The HIV care continuum for sexually active transgender women in three metropolitan municipalities in South Africa: findings from a biobehavioural survey 2018-19

BACKGROUND

Despite high HIV prevalence in transgender women in sub-Saharan Africa, to our knowledge no study presents data across the HIV care continuum for this population in the region. The aim of this study was to estimate HIV prevalence and present data to develop the HIV care continuum indicators for transgender women in three South African metropolitan municipalities.

METHODS

Biobehavioural survey data were collected among sexually active transgender women in the metropolitan municipalities of Johannesburg, Buffalo City, and Cape Town, South Africa. Transgender women (aged ≥18 years, self-reporting consensual sex with a man in the 6 months before the survey) were recruited using respondent-driven sampling (RDS). An interviewer-administered questionnaire was used to determine awareness of HIV status; blood specimens were collected on dried blood spots to test for HIV antibodies, antiretroviral treatment (ART) exposure, and viral load suppression. Population-based estimates of HIV 95-95-95 cascade indicators were derived by use of individualised RDS weights with RDS Analyst software. Multivariate stepwise backward logistic regression modelling was used to determine factors associated with each cascade indicator. All eligible participants were included in the final analysis.

FINDINGS

Between July 26, 2018, and March 15, 2019, we enrolled 887 sexually active transgender women: 323 in Johannesburg, 305 in Buffalo City, and 259 in Cape Town. HIV prevalence was highest in Johannesburg where 229 (74·1%) of 309 tests were positive (weighted prevalence estimate 63·3%, 95% CI 55·5-70·5), followed by Buffalo City where 121 (43·7%) of 277 were positive (46·1%, 38·7-53·6), and then Cape Town where 122 (48·4%) of 252 were positive (45·6%, 36·7-54·7). In Johannesburg, an estimated 54·2% (95% CI 45·8-62·4) of transgender women with HIV knew their positive status, in Cape Town this was 24·2% (15·4-35·8), and in Buffalo City this was 39·5% (27·1-53·4). Among those who knew their status, 82·1% (73·3-88·5) in Johannesburg, 78·2% (57·9-90·3) in Cape Town, and 64·7% (45·2-80·2) in Buffalo City were on ART. Of those on ART, 34·4% (27·2-42·4) in Johannesburg, 41·2% (30·7-52·6) in Cape Town, and 55·0% (40·7-68·4) in Buffalo City were virally suppressed.

INTERPRETATION

Innovative strategies are needed to inform efforts to diagnose and to treat transgender women living with HIV promptly to achieve viral load suppression. Differentiated HIV services tailored to transgender women of race groups other than Black South African, and those with low education attainment and low outreach exposure, innovative testing, and adherence strategies should be developed to improve the HIV cascade for South African transgender women.

FUNDING

The US President's Emergency Plan For AIDS Relief and US Centers for Disease Control and Prevention.

Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It?

This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.

Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review

OBJECTIVES

Low-and-middle-income countries (LMICs) bear a disproportionate burden of cervical cancer mortality. We aimed to identify what is currently known about barriers to cervical cancer screening among women in LMICs and propose remedial actions.

DESIGN

This was a systematic review using Medical Subject Headings (MeSH) terms in Google Scholar, PubMed, Scopus, and Web of Science databases. We also contacted medical associations and universities for grey literature and checked reference lists of eligible articles for relevant literature published in English between 2010 and 2020. We summarized the findings using a descriptive narrative based on themes identified as levels of the social ecological model.

SETTING

We included studies conducted in LMICs published in English between 2010 and 2020.

PARTICIPANTS

We included studies that reported on barriers to cervical cancer screening among women 15 years and older, eligible for cervical cancer screening.

RESULTS

Seventy-nine articles met the inclusion criteria. We identified individual, cultural/traditional and religious, societal, health system, and structural barriers to screening. Lack of knowledge and awareness of cervical cancer in general and of screening were the most frequent individual level barriers. Cultural/traditional and religious barriers included prohibition of screening and unsupportive partners and families, while social barriers were largely driven by community misconceptions. Health system barriers included policy and programmatic factors, and structural barriers were related to geography, education and cost. Underlying reasons for these barriers included limited information about cervical cancer and screening as a preventive strategy, poorly resourced health systems that lacked policies or implemented them poorly, generalised limited access to health services, and gender norms that deprioritize the health needs of women.

CONCLUSION

A wide range of barriers to screening were identified across most LMICs. Urgent implementation of clear policies supported by health system capacity for implementation, community wide advocacy and information dissemination, strengthening of policies that support women's health and gender equality, and targeted further research are needed to effectively address the inequitable burden of cervical cancer in LMICs.

Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project

BACKGROUND

The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs).

METHODS

This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach.

RESULTS

46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs.

CONCLUSION

In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Screening and Brief Interventions for Alcohol and Other Drug Use Among Pregnant Women Attending Midwife Obstetric Units in Cape Town, South Africa: A Qualitative Study of the Views of Health Care Professionals

INTRODUCTION

Despite the negative consequences of alcohol and other drug use during pregnancy, few interventions for pregnant women are implemented, and little is known about their feasibility and acceptability in primary health care settings in South Africa. As part of the formative phase of screening, brief intervention, and referral to treatment for substance use among women presenting for antenatal care, the present study explored health care workers' attitudes and perceptions about screening, brief intervention, and referral to treatment among this population.

METHODS

Forty-three health care providers at 2 public sector midwife obstetric units in Cape Town, South Africa, were interviewed using an open-ended, semistructured interview schedule designed to identify factors that hinder or support the implementation of screening, brief intervention, and referral to treatment for substance use in these settings. Transcribed interviews were analyzed using the framework approach.

