Social Disequilibrium and the Risk of HIV Acquisition: A Multilevel Study in Rural KwaZulu-Natal Province, South Africa

BACKGROUND

Few population-based multilevel studies have quantified the risks that social context poses in rural communities with high HIV incidence across South Africa. We investigated the individual, social, and community challenges to HIV acquisition risk in areas with high and low incidence of HIV infection (hotspots/coldspots).

METHODS

The cohort (N = 17,376) included all HIV-negative adults enrolled in a population-based HIV surveillance study from 2004 to 2015 in a rural South African community with large labor migrancy. Multilevel survival models were fitted to examine the social determinants (ie, neighborhood migration intensity), community traits (ie, HIV prevalence), and individual determinants of HIV acquisition risk in identified hotspots/coldspots.

RESULTS

The HIV acquisition risk (adjusted hazard ratio [aHR] = 1.05, 95% confidence interval [CI]: 1.01 to 1.09) was greater in hotspots with higher neighborhood migration intensity among men. In women, higher neighborhood migration intensity (aHR = 1.02, 95% CI: 1.01 to 1.02) was associated with a greater HIV acquisition risk, irrespective of whether they lived in hotspot/coldspot communities. HIV acquisition risk was greater in communities with a higher prevalence of HIV in both men (aHR = 1.07, 95% CI: 1.03 to 1.12) and women (aHR = 1.03, 95% CI: 1.01 to 1.05), irrespective of hotspot/coldspot locations.

CONCLUSION

HIV acquisition risk was strongly influenced by gender (ie, young women), behavior (ie, sexual debut, contraception, circumcision), and social determinants. Certain challenges (ie, community disease prevalence) for HIV acquisition risk impacted both sexes, regardless of residence in hotspot/coldspot communities, whereas social determinants (ie, neighborhood migration intensity) were pronounced in hotspots among men. Future intervention scale-up requires addressing the social context that contributes to HIV acquisition risk in rural areas with high migration.

Immunisation coverage in the rural Eastern Cape - are we getting the basics of primary care right? Results from a longitudinal prospective cohort study

BACKGROUND

Immunisations are one of the most cost-effective public health interventions available and South Africa (SA) has implemented a comprehensive immunisation schedule. However, there is disagreement about the level of immunisation coverage in the country and few studies document the immunisation coverage in rural areas.

OBJECTIVE

To examine the successful and timely delivery of immunisations to children during the first 2 years of life in a deeply rural part of the Eastern Cape Province of SA.

METHODS

From January to April 2013, a cohort of sequential births (N=470) in the area surrounding Zithulele Hospital in the OR Tambo District of the Eastern Cape was recruited and followed up at home at 3, 6, 9, 12 and 24 months post birth, up to May 2015. Immunisation coverage was determined using Road-to-Health cards.

RESULTS

The percentages of children with all immunisations up to date at the time of interview were: 48.6% at 3 months, 73.3% at 6 months, 83.9% at 9 months, 73.3% at 12 months and 73.2% at 24 months. Incomplete immunisations were attributed to stock-outs (56%), lack of awareness of the immunisation schedule or of missed immunisations by the mother (16%) and lack of clinic attendance by the mother (19%). Of the mothers who had visited the clinic for baby immunisations, 49.8% had to make multiple visits because of stock-outs. Measles coverage (of at least one dose) was 85.2% at 1 year and 96.3% by 2 years, but 20.6% of babies had not received a second measles dose (due at 18 months) by 2 years. Immunisations were often given late, particularly the 14-week immunisations.

CONCLUSIONS

Immunisation rates in the rural Eastern Cape are well below government targets and indicate inadequate provision of basic primary care. Stock-outs of basic childhood immunisations are common and are, according to mothers, the main reason for their children's immunisations not being up to date. There is still much work to be done to ensure that the basics of disease prevention are being delivered at rural clinics in the Eastern Cape, despite attempts to re-engineer primary healthcare in SA.

Trends in HIV Prevalence in Pregnant Women in Rural South Africa

BACKGROUND

Despite substantial progress in the delivery of HIV prevention programs, some communities continue to experience high rates of HIV infection. We report on temporal trends in HIV prevalence in pregnant women in a community in rural KwaZulu-Natal in South Africa.

