother or fetus, measure the burden of such a risk, and where appropriate, provide specific reassurance to PrEP users. Safety data needs to be collected across the continuum of the product life cycle from pre-licensure into the post-marketing period, building a safety profile through both passive and active surveillance systems, recognising the strengths and limitations of each, and the potential for bias and confounding. Pharmacovigilance systems that aim to assess the risk of adverse birth outcomes in pregnant women exposed to PrEP and other agents need to consider the special requirements of pregnancy epidemiology to ensure that the data derived from surveillance are sufficiently robust to inform treatment policies. Here we review the known safety profiles of currently available PrEP candidates in women of child-bearing potential, pregnancy and breastfeeding and discuss pragmatic approaches for such surveillance in HIV-endemic LMICs.

Comparison of the diagnostic yield of transbronchial lung biopsies by forceps and cryoprobe in diffuse parenchymal lung disease

Background

Transbronchial lung cryobiopsy (TBLC) in the diagnosis of diffuse parenchymal lung disease (DPLD) has shown a promising yield in recent times, with low post-procedural mortality and morbidity.

Objectives

To compare the yield of TBLC and conventional transbronchial forceps lung biopsy (TBLB).

Methods

A prospective study was carried out in patients with DPLD over a period of 1 year in a tertiary respiratory care institute in New Delhi, India. All 87 patients enrolled underwent both TBLB and TBLC. The procedures were performed in the bronchoscopy suite under conscious sedation and local anaesthesia, with an attempt to take a minimum of three biopsy specimens by conventional TBLB followed by TBLC. A 1.9 mm cryoprobe with a freezing time of 4 - 5 seconds was used. An Arndt endobronchial blocker was used to control bleeding along with locally administered medications.

Results

TBLB and TBLC led to a definitive diagnosis in 27 (31.0%) and 69 (79.3%) cases, respectively. The commonest diagnoses were hypersensitivity pneumonitis, sarcoidosis and pulmonary tuberculosis. TBLC led to additional diagnoses in 42 cases (48.3%). Pneumothorax was observed in 12 cases (13.8%), and moderate bleeding occurred in 63 (72.4%). There were no procedure-related deaths.

Conclusion

TBLC had a better diagnostic yield than conventional TBLB in DPLD. It has the potential to become a safe day-care procedure in a resource-limited setting, if certain precautions are taken.

Study synopsis

What the study adds. Compared with transbronchial forceps lung biopsy, transbronchial lung cryobiopsy (TBLC) led to additional diagnoses in 42 (48.3%) of 87 patients with clinicoradiological features of diffuse parenchymal lung disease. Pneumothorax was observed in 12 cases (13.8%) and moderate bleeding in 63 (72.4%). TBLC without rigid bronchoscopy or advanced airway devices under conscious sedation had a good diagnostic yield with an acceptable adverse events profile.Implications of the findings. TBLC under conscious sedation is not resource intensive and can be carried out in settings with limited resources.

Optimizing the pipeline of multipurpose prevention technologies: opportunities across women's reproductive lifespans

HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a "fig leaf" for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.

Experiences of violence among female and male grade eight learners: baseline findings from the Girls Achieve Power (GAP Year) trial across three South African townships

Background: South African adolescents experience disproportionally high rates of violence, with lifelong health, social and economic impacts. Few papers present risk factors associated with experiences of adolescent violence. Methods: A baseline cross-sectional survey was done (April 2017 – Sept 2018) with 3432 grade 8 learners in the Girls Achieve Power (GAP Year) trial from 26 high schools in three townships (Soweto and Tembisa, Gauteng and Khayelitsha, Western Cape). Collected data on lifetime experiences of different types of violence, perpetrators, and place of violence. Descriptive statistics and logistic regression were used to enumerate experiences of, and factors associated with violence. Results: A total of 2383 respondents are included. Most (63.1%) were girls, 81.5% aged 12-14. In total 25.9% had ever experienced violence, higher among boys (p=<0.001). Physical violence was most common (35.7%), then psychological (21.8%), sexual (13.1%), neglect (10.6%), cyberbullying (7.6%), corporal punishment (6.5%) and economic abuse (4.8%). Boys experienced more physical violence (36.0%); girls experienced more psychological violence (22.2%). Gauteng had double the reports of sexual violence (18.4% vs 7.6%, p<0.001). Violence happened most at school (27.4%), followed by the park (19.8%) or their friends’ home (12.9%). Multivariate analysis showed that boys (aOR 1.68; 95% CV 1.32-2.14; p<0.001), those aged 15-17 years (aOR 1.41; 95% CV 1.04-1.89; p=0.025), those who ever used substances (aOR 1.90; 95% CI 1.9-2.28; p<0.001), and those who sometimes feel worthless (aOR 1.33; 95% CI 1.09-1.63, p=0.005) were at higher odds of ever experiencing violence. Those who had ever had sex were more likely to have ever experienced violence (aOR 1.42; 95% CI 1.10-1.83; p=0.008). Conclusion: Urgently need wider adoption, scaling, and sustaining of evidence-based primary violence prevention and structural interventions are required to reduce the high burden of adolescent violence. Stakeholders across the ecological model are needed to tackle harmful cultural norms that perpetuate violence.

Defining principles for a choice-based approach to HIV prevention

The HIV prevention landscape is on the cusp of an unprecedented era of multiple biomedical prevention products available for distribution. Several HIV prevention options, such as oral pre-exposure prophylaxis (PrEP), dapivirine vaginal rings, and injectable cabotegravir for PrEP, are becoming more widely available. Although the future HIV prevention market promises to be rich in options, it would benefit from a core set of principles that uphold choice in all phases of product development, assessment, and introduction. These principles, as presented in this Viewpoint, show the applicability, opportunities, and challenges of choice in different contexts of HIV prevention and provide checkpoints of accountability. By committing to these principles, stakeholders at national and global levels can advance choice across all phases of the HIV prevention market, thereby ensuring that individuals can realise their right to choose when and how to prevent HIV in their own lives.