RESULTS

Health care providers agreed that there is a substantial need for screening, brief intervention, and referral to treatment for substance use among pregnant women and believe such services potentially could be integrated into routine care. Several women-, staff-, and clinic-level barriers were identified that could hinder the successful implementation in antenatal services. These barriers included the nondisclosure of alcohol and other drug use, the intervention being considered as an add-on service or additional work, negative staff attitudes toward implementation of an intervention, poor staff communication styles such as berating women for their behavior, lack of interest from staff, time constraints, staff shortages, overburdened workloads, and language barriers.

DISCUSSION

The utility of screening, brief intervention, and referral to treatment for addressing substance use among pregnant women in public health midwife obstetric units was supported, but consideration will need to be given to addressing a variety of barriers that have been identified.

Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries

BACKGROUND

About a third of the global HIV infections outside sub-Saharan Africa are related to injecting drug use (IDU), and this accounts for a growing proportion of persons living with HIV. This paper is a response to the need to monitor the state of the HIV epidemic as it relates to IDU and the availability of HIV treatment and harm reduction services in 21 high epidemic countries.

METHODS

A data collection form was designed to cover questions on rates of IDU, prevalence and incidence of HIV and information on HIV treatment and harm reduction services available to people who inject drugs (PWID). National and regional data on HIV infection, IDU in the form of reports and journal articles were sought from key informants in conjunction with a systematic search of the literature.

RESULTS

Completed data collection forms were received for 11 countries. Additional country-specific information was sourced via the literature search. The overall proportion of HIV positive PWID in the selected countries ranged from 3% in Kazakhstan to 58% in Vietnam. While IDU is relatively rare in sub-Saharan Africa, it is the main driver of HIV in Mauritius and Kenya, with roughly 47% and 36% of PWID respectively being HIV positive. All countries had antiretroviral treatment (ART) available to PWID, but data on service coverage were mainly missing. By the end of 2010, uptake of needle and syringe programmes (NSP) in Bangladesh, India and Slovakia reached the internationally recommended target of 200 syringes per person, while uptake in Kazakhstan, Vietnam and Tajikistan reached between 100-200 syringes per person. The proportion of PWID receiving opioid substitution therapy (OST) ranged from 0.1% in Kazakhstan to 32.8% in Mauritius, with coverage of less than 3% for most countries.

CONCLUSIONS

In order to be able to monitor the impact of HIV treatment and harm reduction services for PWID on the epidemic, epidemiological data on IDU and harm reduction service provision to PWID needs to be regularly collected using standardised indicators.

Pregnant women's responses to a tailored smoking cessation intervention: turning hopelessness into competence

BACKGROUND

Cognitive behavioral interventions consisting of brief counseling and the provision of self-help material designed for pregnancy have been documented as effective smoking cessation interventions for pregnant women. However, there is a need to understand how such interventions are perceived by the targeted group.

AIM

To understand the cognitive, emotional, and behavioral responses of pregnant women to a clinic-based smoking cessation intervention.

METHODS

In-depth interviews with women attending four antenatal clinics in Cape Town, South Africa, who were exposed to a smoking intervention delivered by midwives and peer counselors. Women were purposively selected to represent a variation in smoking behavior. Thirteen women were interviewed at their first antenatal visit and 10 were followed up and reinterviewed later in their pregnancies. A content analysis approach was used, which resulted in categories and themes describing women's experiences, thoughts, and feelings about the intervention.

RESULTS

Five women quit, five had cut down, and three could not be traced for follow-up. All informants perceived the intervention positively. Four main themes captured the intervention's role in influencing women's smoking behavior. The process started with 'understanding their reality,' which led to 'embracing change' and 'deciding to hold nothing back,' which created a basis for 'turning hopelessness into a feeling of competence.'

CONCLUSION

The intervention succeeded in shifting women from feeling pessimistic about ever quitting to feeling encouraged to try and quit. Informants rated the social support they received very highly and expressed the need for the intervention to become a routine component of clinic services.

The effectiveness of adapted, best practice guidelines for smoking cessation counseling with disadvantaged, pregnant smokers attending public sector antenatal clinics in Cape Town, South Africa

AIM AND OBJECTIVES

To evaluate the effect of a smoking cessation intervention, based on best practice guidelines on the quit rates of disadvantaged, pregnant women in Cape Town, South Africa.

DESIGN

Quasi-experimental using a natural history cohort as a control group, consisting of women attending antenatal care in 2006 and an intervention cohort, attending the same clinics a year later.

SETTING

Four, public sector antenatal clinics in Cape Town staffed and managed by midwives.

POPULATION

Pregnant women of low socio-economic status.

METHODS

The natural history cohort received usual care, whilst the intervention cohort was offered self-help quit materials in the context of brief counseling by midwives and peer counselors. Smoking behavior was measured in early, mid and late pregnancy. The equivalence of the groups in terms of smoking profile, self-reported smoking and demographic variables was assessed at baseline.

MAIN OUTCOME MEASURES

Quit rates measured by urinary cotinine towards the end of pregnancy (36-39 weeks gestation).

RESULTS

The two cohorts were comparable at baseline. The difference in quit rates between the two cohorts in late pregnancy was 5.3% (95% CI: 3.2-7.4%, p < 0.0001) in an intention to treat analysis. There was also a significant difference in reduction of smoking of 11.8% (95% CI: 5.0-18.4%, p = 0.0006).

CONCLUSION

A smoking cessation intervention based on best practice guidelines was effective among high risk, pregnant smokers in South Africa.