Health facility users' knowledge, perceptions, and practices about infant feeding in the context of option B+ in South Africa: a qualitative study.

BACKGROUND: HIV and sub-optimal infant feeding practices remain important threats to child growth, development, and survival in low- and middle-income countries. To our knowledge, few studies have explored health service users' perspective of infant feeding in the context of WHO Option B+ policy to prevent vertical HIV transmission (PMTCT). This paper is a sub-analysis of qualitative data from a mixed-methods multi-level process evaluation of Option B+ implementation in South Africa (SA). In this study we explored health facility users' infant feeding knowledge, perceptions, and practices one year after SA adopted the 2016 updated World Health Organization prevention of mother-to-child transmission of HIV Option B+ infant feeding guidelines. METHODS: Nineteen focus group discussions (FGDs) were held with six groups of men and women whose infants were aged < 6 months. Participants were attending randomly selected primary health care facilities within six purposively selected priority districts. The six groups included in the FGDs were: (i) adolescent girls and young women living with HIV (WHIV), (ii) adolescent girls and young women not living with HIV (WNHIV), (iii) older postnatal WHIV (iv) older postnatal WNHIV (v) pregnant women, and (vi) men. Data collection took place between April and December 2018. Data analysis involved coding and thematic framework analysis. RESULTS: Women and men have suboptimal knowledge of the recommended breastfeeding duration and exclusive breastfeeding, especially for HIV-exposed infants. Most women received sub-optimal infant feeding counselling and mixed messages from health care workers. Fewer WHIV initiated breastfeeding at birth compared to WNHIV. Most parents believed that HIV-exposed infants should be breastfed for 6 months and many postnatal women on antiretroviral drugs and younger mothers lacked confidence to breastfeed beyond 6 months. Mixed feeding was predominant among all women due to individual, family, and socio-structural barriers. Many men were supportive on infant feeding; however, they lacked the appropriate information and skills to influence their partners' infant feeding decisions. CONCLUSIONS: Differences in breastfeeding practices between WHIV and WNHIV are highly influenced by the lack of knowledge of infant feeding policy recommendations. Multiple-level factors deter many mothers from adhering to recommended guidelines. Appropriate ongoing infant feeding counselling and breastfeeding support are required for women and their partners.

Approaches and strategies used in the training and supervision of Health Extension Workers (HEWs) delivering integrated community case management (iCCM) of childhood illness in Ethiopia: a qualitative rapid appraisal.

BACKGROUND: Globally, preventable and treatable childhood conditions such as pneumonia, diarrhoea, malaria, malnutrition and newborn conditions still account for 75% of under-five mortality. To reduce the mortality rate from these conditions, Ethiopia launched an ambitious Health Extension Programme (HEP) in 2003. Trained Community Health Workers (CHWs), named Health Extension Workers (HEWs) were deployed to deliver a package of care which includes integrated Community Case-Management (iCCM) of common childhood diseases. OBJECTIVES: This qualitative study aimed to explore approaches and strategies used in the HEW training and supervision as part of an evaluation of the Catalytic Initiative to Save a Million Lives. METHOD: A qualitative rapid appraisal study using focus group discussions and in-depth interviews was conducted. RESULTS: Training of HEWs followed a cascaded training of trainer approach supported by implementing partners under guidance of the Ministry of Health. A comprehensive planning phase enabled good coverage of districts and consistency in training approaches. Training was complemented by on-going supportive supervision. HEW motivation was enhanced through regular review meetings and opportunities for career progression. CONCLUSION: These findings describe a thorough approach to training and supervision of HEWs delivering iCCM in rural Ethiopia. Ongoing investments by partners will be critical for long-term sustainability.

What Influences Linkage to Care After Home-Based HIV Counseling and Testing?

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients' desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients' emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.

Correction to: Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed South African infants and children.

[This corrects the article DOI: 10.1186/s13006-015-0041-x.].

An assessment of quality of home-based HIV counseling and testing performed by lay counselors in a rural sub-district of KwaZulu-Natal, South Africa.

HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV/AIDS, and promoted as an essential tool in scaling up and improving access to treatment, care and support especially in community settings. Home-based HCT (HBHCT) is a model that has consistently been found to be highly acceptable and has improved HCT coverage and uptake in low- and middle-income countries since 2002. It involves trained lay counselors going door-to-door offering pre-test counseling and providing HCT services to consenting eligible household members. Currently, there are few studies reporting on the quality of HBHCT services offered by lay counselors especially in Sub-Saharan Africa, including South Africa. This is a quantitative descriptive sub-study of a community randomized trial (Good Start HBHCT trial) which describes the quality of HBHCT provided by lay counselors. Quality of HBHCT was measured as scores comparing observed practice to prescribed protocols using direct observation. Data were collected through periodic observations of HCT sessions and exit interviews with clients. Counselor quality scores for pre-test counseling and post-test counseling sessions were created to determine the level of quality. For the client exit interviews a continuous score was created to assess how satisfied the clients were with the counseling session. A total of 196 (3%) observational assessments and 406 (6%) client exit interviews were completed. Overall, median scores for quality of counseling and testing were high for both HIV-negative and HIV-positive clients. For exit interviews all 406 (100%) clients had overall satisfaction with the counseling and testing services they received, however 11% were concerned about the counselor keeping their discussion confidential. Of all 406 clients, 393 (96.8%) intended to recommend the service to other people. In ensuring good quality HCT services, ongoing quality assessments are important to monitor quality of HCT after training.

Reduction in child mortality in Ethiopia: analysis of data from demographic and health surveys.

BACKGROUND: To examine changes in under-5 mortality, coverage of child survival interventions and nutritional status of children in Ethiopia between 2000 and 2011. Using the Lives Saved Tool, the impact of changes in coverage of child survival interventions on under-5 lives saved was estimated. METHODS: Estimates of child mortality were generated using three Ethiopia Demographic and Health Surveys undertaken between 2000 and 2011. Coverage indicators for high impact child health interventions were calculated and the Lives Saved Tool (LiST) was used to estimate child lives saved in 2011. RESULTS: The mortality rate in children younger than 5 years decreased rapidly from 218 child deaths per 1000 live births (95% confidence interval 183 to 252) in the period 1987-1991 to 88 child deaths per 1000 live births in the period 2007-2011 (78 to 98). The prevalence of moderate or severe stunting in children aged 6-35 months also declined significantly. Improvements in the coverage of interventions relevant to child survival in rural areas of Ethiopia between 2000 and 2011 were found for tetanus toxoid, DPT3 and measles vaccination, oral rehydration solution (ORS) and care-seeking for suspected pneumonia. The LiST analysis estimates that there were 60 700 child deaths averted in 2011, primarily attributable to decreases in wasting rates (18%), stunting rates (13%) and water, sanitation and hygiene (WASH) interventions (13%). CONCLUSIONS: Improvements in the nutritional status of children and increases in coverage of high impact interventions most notably WASH and ORS have contributed to the decline in under-5 mortality in Ethiopia. These proximal determinants however do not fully explain the mortality reduction which is plausibly also due to the synergistic effect of major child health and nutrition policies and delivery strategies.

Assessment of Malawi's success in child mortality reduction through the lens of the Catalytic Initiative Integrated Health Systems Strengthening programme: Retrospective evaluation.

BACKGROUND: Malawi is estimated to have achieved its Millennium Development Goal (MDG) 4 target. This paper explores factors influencing progress in child survival in Malawi including coverage of interventions and the role of key national policies. METHODS: We performed a retrospective evaluation of the Catalytic Initiative (CI) programme of support (2007-2013). We developed estimates of child mortality using four population household surveys undertaken between 2000 and 2010. We recalculated coverage indicators for high impact child health interventions and documented child health programmes and policies. The Lives Saved Tool (LiST) was used to estimate child lives saved in 2013. RESULTS: The mortality rate in children under 5 years decreased rapidly in the 10 CI districts from 219 deaths per 1000 live births (95% confidence interval (CI) 189 to 249) in the period 1991-1995 to 119 deaths (95% CI 105 to 132) in the period 2006-2010. Coverage for all indicators except vitamin A supplementation increased in the 10 CI districts across the time period 2000 to 2013. The LiST analysis estimates that there were 10 800 child deaths averted in the 10 CI districts in 2013, primarily attributable to the introduction of the pneumococcal vaccine (24%) and increased household coverage of insecticide-treated bednets (19%). These improvements have taken place within a context of investment in child health policies and scale up of integrated community case management of childhood illnesses. CONCLUSIONS: Malawi provides a strong example for countries in sub-Saharan Africa of how high impact child health interventions implemented within a decentralised health system with an established community-based delivery platform, can lead to significant reductions in child mortality.

Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed South African infants and children.

BACKGROUND: South Africa has the highest prevalence of overweight/obesity in Sub-Saharan Africa. Assessing the effect of modifiable factors such as early infant feeding on growth velocity and overweight/obesity is therefore important. This paper aimed to assess the effect of infant feeding in the transitional period (12 weeks) on 12-24 week growth velocity amongst HIV unexposed children using WHO growth velocity standards and on the age and sex adjusted body mass index (BMI) Z-score distribution at 2 years. METHODS: Data were from 3 sites in South Africa participating in the PROMISE-EBF trial. We calculated growth velocity Z-scores using the WHO growth standards and assessed feeding practices using 24-hour and 7-day recall data. We used quantile regression to study the associations between 12 week infant feeding and 12-24 week weight velocity (WVZ) with BMI-for-age Z-score at 2 years. We included the internal sample quantiles (70th and 90th centiles) that approximated the reference cut-offs of +2 (corresponding to overweight) and +3 (corresponding to obesity) of the 2 year BMI-for-age Z-scores. RESULTS: At the 2-year visit, 641 children were analysed (median age 22 months, IQR: 17-26 months). Thirty percent were overweight while 8.7% were obese. Children not breastfed at 12 weeks had higher 12-24 week mean WVZ and were more overweight and obese at 2 years. In the quantile regression, children not breastfed at 12 weeks had a 0.37 (95% CI 0.07, 0.66) increment in BMI-for-age Z-score at the 50th sample quantile compared to breast-fed children. This difference in BMI-for-age Z-score increased to 0.46 (95% CI 0.18, 0.74) at the 70th quantile and 0.68 (95% CI 0.41, 0.94) at the 90th quantile . The 12-24 week WVZ had a uniform independent effect across the same quantiles. CONCLUSIONS: This study demonstrates that the first 6 months of life is a critical period in the development of childhood overweight and obesity. Interventions targeted at modifiable factors such as early infant feeding practices may reduce the risks of rapid weight gain and subsequent childhood overweight/obesity.

Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South Africa.

INTRODUCTION: Lack of universal, annual testing for human immunodeficiency virus (HIV) in health facilities suggests that expansion of HIV testing and counselling (HTC) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. Consideration should be given to the ability of lay counsellors to perform home-based HTC in community settings. METHODS: We implemented a community cluster randomized controlled trial of home-based HTC in Sisonke District, South Africa. Trained lay counsellors conducted door-to-door HIV testing using the same rapid tests used by the local health department at the time of the study (SD Bioline and Sensa). To monitor testing quality and counsellor skill, additional dry blood spots were taken and sent for laboratory-based enzyme-linked immunosorbent assay (ELISA) testing. Sensitivity and specificity were calculated using the laboratory result as the gold standard. RESULTS AND DISCUSSION: From 3986 samples, the counsellor and laboratory results matched in all but 23 cases. In 18 cases, the counsellor judged the result as indeterminate, whereas the laboratory judged 10 positive, eight negative and three indeterminate, indicating that the counsellor may have erred on the side of caution. Sensitivity was 98.0% (95% CI: 96.3-98.9%), and specificity 99.6% (95% CI: 99.4-99.7%), for the lay counsellor field-based rapid tests. Both measures are high, and the lower confidence bound for specificity meets the international standard for assessing HIV rapid tests. CONCLUSIONS: These findings indicate that adequately trained lay counsellors are capable of safely conducting high-quality rapid HIV tests and interpreting the results as per the kit guidelines. These findings are important given the likely expansion of community and home-based testing models and the shortage of clinically trained professional staff.

Effect of home based HIV counselling and testing intervention in rural South Africa: cluster randomised trial.