METHODS

Annual, anonymous cross-sectional HIV sero-prevalence surveys were conducted between 2001 and 2013 among first visit prenatal clinic attendees. The time periods 2001 to 2003 were defined as pre-antiretroviral therapy (ART), 2004 to 2008 as early ART, and 2009 to 2013 as contemporary ART roll-out, to correspond with the substantial scale-up of ART program.

RESULTS

Overall, HIV prevalence rose from 35.3% [95% confidence interval (CI): 32.3 to 38.3] pre-ART (2001-2003) to 39.0% (95% CI: 36.8 to 41.1) in the early ART (2004-2008) to 39.3% (95% CI: 37.2 to 41.4) in the contemporary ART (2009-2013) roll-out periods. In teenage women (<20 years), HIV prevalence declined from 22.5% (95% CI: 17.5 to 27.5) to 20.7% (95% CI: 17.5 to 23.8) and to 17.2% (95% CI: 14.3 to 20.2) over the similar ART roll-out periods (P = 0.046). Prevalence increased significantly in women 30 years and older (P < 0.001) over the same time period largely because of survival after ART scale up. Teenage girls with male partners of age 20-24 and ≥ 25 years had a 1.7-fold (95% CI: 1.3-2.4; P = 0.001) and 3-fold (95% CI: 2.1 to 4.3; P < 0.001) higher HIV prevalence respectively.

CONCLUSIONS

Notwithstanding the encouraging decline in teenagers, the ongoing high HIV prevalence in pregnant women in this rural community, despite prevention and treatment programs, is deeply concerning. Targeted interventions for teenagers, especially for those in age-disparate relationships, are needed to impact this HIV epidemic trajectory.

HIV-positive status disclosure in patients in care in rural South Africa: implications for scaling up treatment and prevention interventions

A nuanced understanding of HIV-positive status disclosure is urgently needed to inform the implementation of prevention interventions, including TasP and PrEP. To provide such understanding for the high HIV-burden setting of rural KwaZulu-Natal, we conducted a prospective cohort study to characterize determinants and trends in HIV-positive status disclosure. 687 consenting HIV-positive individuals (73.2 % female; 60.3 % ART initiated) were enrolled. Reports of any incidence of disclosure to either a family member or sexual partner at enrollment and follow-up visits (median 4.4 months post-enrolment) were common (91.0 %); however, reports of disclosure specifically to sexual partners were relatively rare (34.1 %), especially in women (29.8 %). Participants not engaged in a stable partnerships, not ART-imitated, and/or who had disclosed to their family were at risk of non-disclosure to sexual partners. These data highlight both an urgent need to empower HIV-positive individuals, and the significant barriers to targeting sero-discordant couples for HIV prevention in this setting.

"It's my secret": barriers to paediatric HIV treatment in a poor rural South African setting

In South Africa, a third of children born are exposed to HIV, while fewer undergo an HIV confirmatory test. Anti-retroviral therapy (ART) coverage among children remains low-despite roll-out of the national ART programme in South Africa in 2004. This study sought to understand critical barriers to seeking HIV-related care for children in rural South Africa. Data presented in this article derive from community-based qualitative research in poor rural villages in north-east South Africa; this includes 21 in-depth interviews in 2008 among caregivers of children identified as HIV-positive in 2007 from a randomly selected community-based sample. Using NVIVO 8, data were coded and analysed, using a constant comparative method to identify themes and their repetitions and variations. Structural barriers leading to poor access to health care, and social and systems barriers, all influenced paediatric HIV treatment seeking. Of concern was the expressed need to maintain secrecy regarding a child's HIV status to avoid stigma and discrimination, and misconceptions regarding the course of HIV disease in children; this led to a delay in seeking appropriate care. These barriers need to be addressed, including through focused awareness campaigns, improved access to health care and interventions to address rural poverty and development at both household and community levels. In addition, training of health care professionals to improve their attitudes and practice may be necessary. However, this study only provides the perspective of the caregivers; further studies with health care providers are needed to gain a fuller picture for appropriate policy and practice guidance.