Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment.

OBJECTIVES: Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa. METHODS: Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities. RESULTS: We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12). CONCLUSIONS: Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

A systematic review of antimicrobial resistance in Neisseria gonorrhoeae and Mycoplasma genitalium in sub-Saharan Africa.

OBJECTIVES: Limited antimicrobial resistance (AMR) surveillance coupled with syndromic management of sexually transmitted infections (STIs) in sub-Saharan Africa (SSA) could be contributing to an increase in AMR in the region. This systematic review aimed to synthesize data on the prevalence of AMR in common STIs in SSA and identify some research gaps that exist. METHODS: We searched three electronic databases for studies published between 1 January 2000 and 26 May 2020. We screened the titles and abstracts for studies that potentially contained data on AMR in SSA. Then we reviewed the full text of these studies to identify articles that reported data on the prevalence of AMR in Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium in SSA. We summarized the data using a narrative synthesis. RESULTS: The 40 included studies reported on AMR data from 7961 N. gonorrhoeae isolates from 15 countries in SSA and 350 M. genitalium specimens from South Africa. All four SSA regions reported very high rates of ciprofloxacin, tetracycline and penicillin resistance in N. gonorrhoeae. Resistance to cefixime or ceftriaxone was observed in all regions except West Africa. Azithromycin resistance, recommended as part of dual therapy with an extended-spectrum cephalosporin for gonorrhoea, was reported in all the regions. Both macrolide and fluoroquinolone-associated resistance were reported in M. genitalium in South Africa. Studies investigating AMR in C. trachomatis and T. vaginalis were not identified. CONCLUSIONS: There is a need to strengthen AMR surveillance in SSA for prompt investigation and notification of drug resistance in STIs.

Health care providers' attitudes toward and experiences delivering oral PrEP to adolescent girls and young women in Kenya, South Africa, and Zimbabwe.

BACKGROUND: In Kenya, South Africa, and Zimbabwe, oral pre-exposure prophylaxis (PrEP) is recommended for adolescent girls and young women (AGYW) at high risk of HIV. Health providers play a critical role in the uptake and effective use of sexual and reproductive health services; however, few published studies have explored providers' attitudes toward and experiences delivering PrEP to AGYW. METHODS: We conducted a cross-sectional qualitative study, interviewing 113 providers at 36 public, private, and nongovernmental health facilities in Kenya, South Africa, and Zimbabwe that were offering PrEP during the research period or were likely to offer PrEP in the future. Data were coded in NVivo 11, and an applied thematic analysis was conducted. RESULTS: Most providers preferred that adolescent girls wait until age 18 to have sex but acknowledged that many girls younger than 18 could benefit from oral PrEP. Their primary concern was whether adolescent girls would be able to take PrEP daily, especially if they do not tell their parents or partners they are using it. Providers reported that it was more challenging to deliver PrEP and other HIV services to girls younger than 18. Those with experience providing PrEP pointed to stigma and lack of PrEP awareness in communities as two primary barriers to PrEP uptake and use. CONCLUSIONS: Providers were generally accepting of oral PrEP as an HIV prevention option for AGYW; however, many had negative attitudes about adolescent girls being sexually active and concerns about whether they could take PrEP daily. Results were used to update national PrEP training materials to address negative provider attitudes about PrEP use by AGYW.

Lesbian, gay, and bisexual (LGB) people's experiences of nursing health care: An emancipatory nursing practice integrative review.

AIM: To review current research on lesbian, gay, and bisexual (LGB) individuals' experience of nursing services from an emancipatory nursing practice framework. BACKGROUND: As LGB issues are marginalized in health care, it is important to understand LGB individuals' experiences of nursing. DESIGN: An integrative literature review using critical analysis based on an emancipatory nursing practice framework was conducted. DATA SOURCES: A search of all English nursing journals in the World of Science database was conducted. REVIEW METHODS: Established methods were used to search, identify, and appraise articles meeting the criteria of examining LGB individuals' experiences of nursing services, published in the years 2009 to 2015. Sixteen articles that met the inclusion criteria were identified independently by the two authors. Data were analysed using descriptive and critical phases of enquiry. RESULTS: Results show a nexus of experiences of exclusion and oppressive social norms. Our analytical framework highlighted absences in nursing practice. No research indicates that LGB people experience nurses as advocates or participatory health care processes. CONCLUSION: Standards, training, and systems need to be devised that ensure inclusionary nursing practices, that encourage nurses to act as advocates for LGB health care justice, and that allow LGB individual to participate in the development of health care policies and procedures.

The emancipatory potential of nursing practice in relation to sexuality: a systematic literature review of nursing research 2009-2014.

Nurses play a key role in the provision of services in relation to sexuality in both primary and sexual and reproductive health-care. Given the intersection of sexualities with a range of social injustices, this study reviews research on nursing practice concerning sexuality from an emancipatory/social justice perspective. A systematic review of English articles published in nursing journals appearing on the Web of Science database from 2009 to 2014 was conducted. Thirty-eight articles met the inclusion criteria. Analysis consisted of a descriptive phase (types and location of studies, aspects of sexualities focused on, target health users and aspects of nursing practice focused on) and a critical/emancipatory phase. In terms of practice, our analysis revealed that: barriers exist to the integration of issues relating to sexuality in nursing practice; the social location of nurses and their personal feelings regarding sexuality influence their practice; content that addresses gendered norms and media that assist in communication underpin some emancipatory practices. Few studies locate analyses of nursing practice within gendered, cultural and social norms; consider advocacy as part of the practice of nurses; or analyse the promotion of health user participation in health services and structures. The implications for emancipatory practice are drawn out.