OBJECTIVE: To assess the effect of home based HIV counselling and testing on the prevalence of HIV testing and reported behavioural changes in a rural subdistrict of South Africa. DESIGN: Cluster randomised controlled trial. SETTING: 16 communities (clusters) in uMzimkhulu subdistrict, KwaZulu-Natal province, South Africa. PARTICIPANTS: 4154 people aged 14 years or more who participated in a community survey. INTERVENTION: Lay counsellors conducted door to door outreach and offered home based HIV counselling and testing to all consenting adults and adolescents aged 14-17 years with guardian consent. Control clusters received standard care, which consisted of HIV counselling and testing services at local clinics. MAIN OUTCOME MEASURES: Primary outcome measure was prevalence of testing for HIV. Other outcomes were HIV awareness, stigma, sexual behaviour, vulnerability to violence, and access to care. RESULTS: Overall, 69% of participants in the home based HIV counselling and testing arm versus 47% in the control arm were tested for HIV during the study period (prevalence ratio 1.54, 95% confidence interval 1.32 to 1.81). More couples in the intervention arm had counselling and testing together than in the control arm (2.24, 1.49 to 3.03). The intervention had broader effects beyond HIV testing, with a 55% reduction in multiple partners (0.45, 0.33 to 0.62) and a stronger effect among those who had an HIV test (0.37, 0.24 to 0.58) and a 45% reduction in casual sexual partners (0.55, 0.42 to 0.73). CONCLUSIONS: Home based HIV counselling and testing increased the prevalence of HIV testing in a rural setting with high levels of stigma. Benefits also included higher uptake of couple counselling and testing and reduced sexual risk behaviour. TRIAL REGISTRATION: Current Controlled Trials ISRCTN31271935.

Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa.

BACKGROUND: HIV counselling and testing (HCT) is a critical gateway for addressing HIV prevention and linking people to treatment, care, and support. Since national testing rates are often less than optimal, there is growing interest in expanding testing coverage through the implementation of innovative models such as home-based HIV counselling and testing (HBHCT). With the aim of informing scale up, this paper discusses client characteristics and acceptability of an HBHCT intervention implemented in rural South Africa. METHODS: Trained lay counsellors offered door-to-door rapid HIV testing in a rural sub-district of KwaZulu-Natal, South Africa. Household and client data were captured on cellular phones and transmitted to a web-based data management system. Descriptive analysis was undertaken to examine client characteristics, testing history, HBHCT uptake, and reasons for refusal. Chi-square tests were performed to assess the association between client characteristics and uptake. RESULTS: Lay counsellors visited 3,328 households and tested 75% (5,086) of the 6,757 people met. The majority of testers (73.7%) were female, and 57% had never previously tested. With regard to marital status, 1,916 (37.7%), 2,123 (41.7%), and 818 (16.1%) were single, married, and widowed, respectively. Testers ranged in age from 14 to 98 years, with a median of 37 years. Two hundred and twenty-nine couples received couples counselling and testing; 87.8%, 4.8%, and 7.4% were concordant negative, concordant positive, and discordant, respectively. There were significant differences in characteristics between testers and non-testers as well as between male and female testers. The most common reasons for not testing were: not being ready/feeling scared/needing to think about it (34.1%); knowing his/her status (22.6%), being HIV-positive (18.5%), and not feeling at risk of having or acquiring HIV (10.1%). The distribution of reasons for refusal differed significantly by gender and age. CONCLUSIONS: These findings indicate that HBHCT is acceptable in rural South Africa. However, future HBHCT programmes should carefully consider community context, develop strategies to reach a broad range of clients, and tailor intervention messages and services to meet the unique needs of different sub-groups. It will also be important to understand and address factors related to refusal of testing.

Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health.

BACKGROUND: Breastfeeding is a critical component of interventions to reduce child mortality. Exclusive breastfeeding practice is extremely low in South Africa and there has been no improvement in this over the past ten years largely due to fears of HIV transmission. Early cessation of breastfeeding has been found to have negative effects on child morbidity and survival in several studies in Africa. This paper reports on determinants of early breastfeeding cessation among women in South Africa. METHODS: This is a sub group analysis of a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008 (ClinicalTrials.gov no: NCT00397150). Infant feeding recall of 22 food and fluid items was collected at 3, 6, 12 and 24 weeks postpartum. Women's experiences of breast health problems were also collected at the same time points. 999 women who ever breastfed were included in the analysis. Univariable and multivariable logistic regression analysis adjusting for site, arm and cluster, was performed to determine predictors of stopping breastfeeding by 12 weeks postpartum. RESULTS: By 12 weeks postpartum, 20% of HIV-negative women and 40% of HIV-positive women had stopped all breastfeeding. About a third of women introduced other fluids, most commonly formula milk, within the first 3 days after birth. Antenatal intention not to breastfeed and being undecided about how to feed were most strongly associated with stopping breastfeeding by 12 weeks (Adjusted odds ratio, AOR 5.6, 95% CI 3.4 - 9.5 and AOR 4.1, 95% CI 1.6 - 10.8, respectively). Also important was self-reported breast health problems associated with a 3-fold risk of stopping breastfeeding (AOR 3.1, 95%CI 1.7 - 5.7) and the mother having her own income doubled the risk of stopping breastfeeding (AOR 1.9, 95% CI 1.3 - 2.8). CONCLUSION: Early cessation of breastfeeding is common amongst both HIV-negative and positive women in South Africa. There is an urgent need to improve antenatal breastfeeding counselling taking into account the challenges faced by working women as well as early postnatal lactation support to prevent breast health problems.

