Estimation of SARS-CoV-2 Seroprevalence in Central North Carolina: Accounting for Outcome Misclassification in Complex Sample Designs.

BACKGROUND: Population-based seroprevalence studies are crucial to understand community transmission of COVID-19 and guide responses to the pandemic. Seroprevalence is typically measured from diagnostic tests with imperfect sensitivity and specificity. Failing to account for measurement error can lead to biased estimates of seroprevalence. Methods to adjust seroprevalence estimates for the sensitivity and specificity of the diagnostic test have largely focused on estimation in the context of convenience sampling. Many existing methods are inappropriate when data are collected using a complex sample design. METHODS: We present methods for seroprevalence point estimation and confidence interval construction that account for imperfect test performance for use with complex sample data. We apply these methods to data from the Chatham County COVID-19 Cohort (C4), a longitudinal seroprevalence study conducted in central North Carolina. Using simulations, we evaluate bias and confidence interval coverage for the proposed estimator compared with a standard estimator under a stratified, three-stage cluster sample design. RESULTS: We obtained estimates of seroprevalence and corresponding confidence intervals for the C4 study. SARS-CoV-2 seroprevalence increased rapidly from 10.4% in January to 95.6% in July 2021 in Chatham County, North Carolina. In simulation, the proposed estimator demonstrates desirable confidence interval coverage and minimal bias under a wide range of scenarios. CONCLUSION: We propose a straightforward method for producing valid estimates and confidence intervals when data are based on a complex sample design. The method can be applied to estimate the prevalence of other infections when estimates of test sensitivity and specificity are available.

SARS-CoV-2 infection in central North Carolina: Protocol for a population-based longitudinal cohort study and preliminary participant results.

Public health surveillance systems likely underestimate the true prevalence and incidence of SARS-CoV-2 infection due to limited access to testing and the high proportion of subclinical infections in community-based settings. This ongoing prospective, observational study aimed to generate accurate estimates of the prevalence and incidence of, and risk factors for, SARS-CoV-2 infection among residents of a central North Carolina county. From this cohort, we collected survey data and nasal swabs every two weeks and venous blood specimens every month. Nasal swabs were tested for the presence of SARS-CoV-2 virus (evidence of active infection), and serum specimens for SARS-CoV-2-specific antibodies (evidence of prior infection). As of June 23, 2021, we have enrolled a total of 153 participants from a county with an estimated 76,285 total residents. The anticipated study duration is at least 24 months, pending the evolution of the pandemic. Study data are being shared on a monthly basis with North Carolina state health authorities and future analyses aim to compare study data to state-wide metrics over time. Overall, the use of a probability-based sampling design and a well-characterized cohort will enable collection of critical data that can be used in planning and policy decisions for North Carolina and may be informative for other states with similar demographic characteristics.

HIV-Related Knowledge, Attitudes, and Behaviors among Grade 10 Girls and Boys in Mpumalanga and KwaZulu-Natal: Cross-Sectional Results.

BACKGROUND: Young people in KwaZulu-Natal and Mpumalanga South Africa are at high risk of HIV and other sexually transmitted infections. Programs are needed to reach these young people and change their knowledge, attitudes, and behaviors. OBJECTIVE: The objective of this study is to use cross-sectional data from grade 10 female and male learners in randomly assigned intervention and control schools to examine knowledge, attitudes, and sexual behaviors. METHODS: Participants were in grade 10 in the 2018 school year and were attending schools randomly assigned to the intervention and control arms for implementation of the Department of Basic Education's adapted life orientation curriculum that included scripted lesson plans. The study took place in two high HIV prevalence provinces in South Africa. Participants completed self-administered tablet-based surveys and female participants provided a dried blood spot for HIV testing. RESULTS: Results demonstrate that two-fifths to one-half of male learners reported being sexually experienced and a quarter (KwaZulu-Natal) to a third (Mpumalanga) of the female learners reported the same. A greater percentage of learners in Mpumalanga reported consistent condom use than learners in KwaZulu-Natal. HIV prevalence among female grade 10 learners in both provinces was about 6-7%. No notable differences are observed between intervention and control school learners on the knowledge, attitudes, and behavior outcomes. CONCLUSION: The findings demonstrate the importance of developing HIV prevention programs for young people in high HIV prevalence provinces since these young people remain at high risk for HIV and other negative outcomes. TRIAL REGISTRATION: This study has been registered at ClinicalTrials.gov. The trial registration number is: NCT04205721. The trial was retrospectively registered on December 18, 2019.

