Integrating 'undetectable equals untransmittable' into HIV counselling in South Africa: the development of locally acceptable communication tools using intervention mapping.

BACKGROUND: The global campaign for "Undetectable equals Untransmittable" (U = U) seeks to spread awareness of HIV treatment as prevention, aiming to enhance psychological well-being and diminish stigma. Despite its potential benefits, U = U faces challenges in Sub-Saharan Africa, with low awareness and hesitancy to endorse it. We sought to develop a U = U communications intervention to support HIV counselling in primary healthcare settings in South Africa. METHODS: We used Intervention Mapping (IM), a theory-based framework to develop the "Undetectable and You" intervention for the South African context. The six steps of the IM protocol were systematically applied to develop the intervention including a needs assessment consisting of a systematic review and qualitative research including focus group discussions (FGD) and key informant (KI) interviews. Program objectives and target population were determined before designing the intervention components and implementation plan. RESULTS: The needs assessment indicated low global U = U awareness, especially in Africa, and scepticism about its effectiveness. Lay counsellors and clinic managers stressed the need for a simple and standardized presentation of U = U addressing both patients' needs for encouragement and modelling of U = U success but also clear guidance toward ART adherence behaviour. Findings from each step of the process informed successive steps. Our final intervention consisted of personal testimonials of PLHIV role models and their partners, organized as an App to deliver U = U information to patients in primary healthcare settings. CONCLUSIONS: We outline an intervention development strategy, currently in evaluation stage, utilizing IM with formative research and input from key U = U stakeholders and people living with HIV (PLHIV).

Assessment of facility-based tuberculosis data quality in an integrated HIV/TB database in three South African districts.

BACKGROUND: Assessment of data quality is essential to successful monitoring & evaluation of tuberculosis (TB) services. South Africa uses the Three Interlinked Electronic Register (TIER.Net) to monitor TB diagnoses and treatment outcomes. We assessed the quality of routine programmatic data as captured in TIER.Net. METHODS: We reviewed 277 records from routine data collected for adults who had started TB treatment for drug-sensitive (DS-) TB between 10/2018-12/2019 from 15 facilities across three South African districts using three sources and three approaches to link these (i.e., two approaches compared TIER.NET with the TB Treatment Record while the third approach compared all three sources of TB data: the TB treatment record or patient medical file; the TB Identification Register; and the TB module in TIER.Net). We report agreement and completeness of demographic information and key TB-related variables across all three data sources. RESULTS: In our first approach we selected 150 patient records from TIER.Net and found all but one corresponding TB Treatment Record (99%). In our second approach we were also able to find a corresponding TIER.Net record from a starting point of the paper-based, TB Treatment Record for 73/75 (97%) records. We found fewer records 55/75 (73%) in TIER.Net when we used as a starting point records from the TB Identification Register. Demographic information (name, surname, date of birth, and gender) was accurately reported across all three data sources (matching 90% or more). The reporting of key TB-related variables was similar across both the TB Treatment Record and the TB module in TIER.Net (p>0.05). We observed differences in completeness and moderate agreement (Kappa 0.41-0.60) for site of disease, TB treatment outcome and smear microscopy or X-ray as a diagnostic test (p<0.05). We observed more missing items for the TB Treatment record compared to TIER.Net; TB treatment outcome date and site of disease specifically. In comparison, TB treatment start dates as well as HIV-status recording had higher concordance. HIV status and lab results appeared to be more complete in the TB module in TIER.Net than in the TB Treatment Records, and there was "good/substantial" agreement (Kappa 0.61-0.80) for HIV status. DISCUSSION AND CONCLUSION: Our key finding was that the TB Module in TIER.Net was more complete in some key variables including TB treatment outcome. Most TB patient records we reviewed were found on TIER.Net but there was a noticeable gap of TB Identification patient records from the paper register as compared to TIER.Net, including those who tested TB-negative or HIV-negative. There is evidence of complete and "good/substantial" data quality for key TB-related variables, such as "First GeneXpert test result" and "HIV status." Improvements in data completeness of TIER.Net compared to the TB Treatment Record are the most urgent area for improvement, especially recording of TB treatment outcomes.