Community group membership and stigmatising attitudes towards people living with HIV in Eastern Zimbabwe.

Stigmatising attitudes towards people living with HIV and AIDS (PLHIV) are hampering attempts to control HIV epidemics in sub-Saharan African countries. This study measures the effect of social capital, in the form of local community groups, in reducing stigma and tests a new explanatory framework for the association between community group membership and less stigmatising attitudes. Prospective data on membership of a wide range of different community groups and stigmatising attitudes (being unwilling to care for a relative with AIDS), collected from a general population cohort of 5,253 men and women aged 15-54 years in eastern Zimbabwe between 2003 and 2008 were analysed using multivariable logistic regression. 36 % of respondents were members of community groups throughout the study period. Individuals in community groups were less likely to express stigmatising attitudes towards PLHIV-3.4 versus 9.5 % (adjusted odds ratio = 0.46, p < 0.001). Discussions of care for PLHIV within groups, improved knowledge about AIDS, greater exposure to PLHIV, and increased uptake of HIV testing and counselling did not account for the association. Further work is needed to identify the mechanisms through which community participation can reduce stigma. Nevertheless, these findings suggest that promoting well-informed discussions about HIV within pre-existing community groups and involving these groups in stigma reduction programmes could be effective means of reducing stigma at the grassroots level.

The Binary Order of Things: A Discursive Study of Nursing Students' Talk on Providing, and Learning About, LGBT Patient Care.

Against the backdrop of the healthcare inequities and maltreatment facing LGBT patients, recommendations have been made for the inclusion of LGBT health topics in nursing curricula. Based on data collected in focus group discussions with South African nursing students, we complicate the assumption that training focused on health-specific knowledge will effectively reform providers' prejudicial practices. Findings reveal ambivalence: silence and discrimination versus inclusive humanism. Participants drew on discourses of ignorance, religion, and egalitarian treatment to justify their inadequacy regarding LGBT patients; while doing so, however, they deployed othering discourses in which homophobic and transphobic disregard is rendered acceptable, and "scientifically" supported through binary, deterministic views of sexuality and gender. Such "expert" views accord with Foucault's notion of "grotesque discourse." We conclude with a discussion of the findings' implications for nursing education; we call for the recognition and teaching of binary ideology as a form of discursive violence over LGBT lives.

Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa.

BACKGROUND: South Africa became the first country in Africa to introduce oral PrEP in June 2016. The National Department of Health has used a phased approach to rollout, allowing for a dynamic learn-and-adapt process which will lead ultimately to scale-up. Phased rollout began with provision of oral PrEP at facilities providing services to sex workers in 2016 and was expanded in 2017, first to facilities providing services to MSM and then to students at selected university campus clinics, followed by provision at primary health care facilities. Programmatic data shows variability in initiation and continuation between these populations. This study examines factors related to PrEP initiation, continuation, and discontinuation at facilities providing services to sex workers and MSM during the national PrEP rollout. METHODS: A cross-sectional survey was administered September 2017-January 2018 among clients (ages 18-62 and providers at 9 facilities implementing oral PrEP in South Africa, followed by in-depth interviews. The client survey captured PrEP initiation, continuation and discontinuation. Analysis was performed in STATA 13 for survey data and thematic analysis was performed in NViVO 11 for in-depth interview data. RESULTS: 299 clients (203 from sex worker facilities, 96 from MSM facilities) participated in the survey and additionally, in-depth interviews were conducted with 29 clients. Participants self-identified as either current users (n = 94; 36.2%), past users (n = 80; 30.8%) and never users of PrEP (n = 86; 33.1%). Participants who had never used PrEP either cited not being offered PrEP by a provider (57%, n = 49) or declining PrEP (43%, n = 37) as reasons for lack of uptake. The primary reason for declining to use oral PrEP was fear of side effects (41.7%, n = 15). The primary reasons for initiating and continuing on oral PrEP were all related to perceived risk associated with sexual activity. The majority of participants (87.9%, n = 153) also noted that printed IEC materials influenced their decision to initiate PrEP. Qualitative data suggested that several clients initiated on PrEP because they wanted additional protection beyond using condoms due to challenges such as partners refusing to use condoms, having partners with unknown HIV status, having multiple partners, involvement in sex work, or having a partner living with HIV. The majority (73.8%, n = 59) of participants who discontinued oral PrEP cited side effects as the primary reason for discontinuation, followed by feeling stigmatized (18.8%, n = 15). CONCLUSION: This study provides valuable insights on early rollout of PrEP of how clients perceive oral PrEP and where to target efforts to improve the uptake of this highly effective HIV prevention product. By identifying strengths and areas for improvement, the ACCESS study has generated evidence that can be used to guide high quality scale-up in South Africa and may be instructive for other countries' efforts to expand quality access to oral PrEP.