Health technology assessment for sexual reproductive health and rights benefits package design in sub-Saharan Africa: A scoping review of evidence-informed deliberative processes.

BACKGROUND: Health technology assessment uses a multidisciplinary approach to support health benefits package design towards universal health coverage. The evidence-informed deliberative process framework has been used alongside Health technology assessment to enhance stakeholder participation and deliberations in health benefits package design. Applying the evidence-informed deliberative framework for Health assessment could support the morally diverse sexual reproductive health and rights (SRHR) benefits package design process. However, evidence on participation and deliberations for stakeholders in health technology assessment for SRHR benefits package design has not been curated in sub-Saharan Africa. This study synthesises literature to fill this gap. METHODS: This scoping review applies the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, and deductive analysis following the evidence-informed deliberative processes framework. The search strategy uses the Guttmacher-Lancet Commission-proposed comprehensive definition of SRHR and the World Health Organisation's universal health coverage compendium of SRHR interventions to generate search terms. Six databases and biographical hand searches were used to identify studies in Sub-Saharan Africa from 1994. RESULTS: A total of 14 studies met the inclusion criteria. Evidence for yearly public budgets and explicit SRHR health technology assessment processes was not found. In 12 of the studies reviewed, new advisory committees were set up specifically for health technology assessment for SRHR priority-setting and benefits package design. In all decision-making processes reviewed, the committee member roles, participation and deliberations processes, and stakeholder veto powers were not clearly defined. Patients, the public, and producers of health technology were often excluded in the health technology assessment for the SRHR benefits package design. Most health technology assessment processes identified at least one decision-making criterion but failed to use this in their selection and appraisal stages for SRHR benefits design. The identification, selection, and scoping stages in health technology assessment for SRHR were non-existent in most studies. In 11 of the 14 processes of the included studies, stakeholders were dissatisfied with the health policy recommendation from the appraisal process in health technology assessment. Perceived benefits for evidence-informed deliberative processes included increased stakeholder engagement and fairness in decision-making. CONCLUSION: To support the integration of diverse social values in health technology assessment for fairer SRHR benefits package design, evidence from this review suggests the need to institutionalise health technology assessment, establish prioritisation decision criteria, involve all relevant stakeholders, and standardise the process and assessment methodological approaches.

Addressing COVID-19 vulnerabilities: How do we achieve global health security in an inequitable world.

The spread of the serve acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, [WHO. (2019). Naming the coronavirus disease (COVID-19) and the virus that causes it. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it] and is responsible for the COVID-19 pandemic is another in a long line of Coronavirus outbreak - and unlikely to be the last. More than a year into the pandemic, SARS-CoV-2 has exposed the dangerous hollowness of a global commitment to global health security. Global health security (GHS) has no uncontested definition, and despite ample pandemic warnings (HIV, H1N1, SARS, MERS-CoV, Ebola, Zika) the world, remains woefully unprepared for an adequate pandemic response; its lack of preparation the predicable result of inattention to equity and with it global health security. The first section of this paper lays out the particular challenges of COVID-19 for less well-resourced countries. The second part discusses the inequities being perpetuated and accentuated in the development and distribution of COVID-19 vaccines. The third section discusses ways to address these global inequities and its related complexities. We conclude by restating some of the key priorities for achieving GHS.

Evaluating DREAMS HIV prevention interventions targeting adolescent girls and young women in high HIV prevalence districts in South Africa: protocol for a cross-sectional study.

BACKGROUND: Young women in sub-Saharan Africa remain at the epicentre of the HIV epidemic, with surveillance data indicating persistent high levels of HIV incidence. In South Africa, adolescent girls and young women (AGYW) account for a quarter of all new HIV infections. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is a strategy introduced by the United States President's Emergency Plan for AIDS Relief (PEPFAR) aimed at reducing HIV incidence among AGYW in 10 countries in sub-Saharan Africa by 25% in the programme's first year, and by 40% in the second year. This study will assess the change in HIV incidence and reduction in risk associated behaviours that can be attributed to the DREAMS initiative in South Africa, using a population-based cross-sectional survey. METHODS: Data will be collected from a household-based representative sample of AGYW (between the ages 12-24 years) in four high prevalence districts (more than 10% of the population have HIV in these districts) in South Africa in which DREAMS has been implemented. A stratified cluster-based sampling approach will be used to select eligible participants for a cross-sectional survey with 18,500, to be conducted over 2017/2018. A questionnaire will be administered containing questions on sexual risk behaviour, selected academic and developmental milestones, prevalence of gender based violence, whilst examining exposure to DREAMS programmes. Biological samples, including two micro-containers of blood and self-collected vulvovaginal swab samples, are collected in each survey to test for HIV infection, HIV incidence, sexually transmitted infections (STIs) and pregnancy. This study will measure trends in population level HIV incidence using the Limiting antigen (LAg) Avidity Enzyme Immuno-Assay (EIA) and monitor changes in HIV incidence. DISCUSSION: Ending the HIV/AIDS pandemic by 2030 requires the continual monitoring and evaluation of prevention programmes, with the aim of optimising efforts and ensuring the achievement of epidemic control. This study will determine the impact DREAMS interventions have had on HIV incidence among AGYW in a 'real world, non-trial setting'.