Impact evaluation of scripted lesson plans for HIV-related content in a life orientation curriculum: results from two provinces in South Africa.

BACKGROUND: Young people under age 25 years are a key population at risk of unintended pregnancies, HIV and other sexually transmitted infections. School-based programming, focusing on youth under 17 years is strategic given that many in this age group are in school or are required to be in school and spend a considerable amount of their time at school. Prior evaluations of school-based HIV prevention programs for young people often employed weak study designs or lacked biomarkers (e.g., HIV or STI testing) to inform outcomes. METHODS: This study used longitudinal data collected in 2016 from a cohort of grade-8 girls from Mpumalanga and KwaZulu-Natal Provinces in South Africa. We followed them for 2 years to examine the impact of the South African Department of Basic Education's revised scripted lesson plans for the HIV and sexual content of a "life orientation" curriculum on knowledge, attitudes, condom use behaviors, pregnancy incidence, and genital herpes incidence. Schools were randomized to intervention and control arms. Multivariable analyses were undertaken using hazard modeling for incidence-based outcomes (genital herpes and pregnancy) and generalized linear latent and mixed modeling for outcomes measured at each time period (knowledge, attitudes, and condom use). RESULTS: At end line, 105 schools were included from the two provinces (44 from Mpumalanga and 61 from KwaZulu-Natal). Fifty-five were intervention and fifty were control schools. A total of 2802 girls were surveyed at both time periods (1477 intervention and 1325 control). At baseline, participating girls were about 13.6 years; by end line, they were about 2 years older. Longitudinal data demonstrated few differences between intervention and control groups on knowledge, attitudes, condom use, genital herpes, and pregnancy experience. Monitoring data demonstrated that the program was not implemented as intended. Our results demonstrated 7% incidence of genital herpes in the two-year follow-up period indicating sexual risk-taking among our cohort. CONCLUSIONS: We did not find significant effects of the revised life orientation curriculum on key outcomes; however, this may reflect poor implementation. Future HIV prevention programs for young people need to be implemented with fidelity to ensure they meet the crucial needs of the next generation. TRIAL REGISTRATION: This study has been registered at ClinicalTrials.gov . The trial registration number is: NCT04205721 . The trial was retrospectively registered on December 18, 2019.

Improving Referrals for HIV Care Through Organizational Network Analysis.

CONTEXT: The link between testing for HIV and obtaining antiretroviral therapy (ART) is central to the HIV/AIDS control strategies of UNAIDS (the "90-90-90" goals) and the International Association of Providers of AIDS Care ("Test and Start"). To ensure that 90% of those diagnosed with HIV/AIDS begin ART and 90% of those on ART achieve viral suppression, service providers not providing all services need to refer patients to other organizations. SETTING: Homa Bay, Kenya. OBJECTIVE: Homa Bay county's HIV/AIDS prevalence is one of the country's highest. We identified the organizations providing some aspect of HIV/AIDS care and investigated ways in which they work together, or do not, to cover the comprehensive needs of those they serve. DESIGN AND PARTICIPANTS: We identified 56 organizations and interviewed a representative from each about his or her organization's services and its connections with the other 55, with particular interest in referrals from sites that test for HIV but do not treat infections to sites that do treat infections. MAIN OUTCOME MEASURE: Referral connections. RESULTS: Referral connections among the 56 in the past 30 days were relatively rare, averaging fewer than 2; 13 organizations made no referrals at all. Notably, 5 facilities that test for HIV did not refer their clients to an ART provider. We found 2 distinct clusters of connected organizations: one in Homa Bay Township and the other in Rangwe subcounty. When we convened the organizations and presented our results to them, they expressed interest in establishing better connections and referrals. CONCLUSIONS: Homa Bay has an opportunity to improve care for people with HIV/AIDS, in particular ensuring that those testing positive receive treatment, simply by making better use of the services already available. This can be achieved by informing each organization of the services provided by each of the others and by bringing the organizations together to plan and monitor the services' coordination. These steps could be implemented separately in each of the 2 organizational clusters.