Introduction and integration of PrEP and sexual and reproductive health services for young people: Health provider perspectives from South Africa

South Africa has one of the largest HIV epidemics in the world, with particularly high prevalence among adolescent girls and young women (AGYW). Oral PrEP was introduced in the public sector in 2016 in a phased manner. Given the important role played by health providers, research was undertaken to understand their experiences of and attitudes towards introduction of PrEP as a new HIV prevention method, and its integration within broader sexual and reproductive health (SRH) services for youth. A survey was undertaken with 48 purposively sampled health providers working in primary health care facilities and mobile clinics in three provinces in South Africa. Qualitative analysis was performed on free-text responses to open-ended questions in the survey, using an inductive approach to code the data in NVivo v.12 software. Health providers expressed concerns about adding a new service to an already overburdened health system, and worried that young people seeking PrEP would divert staff from other critical services. While most recognised the benefits and opportunities afforded by HIV and SRH service integration, providers highlighted the extra time and resources such integration would require. Many were anxious that PrEP would encourage disinhibition and increase unprotected sex among AGYW, and held judgemental attitudes about young people, seen as largely incapable of taking responsibility for their health. Findings underscore the importance of consulting health providers about implementation design and providing channels for them to express their misgivings and concerns, and training needs to be designed to address provider attitudes and values. Opportunities need to be sought to strengthen the provision of adolescent and youth friendly services-including adolescent-health provider dialogues. Insights from this study can assist in guiding the introduction of new HIV prevention methods into the future.

Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa

Background

In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa.

Methods

Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods.

Results

Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort.

Conclusion

Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.

Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

Background: Adolescence is a time of psycho-social and physiological changes, with increased associated health risks including vulnerability to pregnancy, HIV, sexually transmitted infections, and gender-based violence. Adolescent learners, from three townships in South Africa, participated in a 44 session, after-school asset-building intervention (GAP Year), over 2 years providing sexual and reproductive health (SRH) education. This paper explores adolescent learners' SRH, sexual risk and rights knowledge; perceptions about transactional sex; and contraceptive method preferences and decision-making practices. Methods: The intervention was conducted in 13 secondary schools across Khayelitsha, Thembisa, and Soweto, South Africa. A baseline survey collected socio-demographic data prior to the intervention. Overall, 26 focus group discussions (FGDs): 13 male and 13 female learner groups, purposively selected from schools, after completing the intervention (2 years after baseline data collection). Descriptive analyses were conducted on baseline data. Qualitative data were thematically coded, and NVivo was used for data analysis. Results: In total, 194 learners participated in the FGDs. Mean age at baseline was 13.7 years (standard deviation 0.91). Participants acquired SRH and rights knowledge during the GAP Year intervention. Although transactional sex was viewed as risky, some relationships were deemed beneficial and necessary for material gain. Negative healthcare provider attitudes were the main barrier to healthcare service utilisation. There was awareness about the benefits of contraceptives, but some myths about method use. The injectable was the preferred contraceptive method, followed by the implant, with equal preference for condoms and oral pill. Conclusions : An afterschool intervention at school is a viable model for the provision of SRH and rights education to learners. Recommendations include the need for risk reduction strategies in the curriculum, dealing with misconceptions, and the promotion of informed decision making. Endeavours to ensure health services are youth friendly is a priority to limit barriers to accessing these services.

Measuring and evaluating sexual health in the era of digital health: challenges and opportunities

Digital health has become increasingly embedded within sexual health service delivery and is now an established part of the user journey. It can support the provision of information and access to care across the sexual health continuum and facilitate the delivery of differentiated care with tailored and layered interventions that meet an individual's and target populations' need. However, despite advances in digital health, many challenges remain in the measurement and evaluation of sexual health. Reaching underserved populations, ensuring that both the intervention and the outcomes being measured are appropriate, and consistent collection of data (across settings and over time) are all potential obstacles to a full realisation of these opportunities. In order for digital health to improve sexual health and wellbeing, and reduce morbidity, the following need to occur: (1) ensure the necessary digital, health care, laboratory, legal and regulatory and surveillance infrastructure is in place to provide access to those with a sexual health need; (2) empowerment of end users and communities to take control of their own health through engagement in the development of interventions, and to ensure that outcomes of importance are measured; (3) tailoring and layering of interventions to provide equitable access to care; (4) integrating the digital ecosystem with the existing healthcare and external ecosystem; (5) measure and evaluate the unmet needs, gaps and quality of the experience, taking a realist evaluation approach; and (6) measure and evaluate the economic and distributional impacts associated with digital services or interventions in sexual health.

Contraception knowledge and uptake among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Background: South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods: A baseline cross sectional survey was conducted among 3432 grade 8s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results: In total, 2383 learners, completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion: This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

Evaluating the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe programme, what's worked and what more needs to be done?

This paper is a commentary framing a series of papers on the evaluation of several aspects of the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) programme. The paper highlights the scope and challenges with evaluating a large, complex and ambitious programme like DREAMS.

