Drug-resistant bacterial infections: We need urgent action and investment that focus on the weakest link.

Despite high mortality and morbidity, drug-resistant bacterial infections remain the forgotten pandemic. We argue for strengthening of diagnostics, WASH (water, sanitation, and hygiene) and infection prevention and control to reduce drug-resistant infections, as an integral part of sustainable high-quality health services, particularly in low- and middle-income countries.

Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017.

HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15-49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa.

Evaluation of cancer screening services provided for people living with HIV in Botswana, 2022-2023.

People living with human immunodeficiency virus (PLHIV) have an increased risk of cancers. Currently, Botswana has no screening guidelines for common cancers in PLHIV except cervical cancer. Also, the proportion of PLHIV who are screened for cancer is unknown. This study aimed to evaluate cancer screening services for PLHIV receiving care in the human immunodeficiency virus (HIV) clinics. Resources for cancer screening were assessed and medical records of adults initiating antiretroviral therapy (ART) from 2020 to 2021 in 20 high-volume HIV clinics in Gaborone and Francistown were reviewed. Questionnaires assessing knowledge and practices of cancer screening were administered to health workers. The majority of clinics had the required resources for cancer screening (specifically cervical cancer). Of the 62 health workers working at the HIV clinics, 57 (91.9%) completed the questionnaire: 35 (62.5%) nurses and 22 (37.5%) doctors. Only 26.3% of the health workers were trained in cervical cancer screening. Doctors were more likely to report practicing routine screening of other cancers (e.g. breast) (p = 0.003) while more nurses reported assessing patients for cancer history during follow-up visits (p = 0.036). Most health workers did not perform physical examinations to detect cancer at initial or follow-up visits. Of the 1000 records of PLHIV reviewed, 57.3% were females, and only 38% of these were screened for cervical cancer. Besides cervical cancer, almost all (97.8%) were not screened for any cancer at ART initiation and during follow-up. These findings highlight the need to improve cancer screening services of PLHIV in Botswana through the training of health workers, and the development and enhanced use of screening guidelines.

Serum microRNA Profiles and Pathways in Hepatitis B-Associated Hepatocellular Carcinoma: A South African Study.

The incidence and mortality of hepatocellular carcinoma (HCC) in Sub-Saharan Africa is projected to increase sharply by 2040 against a backdrop of limited diagnostic and therapeutic options. Two large South African-based case control studies have developed a serum-based miRNome for Hepatitis B-associated hepatocellular carcinoma (HBV-HCC), as well as identifying their gene targets and pathways. Using a combination of RNA sequencing, differential analysis and filters including a unique molecular index count (UMI) ≥ 10 and log fold change (LFC) range > 2: <-0.5 (p < 0.05), 91 dysregulated miRNAs were characterized including 30 that were upregulated and 61 were downregulated. KEGG analysis, a literature review and other bioinformatic tools identified the targeted genes and HBV-HCC pathways of the top 10 most dysregulated miRNAs. The results, which are based on differentiating miRNA expression of cases versus controls, also develop a serum-based miRNA diagnostic panel that indicates 95.9% sensitivity, 91.0% specificity and a Youden Index of 0.869. In conclusion, the results develop a comprehensive African HBV-HCC miRNome that potentially can contribute to RNA-based diagnostic and therapeutic options.

The prevalence of Plasmodium falciparum in sub-Saharan Africa since 1900.

Malaria transmission is influenced by climate, land use and deliberate interventions. Recent declines have been observed in malaria transmission. Here we show that the African continent has witnessed a long-term decline in the prevalence of Plasmodium falciparum from 40% prevalence in the period 1900-1929 to 24% prevalence in the period 2010-2015, a trend that has been interrupted by periods of rapidly increasing or decreasing transmission. The cycles and trend over the past 115 years are inconsistent with explanations in terms of climate or deliberate intervention alone. Previous global initiatives have had minor impacts on malaria transmission, and a historically unprecedented decline has been observed since 2000. However, there has been little change in the high transmission belt that covers large parts of West and Central Africa. Previous efforts to model the changing patterns of P. falciparum transmission intensity in Africa have been limited to the past 15 years or have used maps drawn from historical expert opinions. We provide quantitative data, from 50,424 surveys at 36,966 geocoded locations, that covers 115 years of malaria history in sub-Saharan Africa; inferring from these data to future trends, we would expect continued reductions in malaria transmission, punctuated with resurgences.

The impact of child health interventions and risk factors on child survival in Kenya, 1993-2014: a Bayesian spatio-temporal analysis with counterfactual scenarios.

BACKGROUND: During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined. METHODS: Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993. RESULTS: Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors. CONCLUSION: Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Joint spatio-temporal modelling of adverse pregnancy outcomes sharing common risk factors at sub-county level in Kenya, 2016-2019.