Impact of HIV testing and treatment services on risky sexual behaviour in the uMgungundlovu District, KwaZulu-Natal, South Africa: a cross-sectional study.

INTRODUCTION: The South African public health system plays an important role in the delivery of HIV testing and treatment services. The health system is also an important conduit for targeted behaviour change communication with the expectation that clients who undergo counselling from health personnel, adopt safer sexual practices. Literature remains mixed on the impact these HIV services have on risky sexual behaviour. This analysis examines the sexual behaviour of clients following the utilisation of HIV testing and treatment services in Kwazulu-Natal, South Africa. METHODS: Data were used from two consecutive cross-sectional household surveys undertaken from June 2014 to June 2015 (2014/2015 survey) and from July 2015 to June 2016 (2015/2016 survey) in the uMgungundlovu District of KwaZulu-Natal, South Africa. Collectively, 20,048 randomly selected individuals aged 15 to 49 years old were interviewed across the two surveys. Utilisation of HIV testing and treatment services were used as independent variables and three sexual risk behaviours were used as dependent variables. Multiple regression models assessed the impact HIV testing and treatment services had on sexual risk behaviour while controlling for socio-demographic characteristics. RESULTS: Having tested for HIV had no association with any of the three sexual risk behaviours. However, receiving an HIV positive diagnosis reduced the likelihood of using condoms inconsistently with the respondents' most recent partner (AOR: 0.64; 95% CI 0.54-0.77). Antiretroviral use was negatively associated with inconsistent condom use (AOR: 0.45; 95% CI 0.35-0.58) and number of sexual partners in the previous year (AOR: 0.61; 95% CI 0.46-0.81). CONCLUSIONS: Results indicate that HIV testing and treatment services and the assumed exposure of clients to behaviour change communication, had a limited effect in reducing risky sexual behaviour. Data suggests that the engagement between health personnel and individuals accessing HIV testing and treatment services does not necessarily translate into the adoption of safer sexual practices, with the exception of individuals testing positive for HIV and those on ARV treatment, who had adopted safer sexual practices.

Greater risk for more money: the economics of negotiating condom use amongst sex workers in South Africa.

ABSTRACT The economics of sex work and the effect on safe sex practices remain understudied. This research contributes to a better understanding of how economic opportunity and vulnerability place sex workers (SWs) at an increased risk of STI infection. Using quantitative and qualitative methods, we investigated the role of economic incentives in determining condom use among SWs. The data reveals that SWs are on average, nearly doubling their rates for condomless sex. Our findings that SWs are engaging in condomless sex to increase their earnings, illustrates the point that the context in which they operate influences condom negotiation and consequently, increases risky sexual behaviour.

A Randomized Controlled Trial to Increase HIV Testing Demand Among Female Sex Workers in Kenya Through Announcing the Availability of HIV Self-testing Via Text Message.

We assessed whether informing female sex workers about the availability of HIV self-testing at clinics in Kenya using text messages would increase HIV testing rates. We selected a sample of 2196 female sex workers registered in an electronic health record system who were irregular HIV testers and randomized them to be sent a text message announcing the availability of (1) HIV self-test kits sent three times (intervention), (2) general HIV testing sent three times (enhanced standard of care [SOC]), or (3) general HIV testing sent one time (traditional SOC). Participants in the intervention arm were significantly more likely to test for HIV during 2-month follow-up compared to those in the enhanced SOC (OR 1.9, p = 0.001). There was no difference in HIV testing between those in the enhanced SOC and the traditional SOC arms. Announcing the availability of HIV self-testing via text message increased HIV testing among this high-risk group.

Costing analysis of an SMS-based intervention to promote HIV self-testing amongst truckers and sex workers in Kenya.

OBJECTIVE: HIV testing rates in many sub-Saharan African countries have remained suboptimal, and there is an urgent need to explore strategic yet cost-effective approaches to increase the uptake of HIV testing, especially among high-risk populations. METHODS: A costing analysis was conducted for a randomized controlled trial (RCT) with male truckers and female sex workers (FSWs) registered in the electronic health record system (EHRS) of the North Star Alliance, which offers healthcare services at major transit hubs in Southern and East Africa. The RCT selected a sample of truckers and FSWs who were irregular HIV testers, according to the EHRS, and evaluated the effect of SMSs promoting the availability of HIV self-testing (HIVST) kits in Kenyan clinics (intervention program) versus a general SMS reminding clients to test for HIV (enhanced and standard program) on HIV testing rates. In this paper, we calculated costs from a provider perspective using a mixed-methods approach to identify, measure, and value the resources utilized within the intervention and standard programs. The results of the analysis reflect the cost per client tested. RESULTS: The cost of offering HIVST was calculated to be double that of routine facility-based testing (USD 10.13 versus USD 5.01 per client tested), primarily due to the high price of the self-test kit. In the two study arms that only offered provider-administered HIV testing in the clinic, only 1% of truckers and 6% of FSWs tested during the study period, while in the intervention arm, which also offered HST, approximately 4% of truckers and 11% of FSWs tested. These lower than expected outcomes resulted in relatively high cost per client estimates for all three study arms. Within the intervention arm, 65% of truckers and 72% of FSWs who tested chose the HIVST option. However, within the intervention arm, the cost per additional client tested was lower for FSWs than for truckers, at USD 0.15 per additional client tested versus USD 0.58 per additional client tested, driven primarily by the higher response rates. CONCLUSION: Whilst the availability of HIVST increased HIV testing among both truckers and FSWs, the cost of providing HIVST is higher than that of a routine health facility-based test, driven primarily by the price of the HIV self-test kit. Future research needs to identify strategies which increase demand for HIVST, and determine whether these strategies and the subsequent increased demand for HIVST are cost-effective in relation to the conventional facility based testing currently available.