Climate change knowledge, concerns and experiences in secondary school learners in South Africa

Climate change poses a major threat to the future of today’s youth. Globally, young people are at the forefront of climate change activism. Their ability to engage, however, depends on the level of knowledge of climate change and concern about the topic. We sought to examine levels of knowledge and concerns about climate change among youth in South Africa, and their experiences of heat exposure. Ten questions on climate change knowledge, concerns and experiences were nested within a cross-sectional survey conducted in a cluster randomised trial among 924 secondary school learners in 14 public schools in low-income Western Cape areas. Learners’ mean age was 15.8 years and they were predominately female. While 72.0% of respondents knew that climate change leads to higher temperatures, only 59.7% agreed that human activity is responsible for climate change, and 58.0% believed that climate change affects human health. Two thirds (68.7%) said that climate change is a serious issue and 65.9% indicated action is needed for prevention. Few learners indicated climate change events had affected them, although many reported difficulties concentrating during hot weather (72.9%). Female learners had lower knowledge levels than male learners, but more frequent heat-related symptoms. Learners scoring high on knowledge questions expressed the most concern about climate change and had the highest heat impacts. Many youth seem unaware that climate change threatens their future. Heat-related symptoms are common, likely undermining educational performance, especially as temperatures escalate. More is needed to mainstream climate change into South African school curricula.

Experiences of violence among female and male grade eight learners: baseline findings from the Girls Achieve Power (GAP Year) trial across three South African townships

Background: South African adolescents experience disproportionally high rates of violence, with lifelong health, social and economic impacts. Few papers present risk factors associated with experiences of adolescent violence. Methods: A baseline cross-sectional survey was done (April 2017 – Sept 2018) with 3432 grade 8 learners in the Girls Achieve Power (GAP Year) trial from 26 high schools in three townships (Soweto and Tembisa, Gauteng and Khayelitsha, Western Cape). Collected data on lifetime experiences of different types of violence, perpetrators, and place of violence. Descriptive statistics and logistic regression were used to enumerate experiences of, and factors associated with violence. Results: A total of 2383 respondents are included. Most (63.1%) were girls, 81.5% aged 12-14. In total 25.9% had ever experienced violence, higher among boys (p=<0.001). Physical violence was most common (35.7%), then psychological (21.8%), sexual (13.1%), neglect (10.6%), cyberbullying (7.6%), corporal punishment (6.5%) and economic abuse (4.8%). Boys experienced more physical violence (36.0%); girls experienced more psychological violence (22.2%). Gauteng had double the reports of sexual violence (18.4% vs 7.6%, p<0.001). Violence happened most at school (27.4%), followed by the park (19.8%) or their friends’ home (12.9%). Multivariate analysis showed that boys (aOR 1.57; 95% CV 1.27-1.94; p=0.000), those aged 15-17 years (aOR 1.41; 95% CV 1.07-1.84; p=0.013), those who ever used substances (aOR 1.92; 95% CI 1.54-2.37; p=0.000), and those who sometimes feel worthless (aOR 1.35; 95% CI 1.10-1.64, p=0.003) were at higher odds of ever experiencing violence. Those who had never had sex were less likely to have ever experienced violence (aOR 0.66; 95% CI 0.51-0.83; p=0.001). Conclusion: Urgently need wider adoption, scaling, and sustaining of evidence-based primary violence prevention and structural interventions are required to reduce the high burden of adolescent violence. Stakeholders across the ecological model are needed to tackle harmful cultural norms that perpetuate violence.

Knowledge, uptake and patterns of contraception use among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Background: South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods: A baseline cross sectional survey was conducted among 3432 grade 8’s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results: In total, 2383 learners, completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion: This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

Background: Adolescence is a time of psycho-social and physiological changes, with increased associated health risks including vulnerability to pregnancy, HIV, sexually transmitted infections, and gender-based violence. Adolescent learners, from three townships in South Africa, participated in a 44 session, after-school asset-building intervention (GAP Year), over 2 years providing sexual and reproductive health (SRH) education. This paper explores adolescent learners’ SRH, sexual risk and rights knowledge; perceptions about transactional sex; and contraceptive method preferences and decision-making practices. Methods: The intervention was conducted in 13 secondary schools across Khayelitsha, Thembisa, and Soweto, South Africa. A baseline survey collected socio-demographic data prior to the intervention. Overall, 26 focus group discussions (FGDs): 13 male and 13 female learner groups, purposively selected from schools, after the intervention (2 years after baseline data collection). Descriptive analyses were conducted on baseline data. Qualitative data were thematically coded, and NVivo was used for data analysis. Results: In total, 194 learners participated in the FGDs. Mean age at baseline was 13.7 years (standard deviation 0.91). Participants acquired SRH and rights knowledge during the GAP Year intervention. Although transactional sex was viewed as risky, some relationships were deemed beneficial and necessary for material gain. Negative healthcare provider attitudes were the main barrier to healthcare service utilisation. There was awareness about the benefits of contraceptives, but some myths about method use. The injectable was the preferred contraceptive method, followed by the implant, with equal preference for condoms and oral pill. Conclusions: An afterschool intervention at school is a viable model for the provision of SRH and rights education to learners. Recommendations include the need for risk reduction strategies in the curriculum, dealing with misconceptions, and the promotion of informed decision making. Endeavours to ensure health services are youth friendly is a priority to limit barriers to accessing these services.

Casting a Wide Net: HIV Drug Resistance Monitoring in Pre-Exposure Prophylaxis Seroconverters in the Global Evaluation of Microbicide Sensitivity Project

Global Evaluation of Microbicide Sensitivity projects in 4 countries demonstrated the feasibility of establishing an HIV drug resistance monitoring program for pre-exposure prophylaxis (PrEP). These projects will provide valuable information on seroconversions in the context of PrEP use and will serve to inform Ministries of Health and policy makers on the need for long-term surveillance approaches.

Background:

Evidence of HIV drug resistance (HIVDR) in individuals using oral pre-exposure prophylaxis (PrEP) who acquire HIV is limited to clinical trials and case studies. More data are needed to understand the risk of HIVDR with oral PrEP during PrEP rollout. Mechanisms to collect these data vary, and are dependent on cost, scale of PrEP distribution, and in-country infrastructure for the identification, collection, and testing of samples from PrEP seroconverters.