The MomConnect helpdesk: how an interactive mobile messaging programme is used by mothers in South Africa.

South Africa's MomConnect mobile messaging programme, which aims to promote safe motherhood and improve pregnancy outcomes for South African women, includes a helpdesk feature which allows women registered on the system to ask maternal and child health (MCH)-related questions and to provide feedback on health services received at public health clinics. Messages sent to the helpdesk are answered by staff located at the National Department of Health. We examined event data from the MomConnect helpdesk database to identify any patterns in messages received, such as correlation of frequency or types of messages with location. We also explored what these data could tell us about the helpdesk's effectiveness in improving health service delivery at public health clinics. We found that approximately 8% of registered MomConnect users used the helpdesk, and that usage was generally proportional to the use of antenatal care (ANC) services in provinces (as indicated by number of ANC first visits and number of MomConnect registrations), except in two provinces. Language, category and key topics of helpdesk messages were correlated with provinces. Most users accessed the helpdesk to seek maternal information, and where feedback about health services was provided, there were significantly more compliments than complaints. The MomConnect helpdesk is an important resource providing expectant mothers and mothers of infants with an interactive option for accessing MCH-related information-above that included in the standard MomConnect messages-and advances achievement of the health goals of the MomConnect programme.

Methodology and Baseline Results From the Evaluation of a Sexuality Education Activity in Mpumalanga and KwaZulu-Natal, South Africa.

In South Africa, adolescents and young adults (ages 15-24) are at risk of HIV, sexually transmitted infections, and unintended pregnancies. Recently, the Department of Basic Education has revised its sexuality education content and teaching strategies (using scripted lessons plans) as part of its life orientation curriculum. This paper presents the methodology and baseline results from the evaluation of the scripted lesson plans and supporting activities. A rigorous cluster-level randomized design with random assignment of schools as clusters is used for the evaluation. Baseline results from grade 8 female and male learners and grade 10 female learners demonstrate that learners are at risk of HIV and early and unintended pregnancies. Multivariable analyses demonstrate that household-level food insecurity and living with an HIV-positive person are associated with sexual experience and pregnancy experience. Implications are discussed for strengthening the current life orientation program for future scale-up by the government of South Africa.

Achieving sustainability in health information systems: a field tested measure of country ownership.

BACKGROUND: A country will trust, value, and use, its health information system (HIS) to the extent it has had a role in its creation and maintenance. A sense of ownership contributes in turn to the long-term sustainability of the HIS, and thus the country's ability to monitor and evaluate population health and health services. To facilitate progress toward greater ownership, we developed and tested a tool to measure the country's ownership of its monitoring and evaluation (M&E) system. METHODS: Through a systematic review of the literature, we identified four dimensions of country ownership of an M&E system: partnership, commitment and responsibility, capacity, and accountability. We identified relevant indicators of the dimensions already in use in other tools used to assess M&E systems. We tested the data collection tool with 95 stakeholders of the Tanzanian HIS for HIV/AIDS control. RESULTS: We identified 56 items that addressed elements of the four dimensions. The respondents found our tool for assessing country ownership of an HIS to be clear and relevant, leading to the identification of important issues to be discussed. For example, all stakeholder groups affirmed that the Tanzanian Commission for AIDS is "playing a leadership role in addressing HIV through collaborative partnerships and work across borders to achieve greater impact." While many respondents disagreed with the statement, "There is an adequate number of government monitoring and evaluation posts at the sub-national level." CONCLUSIONS: Stakeholders found the M&E country ownership tool to address relevant questions clearly. It enabled them to identify successes and challenges within four dimensions of country ownership. It thus holds the potential to lead to an agenda for strengthening country ownership. If implemented every few years, the tool can provide a means of monitoring progress through a set of standardized indicators. As country ownership of M&E increases, so will the long-term sustainability of the HIS.