Role of data from cost and other economic analyses in healthcare decision-making for HIV, TB and sexual/reproductive health programmes in South Africa.

An increasing focus on the use of the results of cost analyses and other economic evaluations in health programme decision-making by governments, donors and technical support partners working in low- and middle-income countries is accompanied by recognition that this use is impeded by several factors, including the lack of skills, data and coordination between spheres of the government. We describe our experience generating economic evaluation data for human immunodeficiency virus, tuberculosis and sexual/reproductive health programmes in South Africa alongside the results of a series of in-depth interviews (IDIs) among decision-makers within the South African government and implementing organizations (data users) and producers of economic evaluations (data producers). We summarize results across (1) the process of implementing a new intervention; (2) barriers to the use of cost data and suggested solutions and (3) the transferability of experiences to the planned South African implementation of universal health coverage (UHC). Based on our experience and the IDIs, we suggest concrete steps towards the improvement of economic data use in the planning and the establishment of structures mandated under the transition to UHC. Our key recommendations include the following: (1) compile a publicly available and regularly updated in-country cost repository; (2) increase the availability of programmatic outcomes data at the aggregate level; (3) agree upon and implement a set of primary decision criteria for the adoption and funding of interventions; (4) combine the efforts of health economics institutions into a stringent system for health technology assessments and (5) improve the link between national and provincial planning and budgeting.

Women's costs for accessing comprehensive sexual and reproductive health services: findings from an observational study in Johannesburg, South Africa.

BACKGROUND: Evaluating progress towards the Sustainable Development Goal of universal access to sexual and reproductive (SRH) services requires an understanding of the health needs of individuals and what constitutes access to services. We explored women's costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income. METHODS: We conducted an observational study of women aged 18-49 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. Interviews assessed women's SRH needs (for contraception, fertility problems, menstrual problems, menopause symptoms, sexually transmitted infections (STI), experiences of intimate-partner violence (IPV), and cervical and breast cancer screening) and associated costs. We calculated average and total costs (including out-of-pocket spending, lost income, and estimated value of time spent) for women who incurred costs. We also estimated the total and average costs of meeting all SRH needs in a hypothetical "full needs met" year. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (> 10% of household income). RESULTS: Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12 months; 79.7% incurred costs for accessing care. On average, women spent $28.34 on SRH needs during the prior year. Excluding one HIV-negative woman who spent 112% of her annual income on infertility treatment, HIV-positive women spent more on average annually for SRH care than HIV-negative women. Sixty percent of women reported at least one unmet SRH need. If all participants sought care for all reported needs, their average annual cost would rise to $52.65 per woman. Only two women reported catastrophic expenditure - for managing infertility. CONCLUSIONS: SRH needs are constants throughout women's lives. Small annual costs can become large costs when considered cumulatively over time. As South Africa and other countries grapple with increasing access to SRH services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to SRH services. Literature on women's financial and economic costs for accessing comprehensive sexual and reproductive health care in low- and middle-income countries is extremely limited, and existing literature often overlooks out-of-pocket costs associated with travel, child care, and time spent accessing services. Using data from a survey of 385 women from a public HIV treatment site and two public primary health care facilities in Johannesburg, we found nearly all women reported at least on sexual and reproductive health need and more than 75% of women incurred costs related to those needs. Furthermore, more than half of women surveyed reported not accessing services for their sexual and reproductive health needs, suggesting a total annual cost of more than $50 USD, on average, to access services for all reported needs. While few women spent more than 10% of their total household income on sexual and reproductive health services in the prior year, needs are constant and costs incur throughout a woman's life suggesting accessing services to meet these needs might still result in financial burden. As South Africa grapples with increasing access to sexual and reproductive health services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to services.