Methods:

The Global Evaluation of Microbicide Sensitivity (GEMS) project, in collaboration with country stakeholders, initiated HIVDR monitoring among new HIV seroconverters with prior PrEP use in Eswatini, Kenya, South Africa, and Zimbabwe. Standalone protocols were developed to assess HIVDR among a national sample of PrEP users. In addition, HIVDR testing was incorporated into existing demonstration projects for key populations.

Lessons learned:

Countries are supportive of conducting a time-limited evaluation of HIVDR during the early stages of PrEP rollout. As PrEP rollout expands, the need for long-term HIVDR monitoring with PrEP will need to be balanced with maintaining national HIV drug resistance surveillance for pretreatment and acquired drug resistance. Laboratory capacity is a common obstacle to setting up a monitoring system.

Conclusions:

Establishing HIV resistance monitoring within PrEP programs is feasible. Approaches to drug resistance monitoring may evolve as the PrEP programs mature and expand. The methods and implementation support offered by GEMS assisted countries in developing methods to monitor for drug resistance that best fit their PrEP program needs and resources.

Learner experiences of safety at public high schools in three South African townships: Baseline findings from the National School Safety Framework learner surveys

Background: Despite progressive policies and frameworks on school safety by the Department of Basic Education, safety remains a concern in South African schools. Methods: A cross-sectional descriptive design was employed using the National School Safety Framework (NSSF) 152-question learner survey, exploring perceptions and experiences pertaining to eight safety domains: dangerous objects, drugs and alcohol, bullying, verbal abuse, physical violence, discrimination, sexual violence, and journey to and from school. Grade 9-11 learners from 15 government-funded high schools in the Girls Achieve Power trial in Khayelitsha, Soweto, and Thembisa townships were surveyed (March 2018 - April 2019), sampling 10% of the school population. Data analysis included Principal Component Analysis (PCA), reducing correlated variables into fewer questions, then analysis on a scree plot by calculating eigenvalues; repeated PCA with those that had a minimum eigenvalue of 1 and Cronbach Alpha test for internal reliability. Eleven composite variables were included in the final analysis. Results:  In total, 1034 learners completed the NSSF learner survey; 52.9% were female and the mean age was 16 years (SD=1.36). Results show statistically significant associations between four of the 11 composite variables in relation to sex. Over half (55%) of males have experienced peer provocation and relational aggression (p<0.001). Fifty-eight percent of females reported feeling unsafe on their way to and from school (p<0.003). Over half of males reported that their school was not effective in enforcing discipline (p=0.002) while 58% of females noted they could comfortably report any form of experienced or witnessed violence at school, to their educators (p<0.000). Conclusions: Violence continues to be a concern in South African schools. Interventions should work across the ecological model to effectively prevent and reduce violence at school and community levels. Strengthened NSSF implementation is critical to achieving this. We recommend NSSF learner survey adaptations to increase utility and implementation.

OUP accepted manuscript

Objectives

Limited antimicrobial resistance (AMR) surveillance coupled with syndromic management of sexually transmitted infections (STIs) in sub-Saharan Africa (SSA) could be contributing to an increase in AMR in the region. This systematic review aimed to synthesize data on the prevalence of AMR in common STIs in SSA and identify some research gaps that exist.

Methods

We searched three electronic databases for studies published between 1 January 2000 and 26 May 2020. We screened the titles and abstracts for studies that potentially contained data on AMR in SSA. Then we reviewed the full text of these studies to identify articles that reported data on the prevalence of AMR in Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium in SSA. We summarized the data using a narrative synthesis.

Results

The 40 included studies reported on AMR data from 7961 N. gonorrhoeae isolates from 15 countries in SSA and 350 M. genitalium specimens from South Africa. All four SSA regions reported very high rates of ciprofloxacin, tetracycline and penicillin resistance in N. gonorrhoeae. Resistance to cefixime or ceftriaxone was observed in all regions except West Africa. Azithromycin resistance, recommended as part of dual therapy with an extended-spectrum cephalosporin for gonorrhoea, was reported in all the regions. Both macrolide and fluoroquinolone-associated resistance were reported in M. genitalium in South Africa. Studies investigating AMR in C. trachomatis and T. vaginalis were not identified.

Conclusions

There is a need to strengthen AMR surveillance in SSA for prompt investigation and notification of drug resistance in STIs.

Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP?

Purpose of review

Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women’s risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention.

Recent findings

Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use.

Summary

Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.

Socio-demographic and social support factors related to substance use in South African in-school adolescents: Insights from the Girls Achieve Power (GAP Year) trial in three peri-urban settings

Background: Substance use is a significant public health problem worldwide, with consequences including violence, risky behaviours, and even death. Substance use amongst adolescents is increasing in South Africa, and limited research on frequency, risk and protective factors means that prevention interventions are difficult to design. This paper aims to describe and discuss factors associated with substance use among school-going adolescents in three peri-urban South African settings.

Methods: A cross-sectional analysis was conducted using baseline data from participants in the Girls Achieve Power (GAP Year) trial. Grade 8 learners (N=2383), aged 11-18, were recruited from 26 lowest quintile public high schools in three townships: Soweto and Thembisa in Gauteng Province, and Khayelitsha in Western Cape Province. A baseline survey gathered demographic and behavioural data. Questions relevant to substance use and social support were used for this analysis. Multivariate logistic regression analyses were conducted to identify factors associated with substance use. The final variables were included in an unadjusted and adjusted logistic regression for current substance use, and a multinomial logistic regression for frequency of substance use.