Knowledge of HIV status prior to a community HIV counseling and testing intervention in a rural district of south Africa: results of a community based survey.

BACKGROUND: The low uptake of facility-based HIV counseling and testing (HCT) in South Africa, particularly amongst men and youth has hindered attempts to increase access to effective treatment and prevention strategies. Many barriers to HIV testing have been described including long waiting times, transport to reach facilities, fear of lack of confidentiality and health systems factors such as stock outs of HIV test kits. The aim of this study was to undertake a community survey to determine rates of HCT in a rural area in order to plan a community intervention. METHODS: A community-based survey was undertaken in 16 communities in Sisonke district, KwaZulu-Natal between September and November 2008. A total of 5821 individuals participated in the survey of which 66% were females. Gender specific mixed effects logistic regression models were used to describe differences in socio-economic characteristics, and their association with HIV testing histories. RESULTS: Overall 1833 (32%) individuals in this rural area knew their HIV status. Prior testing was higher amongst women (39%) than amongst men (17%). Older men (> 24 years) were more likely to report having tested for HIV previously, with the highest likelihood (adjusted OR = 4.02; 95% CI: 2.71-5.99) among men in age group, 35-49 years. For women, age group 25-34 years had the highest likelihood of having been previously tested (adjusted OR = 1.30; 95% CI: 1.05-1.66). Being currently pregnant (adjusted OR 3.31; 95% CI: 2.29-4.78) or having a child under five (adjusted OR 7.00; 95% CI: 5.84-8.39) were also associated with prior HIV testing amongst women. CONCLUSIONS: Overall, knowledge of HIV status in this rural sub-district is low. The relatively higher uptake of HIV testing among women is encouraging as it shows that PMTCT services are well functioning. However, these data suggest that there is an urgent need for scaling up HIV testing services in rural communities specifically targeting men and youth.

Vaccination coverage and timeliness in three South African areas: a prospective study.

BACKGROUND: Timely vaccination is important to induce adequate protective immunity. We measured vaccination timeliness and vaccination coverage in three geographical areas in South Africa. METHODS: This study used vaccination information from a community-based cluster-randomized trial promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008. Five interview visits were carried out between birth and up to 2 years of age (median follow-up time 18 months), and 1137 children were included in the analysis. We used Kaplan-Meier time-to-event analysis to describe vaccination coverage and timeliness in line with the Expanded Program on Immunization for the first eight vaccines. This included Bacillus Calmette-Guérin (BCG), four oral polio vaccines and 3 doses of the pentavalent vaccine which protects against diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type B. RESULTS: The proportion receiving all these eight recommended vaccines were 94% in Paarl (95% confidence interval [CI] 91-96), 62% in Rietvlei (95%CI 54-68) and 88% in Umlazi (95%CI 84-91). Slightly fewer children received all vaccines within the recommended time periods. The situation was worst for the last pentavalent- and oral polio vaccines. The hazard ratio for incomplete vaccination was 7.2 (95%CI 4.7-11) for Rietvlei compared to Paarl. CONCLUSIONS: There were large differences between the different South African sites in terms of vaccination coverage and timeliness, with the poorer areas of Rietvlei performing worse than the better-off areas in Paarl. The vaccination coverage was lower for the vaccines given at an older age. There is a need for continued efforts to improve vaccination coverage and timeliness, in particular in rural areas. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT00397150.