BACKGROUND: Adverse pregnancy outcomes jointly account for a high proportion of mortality and morbidity among pregnant women and their infants. Furthermore, the burden attributed to adverse pregnancy outcomes remains high and inadequately characterised due to the intricate interplay of its etiology and shared set of important risk factors. This study sought to quantify and map the underlying risk of multiple adverse pregnancy outcomes in Kenya at sub-county level using a shared component space-time modelling framework. METHODS: Reported sub-county level adverse pregnancy outcomes count from January 2016 - December 2019 were obtained from the Kenyan District Health Information System. A Bayesian hierarchical spatio-temporal model was used to estimate the joint burden of adverse pregnancy outcomes in space (sub-county) and time (year). To improve the precision of our estimates over time and space, information across the outcomes were combined via the shared and the outcome-specific components using a shared component model with spatio-temporal interactions. RESULTS: Overall, the total number of adverse outcomes in pregnancy increased by 14.2% (95% UI: 14.0-14.5) from 88,816 cases in 2016 to 101,455 cases in 2019. Between 2016 and 2019, the estimated low birth weight rate and the pre-term birth rate were 4.5 (95% UI: 4.4-4.7) and 2.3 (95% UI: 2.2-2.5) per 100 live births. The stillbirth and neonatal death rates were estimated to be 18.7 (95% UI: 18.0-19.4) and 6.9 (95% UI: 6.4-7.4) per 1000 live births. The magnitude of the spatio-temporal variation attributed to shared risk was high for pre-term births, low birth weight, neonatal deaths, stillbirths and neonatal deaths, respectively. The shared risk patterns were dominant in sub-counties located along the Indian ocean coastline, central and western Kenya. CONCLUSIONS: This study demonstrates the usefulness of a Bayesian joint spatio-temporal shared component model in exploiting specific and shared risk of adverse pregnancy outcomes sub-nationally. By identifying sub-counties with elevated risks and data gaps, our estimates not only assert the need for bolstering maternal health programs in the identified high-risk sub-counties but also provides a baseline against which to assess the progress towards the attainment of Sustainable Development Goals.

Mapping male circumcision for HIV prevention efforts in sub-Saharan Africa.

BACKGROUND: HIV remains the largest cause of disease burden among men and women of reproductive age in sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk of female-to-male transmission of HIV by 50-60%. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries for VMMC campaigns and set a coverage goal of 80% for men ages 15-49. From 2008 to 2017, over 18 million VMMCs were reported in priority countries. Nonetheless, relatively little is known about local variation in male circumcision (MC) prevalence. METHODS: We analyzed geo-located MC prevalence data from 109 household surveys using a Bayesian geostatistical modeling framework to estimate adult MC prevalence and the number of circumcised and uncircumcised men aged 15-49 in 38 countries in sub-Saharan Africa at a 5 × 5-km resolution and among first administrative level (typically provinces or states) and second administrative level (typically districts or counties) units. RESULTS: We found striking within-country and between-country variation in MC prevalence; most (12 of 14) priority countries had more than a twofold difference between their first administrative level units with the highest and lowest estimated prevalence in 2017. Although estimated national MC prevalence increased in all priority countries with the onset of VMMC campaigns, seven priority countries contained both subnational areas where estimated MC prevalence increased and areas where estimated MC prevalence decreased after the initiation of VMMC campaigns. In 2017, only three priority countries (Ethiopia, Kenya, and Tanzania) were likely to have reached the MC coverage target of 80% at the national level, and no priority country was likely to have reached this goal in all subnational areas. CONCLUSIONS: Despite MC prevalence increases in all priority countries since the onset of VMMC campaigns in 2008, MC prevalence remains below the 80% coverage target in most subnational areas and is highly variable. These mapped results provide an actionable tool for understanding local needs and informing VMMC interventions for maximum impact in the continued effort towards ending the HIV epidemic in sub-Saharan Africa.

Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy.

BACKGROUND: Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes. METHODS: We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access. RESULTS: We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children. CONCLUSIONS: Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

Impact of pretreatment low-abundance HIV-1 drug-resistant variants on virological failure among HIV-1/TB-co-infected individuals.

OBJECTIVES: To determine the impact of pretreatment low-abundance HIV-1 drug-resistant variants (LA-DRVs) on virological failure (VF) among HIV-1/TB-co-infected individuals treated with NNRTI first-line ART. METHODS: We conducted a case-control study of 170 adults with HIV-1/TB co-infection. Cases had at least one viral load (VL) ≥1000 RNA copies/mL after ≥6 months on NNRTI-based ART, and controls had sustained VLs <1000 copies/mL. We sequenced plasma viruses by Sanger and MiSeq next-generation sequencing (NGS). We assessed drug resistance mutations (DRMs) using the Stanford drug resistance database, and analysed NGS data for DRMs at ≥20%, 10%, 5% and 2% thresholds. We assessed the effect of pretreatment drug resistance (PDR) on VF. RESULTS: We analysed sequences from 45 cases and 125 controls. Overall prevalence of PDR detected at a ≥20% threshold was 4.7% (8/170) and was higher in cases than in controls (8.9% versus 3.2%), P = 0.210. Participants with PDR at ≥20% had almost 4-fold higher odds of VF (adjusted OR 3.7, 95% CI 0.8-18.3) compared with those without, P = 0.104. PDR prevalence increased to 18.2% (31/170) when LA-DRVs at ≥2% were included. Participants with pretreatment LA-DRVs only had 1.6-fold higher odds of VF (adjusted OR 1.6, 95% CI 0.6-4.3) compared with those without, P = 0.398. CONCLUSIONS: Pretreatment DRMs and LA-DRVs increased the odds of developing VF on NNRTI-based ART, although without statistical significance. NGS increased detection of DRMs but provided no additional benefit in identifying participants at risk of VF at lower thresholds. More studies assessing mutation thresholds predictive of VF are required to inform use of NGS in treatment decisions.