Results: A total of 22.5% (534) of participants indicated they had ever used substances. Being male was strongly associated with substance use (P<0.001), and less strongly with frequency of substance use. Age significantly predicted substance use, with older adolescents being more likely to engage in substance use (P<0.001); having a parent/guardian employed was negatively associated with substance use (P=0.021). Family-related social support variables were predictive of substance use. Being able to count on friends when things went wrong was predictive of lower frequency of substance use (P=0.019).

Conclusions: These results can inform the targeting of prevention interventions to males and younger learners, as well as ensuring youth interventions build family and peer support to make substance use less likely and less frequent.

Health care providers' attitudes toward and experiences delivering oral PrEP to adolescent girls and young women in Kenya, South Africa, and Zimbabwe

Background

In Kenya, South Africa, and Zimbabwe, oral pre-exposure prophylaxis (PrEP) is recommended for adolescent girls and young women (AGYW) at high risk of HIV. Health providers play a critical role in the uptake and effective use of sexual and reproductive health services; however, few published studies have explored providers’ attitudes toward and experiences delivering PrEP to AGYW.

Methods

We conducted a cross-sectional qualitative study, interviewing 113 providers at 36 public, private, and nongovernmental health facilities in Kenya, South Africa, and Zimbabwe that were offering PrEP during the research period or were likely to offer PrEP in the future. Data were coded in NVivo 11, and an applied thematic analysis was conducted.

Results

Most providers preferred that adolescent girls wait until age 18 to have sex but acknowledged that many girls younger than 18 could benefit from oral PrEP. Their primary concern was whether adolescent girls would be able to take PrEP daily, especially if they do not tell their parents or partners they are using it. Providers reported that it was more challenging to deliver PrEP and other HIV services to girls younger than 18. Those with experience providing PrEP pointed to stigma and lack of PrEP awareness in communities as two primary barriers to PrEP uptake and use.

Conclusions

Providers were generally accepting of oral PrEP as an HIV prevention option for AGYW; however, many had negative attitudes about adolescent girls being sexually active and concerns about whether they could take PrEP daily. Results were used to update national PrEP training materials to address negative provider attitudes about PrEP use by AGYW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06978-0.

Who’s got the power? Expressions of empowerment among in-school adolescents enrolled in the Girls Achieve Power (GAP Year) trial in three peri-urban settings of South Africa

Background: Empowerment is when a person gains mastery of their life and environment. This paper describes three central elements of empowerment (agency, resources, and institutional structures) expressed by adolescents, discussing implications for strengthening adolescent sexual reproductive health, HIV, and violence prevention programming. Methods: A cross-sectional survey was conducted (April 2017 – May 2018) as part of the GAP Year trial among grade eight learners (12 – 18 years) from 26 lowest quintile public high schools in Khayelitsha, Soweto and Thembisa townships, South Africa. Data were on empowerment experiences using a knowledge, attitudes, and practices survey. Descriptive and chi-square test statistics were employed, assessing the association between sociodemographic and domains of empowerment. Results: A total of 2383 adolescents in 26 schools completed the baseline survey: 63.1% female, mean age 13.7 years, 96.9% Black African. Agency: Males (4.04 vs 3.94, p=0.008) and those 15 – 18 years (4.10 vs 3.95, p=0.027) expressed stronger decision-making capacity. Females (3.18 vs 2.92, p<0.001) indicated a greater sense of collective action. Females (0.77 vs 0.72, p=0.008), those aged 12 -14 years (0.76 vs 0.71, p=0.027) and those with at least one parent/guardian employed (p=0.014) had stronger leadership confidence. Resources: Those 12-14 years expressed higher self-esteem (2.18 vs 2.08, p=0.017). Males (2.24 vs 1.87, p<0.001) and those who had at least one parent/guardian employed (p=0.047) had a higher perception of freedom from gender-based violence. Males showed greater mobility (2.89 vs 2.66, p=<0.001). Institutional structures: Coloured participants showed more positive norms than their Black counterparts (5.38 vs 2.12, p=0.005). Conclusions: Males expressed greater empowerment around decision-making, gender-based violence and mobility; females expressed greater collective action and leadership. Working across the ecological model, interventions addressing sex differences, targeting adolescents of all ages, and parental unemployment may strengthen expressions of empowerment, especially adolescents’ safety, mobility, aspirations, and future hopes.

Uptake of Contraception Among Adolescent Girls and Young Women PrEP Clients: Leveraging the Opportunity to Strengthen HIV and Sexual and Reproductive Health Integration

The introduction of oral pre-exposure prophylaxis (PrEP) for HIV prevention was a major breakthrough in South Africa (SA). While the initial introduction focused on issues such as the development and implementation of new guidelines, supply, and the development of demand creation strategies, the need to integrate PrEP services with sexual and reproductive health (SRH) services has gained traction both globally and locally. Project PrEP was implemented in eight healthcare facilities and four mobile clinics in three provinces in SA. Using monitoring data from across the four project clusters, and 4,949 clients, over a 21-month period, we conducted an analysis of baseline routine monitoring data to examine contraceptive uptake in adolescent girls and young women (AGYW) initiating PrEP at project sites. Two-thirds of women (62.3%, n = 3,083) reported the current use of contraception at baseline, with the most commonly used methods being hormonal injectables (61.9%, n = 1,829) and male condoms (19.4%, n = 575). A third (32.3%, n = 603) of the non-contraceptive users accepted a method at PrEP initiation. From a total of 1,007 (32.7%) current contraceptive users at baseline, 865 (85.9%) chose the same or a different method at this visit. The method uptake at PrEP initiation increased the overall contraceptive prevalence by 12.2 to 74.5%. Data indicated that over a third (38.8%, n = 725) who were not using a method at baseline described themselves as consistent condom users. Although a major focus of the project was on PrEP service provision, all women were counseled and offered contraceptive services. The acceptance of a method by a third of non-users was promising; however, more understanding of those who did not take up a method is required. The need to leverage opportunities for the promotion of the integration of HIV and family planning at all levels of PrEP provision was highlighted.