Psychosocial characteristics of primary care-seeking long-distance truck drivers in Kenya and associations with HIV testing.

The 90-90-90 strategy from the Joint United Nations Programme on HIV/AIDS (UNAIDS) to end the AIDS epidemic by 2020 includes, as its first goal, to have 90% of all people living with HIV to know their status. Achieving this goal will depend on effectively reaching high risk populations, which include mobile populations such as truck drivers. This study aimed to characterise a sample of 305 truck drivers recruited from 2 roadside wellness clinics in Kenya in terms of anticipated HIV stigma, self-efficacy, fatalism, gender equity, sensation seeking, and self-esteem, and then determine the association of these psychosocial characteristics with HIV testing behaviour. Greater general self-efficacy was associated with higher income and more years working as a truck driver. Greater fatalism was associated with non-Christian religion, being married, and having a lower income. Greater gender equity was associated with completing high school, being married, and having higher income. Greater sensation seeking was associated with lower income and fewer years employed as a truck driver. In multivariable logistic regression adjusted for demographic variables, anticipated HIV stigma was negatively associated with having ever tested for HIV (adjusted odds ratio [aOR] = 0.79; 95% confidence interval [CI] = 0.63-0.98; p = 0.034) and self-esteem was positively associated with testing (aOR = 1.06; 95% CI = 1.00-1.12; p = 0.038). Associations with HIV testing behaviour were not significant for self-efficacy, fatalism, gender equity, or sensation seeking. Public health interventions aiming to reduce anticipated stigma and increase self-esteem may potentially increase the uptake of HIV testing among truck drivers. Further research is needed to better understand the influence of these psychosocial characteristics on HIV testing.

Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa.

Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with "care" and "capability" among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.

Barriers and facilitators to the uptake of voluntary medical male circumcision (VMMC) among adolescent boys in KwaZulu-Natal, South Africa.

Epidemiological modelling has concluded that if voluntary medical male circumcision (VMMC) is scaled up in high HIV prevalence settings it would lead to a significant reduction in HIV incidence rates. Following the adoption of this evidence by the WHO, South Africa has embarked on an ambitious VMMC programme. However, South Africa still falls short of meeting VMMC targets, particularly in KwaZulu-Natal, the epicentre of the HIV/AIDS epidemic. A qualitative study was conducted in a high HIV prevalence district in KwaZulu-Natal to identify barriers and facilitators to the uptake of VMMC amongst adolescent boys. Focus group discussions with both circumcised and uncircumcised boys were conducted in 2012 and 2013. Analysis of the data was done using the framework approach and was guided by the Social Cognitive Theory focussing on both individual and interpersonal factors influencing VMMC uptake. Individual cognitive factors facilitating uptake included the belief that VMMC reduced the risk of HIV infection, led to better hygiene and improvement in sexual desirability and performance. Cognitive barriers related to the fear of HIV testing (and the subsequent result and stigmas), which preceded VMMC. Further barriers related to the pain associated with the procedure and adverse events. The need to abstain from sex during the six-week healing period was a further prohibiting factor for boys. Timing was crucial, as boys were reluctant to get circumcised when involved in sporting activities and during exam periods. Targeting adolescents for VMMC is successful when coupled with the correct messaging. Service providers need to take heed that demand creation activities need to focus on the benefits of VMMC for HIV risk reduction, as well as other non-HIV benefits. Timing of VMMC interventions needs to be considered when targeting school-going boys.

Weighing up the burden of care on caregivers of orphan children: the Amajuba District Child Health and Wellbeing Project, South Africa.

This paper assesses the burden on orphan caregivers relative to non-orphan caregivers in the context of high HIV/AIDS mortality in South Africa. It presents findings from the third round of a study conducted in the Amajuba District of KwaZulu-Natal between 2003 and 2007. Significant differences were found between orphan and non-orphan caregivers; the former being more likely to care for more children, have poorer health, higher levels of chronic illness, less adult help and they appeared to have more daily responsibilities. Orphan caregivers were also more likely to indicate that children in their care needed help for mental or behavioural problems but overall results showed that only 3.4% of all households had contact with child welfare agencies. The findings question assumptions about the capacity and capability of the extended family to absorb shocks to individuals and families.