Integrating Oral PrEP Into Family Planning Services for Women in Sub-saharan Africa: Findings From a Multi-Country Landscape Analysis

Integration of HIV and family planning (FP) services is a renewed focus area for national policymakers, donors, and implementers in sub-Saharan Africa as a result of high HIV incidence among general-population women, especially adolescent girls and young women (AGYW), and the perception that integrating HIV pre-exposure prophylaxis (PrEP) into FP services may be an effective way to provide comprehensive HIV and FP services to this population. We conducted a focused desk review to develop a PrEP-FP integration framework across five key categories: plans and policies, resource management, service delivery, PrEP use, and monitoring and reporting. The framework was refined via interviews with 30 stakeholders across seven countries at varying stages of oral PrEP rollout: Kenya, Lesotho, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. After refining the framework, we developed a PrEP-FP integration matrix and assessed country-specific progress to identify common enablers of and barriers to PrEP-FP integration. None of the countries included in our analysis had made substantial progress toward integrated PrEP-FP service delivery. Although the countries made progress in one or two categories, integration was often impeded by lack of advancement in other areas. Our framework offers policymakers, program implementers, and health care providers a road map for strategically assessing and monitoring progress toward PrEP-FP integration in their contexts.

Experiences of violence among female and male grade eight learners: baseline findings from the Girls Achieve Power (GAP Year) trial across three South African townships

Background: South African adolescents experience disproportionally high rates of violence, with lifelong health, social and economic impacts. Few papers present risk factors associated with experiences of adolescent violence. Methods: A baseline cross-sectional survey was done (April 2017 – Sept 2018) with 3432 grade 8 learners in the Girls Achieve Power (GAP Year) trial from 26 high schools in three townships (Soweto and Tembisa, Gauteng and Khayelitsha, Western Cape). Collected data on lifetime experiences of different types of violence, perpetrators, and place of violence. Descriptive statistics and logistic regression were used to enumerate experiences of, and factors associated with violence. Results: A total of 2383 respondents are included. Most (63.1%) were girls, 81.5% aged 12-14. In total 26% had ever experienced violence, higher among boys (p=<0.001). Physical violence was most common (35.7%), then psychological (21.8%), sexual (13.1%), neglect (10.6%), cyberbullying (7.6%), corporal punishment (6.5%) and economic abuse (4.8%). Boys experienced more physical violence (36.0%); girls experienced more psychological violence (22.2%). Gauteng had double the reports of sexual violence (18.4% vs 7.6%, p<0.001). Violence happened most at school (27.4%), followed by the park (19.8%) or their friends’ home (12.9%). Multivariate analysis showed that boys (aOR 1.57; 95% CV 1.27-1.94; p=0.000), those aged 15-17 years (aOR 1.41; 95% CV 1.07-1.84; p=0.013), those who ever used substances (aOR 1.92; 95% CI 1.54-2.37; p=0.000), and those who sometimes feel worthless (aOR 1.35; 95% CI 1.10-1.64, p=0.003) were at higher odds of ever experiencing violence. Those who had never had sex were less likely to have ever experienced violence (aOR 0.66; 95% CI 0.51-0.83; p=0.001). Conclusion: Urgently need wider adoption, scaling, and sustaining of evidence-based primary violence prevention and structural interventions are required to reduce the high burden of adolescent violence. Stakeholders across the ecological model are needed to tackle harmful cultural norms that perpetuate violence.

The prevalence of pregnancy among adolescent girls and young women across the Southern African development community economic hub: A systematic review and meta-analysis

Background: Despite the high rate of HIV infections, there is still high rate of early unprotected sex, unintended pregnancy, and unsafe abortions especially among unmarried adolescent girls and young women (AGYW) 10-24 years of age in sub Saharan Africa. AGYW face challenges in accessing health care, contraception needs, and power to negotiate safer sex. This study aimed to estimate the rate of pregnancy among AGYW aged 10-24, 10-19 and 15-19 years in the Southern African Development Community (SADC) economic region. Methods: A systematic review and meta-analysis was used to describe the prevalence of pregnancy among AGYW in 15 SADC member countries between January 2007 and December2017. The articles were extracted from PubMed/MEDLINE, African Index Medicus, and other reports. They were screened and reviewed according to PRISMA methodology to fulfil study eligibility criteria. Results: The overall regional weighted pregnancy prevalence among AGYW 10-24 years of age was 25% (95% CI: 21% to 29%). Furthermore, sub-population 10-19 years was 22% (95% CI:19% to 26%) while 15-19 years was 24% (18% to 30%). There was a significant heterogeneity detected between the studies (I=99.78%, P < 0.001), even within individual countries. Conclusion: The findings revealed a high pregnancy rate among AGYW in the SADC region. This prompts the need to explore innovative research and programs expanding and improving sexual and reproductive health communication to reduce risk and exposure of adolescents to early planned, unplanned and unwanted pregnancies, SRHR challenges, access to care, HIV/STIs, as well as other risk strategies.

Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa

Background

South Africa became the first country in Africa to introduce oral PrEP in June 2016. The National Department of Health has used a phased approach to rollout, allowing for a dynamic learn-and-adapt process which will lead ultimately to scale-up. Phased rollout began with provision of oral PrEP at facilities providing services to sex workers in 2016 and was expanded in 2017, first to facilities providing services to MSM and then to students at selected university campus clinics, followed by provision at primary health care facilities. Programmatic data shows variability in initiation and continuation between these populations. This study examines factors related to PrEP initiation, continuation, and discontinuation at facilities providing services to sex workers and MSM during the national PrEP rollout.

Methods

A cross-sectional survey was administered September 2017-January 2018 among clients (ages 18–62 and providers at 9 facilities implementing oral PrEP in South Africa, followed by in-depth interviews. The client survey captured PrEP initiation, continuation and discontinuation. Analysis was performed in STATA 13 for survey data and thematic analysis was performed in NViVO 11 for in-depth interview data.

Results

299 clients (203 from sex worker facilities, 96 from MSM facilities) participated in the survey and additionally, in-depth interviews were conducted with 29 clients. Participants self-identified as either current users (n = 94; 36.2%), past users (n = 80; 30.8%) and never users of PrEP (n = 86; 33.1%). Participants who had never used PrEP either cited not being offered PrEP by a provider (57%, n = 49) or declining PrEP (43%, n = 37) as reasons for lack of uptake. The primary reason for declining to use oral PrEP was fear of side effects (41.7%, n = 15). The primary reasons for initiating and continuing on oral PrEP were all related to perceived risk associated with sexual activity. The majority of participants (87.9%, n = 153) also noted that printed IEC materials influenced their decision to initiate PrEP. Qualitative data suggested that several clients initiated on PrEP because they wanted additional protection beyond using condoms due to challenges such as partners refusing to use condoms, having partners with unknown HIV status, having multiple partners, involvement in sex work, or having a partner living with HIV. The majority (73.8%, n = 59) of participants who discontinued oral PrEP cited side effects as the primary reason for discontinuation, followed by feeling stigmatized (18.8%, n = 15).

Conclusion

This study provides valuable insights on early rollout of PrEP of how clients perceive oral PrEP and where to target efforts to improve the uptake of this highly effective HIV prevention product. By identifying strengths and areas for improvement, the ACCESS study has generated evidence that can be used to guide high quality scale-up in South Africa and may be instructive for other countries’ efforts to expand quality access to oral PrEP.

Understanding and measuring uptake and coverage of oral pre-exposure prophylaxis delivery among adolescent girls and young women in sub-Saharan Africa

In response to World Health Organization (WHO) guidance recommending oral pre-exposure prophylaxis (PrEP) for all individuals at substantial risk for HIV infection, significant investments are being made to expand access to oral PrEP globally, particularly in sub-Saharan Africa. Some have interpreted early monitoring reports from new programs delivering oral PrEP to adolescent girls and young women (AGYW) as suggestive of low uptake. However, a lack of common definitions complicates interpretation of oral PrEP uptake and coverage measures, because various indicators with different meanings and uses are used interchangeably. Furthermore, operationalising these measures in real-world settings is challenged by the difficulties in defining the denominator for measuring uptake and coverage among AGYW, due to the lack of data and experience required to identify the subset of AGYW at substantial risk of HIV infection. This paper proposes an intervention-centric cascade as a framework for developing a common lexicon of metrics for uptake and coverage of oral PrEP among AGYW. In codifying these indicators, approaches to clearly define metrics for uptake and coverage are outlined, and the discussion on ‘low’ uptake is reframed to focus on achieving the highest possible proportion of AGYW using oral PrEP when they need and want it Recommendations are also provided for making increased investments in implementation research to better quantify the sub-group of AGYW in potential need of oral PrEP.and for improving monitoring systems to more efficiently address bottlenecks in the service delivery of oral PrEP to AGYW so that implementation can be taken to scale.

Reaching at-risk women for PrEP delivery: What can we learn from clinical trials in sub-Saharan Africa?

INTRODUCTION

ARV-based pre-exposure prophylaxis (PrEP) has the potential to avert many new HIV infections, yet little is known about how to reach women at high risk for HIV infection and motivate them to initiate PrEP. Clinical trials have succeeded in recruiting at-risk participants, evidenced by control arm HIV incidence ≥3% (defined by the World Health Organization as "substantial risk"). We examined experiences from HIV prevention trials to document recruitment strategies and identify practical, potentially effective strategies for reaching women in real-world PrEP delivery.

METHODS

We conducted semi-structured qualitative phone interviews with 31 staff from five countries who had worked on one or more of seven ARV-based HIV prevention clinical trials. Questions explored recruitment strategies used to reach women at risk of HIV and to successfully communicate about PrEP (inclusive of oral and vaginal formulations). We structurally coded data in NVivo and analyzed codes to derive themes. We conducted results interpretation webinars with research and programmatic stakeholders to validate findings and develop recommendations.

RESULTS

Clinical trial researchers employed a range of recruitment strategies to recruit at-risk women. They recommended engaging the local community and potential PrEP users via community events, meetings with gatekeepers, and use of community advisory boards; and they encouraged interpersonal communication like presentations in waiting rooms and door-to-door recruitment to address personal concerns and prevent misinformation. Participants also stressed the importance of addressing the challenges that already exist within the health system to create a more enabling environment and delivering positive messages through a variety of communication channels to normalize PrEP.

CONCLUSIONS

Findings from this study provide important insights into potentially effective ways for countries currently rolling out oral PrEP to reach at-risk women with information about PrEP and promote uptake.

Clients' experiences utilizing a safer conception service for HIV affected individuals: implications for differentiated care service delivery models

Background

Safer conception services promote the reproductive health and rights of families, while minimizing HIV transmission risks between partners trying to conceive, as well vertical transmission risks. Implementation data, including clients’ experiences utilizing safer conception services in sub-Saharan Africa are limited.

Methods

Hillbrow Community Health Centre began offering safer conception services for individuals and couples affected by HIV in Johannesburg, South Africa in June 2015. A stratified sub-sample of safer conception clients were consecutively recruited from April 2016–August 2017 for a cross-sectional interview assessing clients’ perceptions of service acceptability and value, as well as perceived safer conception knowledge and self-efficacy. Visual analog scales from 0 to 100 were used to measure clients’ experiences; scores were classified as low, moderate and high acceptance/value/knowledge/self-efficacy if they were < 50, 50–79 and ≥ 80 respectively. Comparisons of scores were made across safer conception visits attended.

Results

Among 692 clients utilizing safer conception services, 120 (17%) were sampled for the process evaluation; sub-sample participant characteristics were similar to the overall cohort. Clients gave a mean score of ≥90-points for each question assessing service acceptability and 96% (114/119) indicated a high perceived value (scores ≥80) for regular safer conception attendance until conception. Fifty-eight percent (n = 70) of clients reported learning something new during the visit completed the day of the survey, though acquisition of new information tended to decrease as visits increased (p = 0.09). In terms of safer conception strategies, 80% of clients reported high levels of knowledge on the impact of antiretroviral treatment (ART) and viral suppression on HIV transmission, 67% reported high levels of knowledge of the importance of STI screening and 56% regarding limiting condomless sex to days of peak fertility; 34% in sero-different relationships reported high pre-exposure prophylaxis (PrEP) knowledge. Self-efficacy varied by safer conception methods and was similar across study visits.

Conclusions

Clients perceived high value from their safer conception visits and preferred regular attendance until conception, however we observed a plateau in knowledge and self-efficacy across subsequent visits after initially attending safer conception care. More intensive services may be appropriate for certain clients based on clinical circumstances, but many couples may potentially receive a ‘lighter touch’ approach while still minimizing HIV transmission risks.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0718-5) contains supplementary material, which is available to authorized users.

Integrating Cervical Cancer Screening Into Safer Conception Services to Improve Women's Health Outcomes: A Pilot Study at a Primary Care Clinic in South Africa

BACKGROUND

Sub-optimal cervical cancer screening in low- and middle-income countries contributes to preventable cervical cancer deaths, particularly among human immunodeficiency virus (HIV)-positive women. We assessed feasibility and outcomes of integrating cervical cancer screening into safer conception services for HIV-affected women.

METHODS

At a safer conception service in Johannesburg, South Africa, HIV-affected women desiring pregnancy received a standard package of care designed to minimize HIV transmission risks while optimizing prepregnancy health. All eligible women were offered Papanicolaou smear, and those with significant pathology were referred for colposcopy before attempting pregnancy. Multivariable analyses identified associations between patient characteristics and abnormal pathology.

RESULTS

In total, 454 women were enrolled between June 2015 and April 2017. At enrolment, 91% were HIV-positive, 92% were on antiretroviral therapy (ART) and 82% virally suppressed. Eighty-three percent (376 of 454) of clients were eligible for cervical cancer screening and 85% (321 of 376) of these completed screening. More than half had abnormal cervical pathology (185 of 321) and 20% required colposcopy for possible high-grade or persistently atypical lesions (64 of 321). Compared with HIV-negative women, abnormal pathology was more likely among HIV-positive women, both those on ART <2 years (adjusted prevalence ratio, 2.5; 95% confidence interval, 1.2-5.0) and those on ART 2 years or longer (adjusted prevalence ratio, 2.1; 95% confidence interval, 1.0-4.2).

CONCLUSIONS

Integrating cervical cancer screening into safer conception care was feasible with high coverage, including for HIV-positive women. Significant pathology, requiring colposcopy, was common, even among healthy women on ART. Safer conception services present an opportunity for integration of cervical cancer screening to avert preventable cancer-related deaths among HIV-affected women planning pregnancy.

Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15–49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57–0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued.

Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.

Implementing the Good Participatory Practice Guidelines in the Girls Achieve Power Trial in South Africa

The Good Participatory Practice (GPP) guidelines provide a framework for stakeholder engagement within clinical trials, to ensure a study's acceptability, feasibility, and improving the overall research quality; however, they have rarely been applied beyond this setting, and no literature exists on its application in adolescent research. A review of the 2011 GPP guidelines was undertaken to identify which 16 GPP topic areas could be applied and adapted for implementing an ecological asset building intervention, that is, the Girls Achieve Power (GAP Year) cluster randomized controlled trial for reducing school dropout and increasing reporting of gender-based violence in Gauteng and Western Cape province in South Africa. The 16 GPP topic areas were adapted and implemented to guide stakeholder engagement for GAP Year. We show the usability and adaptability of the GPP framework for guiding stakeholder engagement in non-clinical trials like GAP Year; however it requires adapting to respond to the unique needs of the beneficiaries.

Prevalence of HIV and HIV-related diseases in the adult medical wards of a tertiary hospital in Durban, South Africa

Our objective was to determine the prevalence of HIV and the distribution of HIV-related diseases among adult, medical inpatients. Consecutive admissions were recruited and a single ELISA assay was used to determine HIV infection. Demographic and clinical details were extracted from clinical records. Of 507 patients, 54% were infected with HIV of which 84% had AIDS. HIV-infected patients were significantly younger (34.9 years) than uninfected patients (47.1 years) and had significantly higher risks for oral/oesophageal candidiasis (risk ratio [RR] 18.6), generalized lymphadenopathy (RR 7.1), unexplained fever (RR 7.0), chronic diarrhoea (RR 6.2) and pulmonary tuberculosis (RR 3.1). Pulmonary tuberculosis was present in 56% of HIV cases. Mortality was 22% for HIV cases and 9% ( P=0.016) for others. The mean length of hospital stay was the same for HIV-infected and uninfected patients. AIDS is the most common reason for admission to adult medical wards and will increasingly limit the number of beds available for non-AIDS patients.