Mapping of anaemia prevalence among pregnant women in Kenya (2016-2019).

BACKGROUND: Reducing the burden of anaemia is a critical global health priority that could improve maternal outcomes amongst pregnant women and their neonates. As more counties in Kenya commit to universal health coverage, there is a growing need for optimal allocation of the limited resources to sustain the gains achieved with the devolution of healthcare services. This study aimed to describe the spatio-temporal patterns of maternal anaemia prevalence in Kenya from 2016 to 2019. METHODS: Quarterly reported sub-county level maternal anaemia cases from January 2016 - December 2019 were obtained from the Kenyan District Health Information System. A Bayesian hierarchical negative binomial spatio-temporal conditional autoregressive (CAR) model was used to estimate maternal anaemia prevalence by sub-county and quarter. Spatial and temporal correlations were considered by assuming a conditional autoregressive and a first-order autoregressive process on sub-county and seasonal specific random effects, respectively. RESULTS: The overall estimated number of pregnant women with anaemia increased by 90.1% (95% uncertainty interval [95% UI], 89.9-90.2) from 155,539 cases in 2016 to 295,642 cases 2019. Based on the WHO classification criteria, the proportion of sub-counties with normal prevalence decreased from 28.0% (95% UI, 25.4-30.7) in 2016 to 5.4% (95% UI, 4.1-6.7) in 2019, whereas moderate anaemia prevalence increased from 16.8% (95% UI, 14.7-19.1) in 2016 to 30.1% (95% UI, 27.5-32.8) in 2019 and severe anaemia prevalence increased from 7.0% (95% UI, 5.6-8.6) in 2016 to 16.6% (95% UI, 14.5-18.9) in 2019. Overall, 45.1% (95% UI: 45.0-45.2) of the estimated cases were in malaria-endemic sub-counties, with the coastal endemic zone having the highest proportion 72.8% (95% UI: 68.3-77.4) of sub-counties with severe prevalence. CONCLUSION: As the number of women of reproductive age continues to grow in Kenya, the use of routinely collected data for accurate mapping of poor maternal outcomes remains an integral component of a functional maternal health strategy. By unmasking the sub-county disparities often concealed by national and county estimates, our study findings reiterate the importance of maternal anaemia prevalence as a metric for estimating malaria burden and offers compelling policy implications for achieving national nutritional targets.

A behavioural change intervention study for the prevention of childhood obesity in South Africa: protocol for a randomized controlled trial.

BACKGROUND: South Africa is currently undergoing a nutrition transition, and overweight and obesity is on the increase in South African children. Urbanization and other health determinants have led to reduced physical activity and unhealthy eating that have increased the risk of adverse chronic health conditions. This study aims to provide evidence of the effectiveness of a school-based intervention study that targets diet and physical activity for the prevention of child and adolescent overweight and/or obesity. METHODS: We will employ a mixed method study design which is divided into two phases. Phase 1, namely the qualitative elicitation research phase will inform the development of the quantitative intervention phase (phase 2), consisting of a cluster-randomized trial, based on input from key stakeholders. The study will be undertaken in 16 government-funded primary schools in the iLembe district of KwaZulu-Natal, South Africa. The study will target learners in Grades 4 and 7, their parents, Life Orientation educators, school principals and members of school governing bodies. Assessment for the primary objective (BMI Z scores), and the secondary objectives (change in knowledge, attitudes and behaviours regarding diet and physical activity) in both study arms will be conducted at baseline in March 2020 and at the end of the study in October 2020. DISCUSSION: The study will be a novel combined mixed methods/RCT design that focuses on diet, physical activity school and family-based interventions in the context of rapidly increasing overweight and obesity prevalence in KwaZulu-Natal. To encourage behaviour change and management of malnutrition, education including diet and physical activity, is an important strategy that must be considered. Nutrition education extends beyond the dissemination of food information; it includes addressing the needs of participants, empowers and encourages decision-making and choice of foods, change in nutrition attitudes, beliefs and influences based on resources available and within cultural boundaries. TRIAL REGISTRATION: Pan African Clinical Trial Registry PACTR201711002699153. Protocol registered on 16 November 2017.

Investigating the spatial variation and risk factors of childhood anaemia in four sub-Saharan African countries.

BACKGROUND: The causes of childhood anaemia are multifactorial, interrelated and complex. Such causes vary from country to country, and within a country. Thus, strategies for anaemia control should be tailored to local conditions and take into account the specific etiology and prevalence of anaemia in a given setting and sub-population. In addition, policies and programmes for anaemia control that do not account for the spatial heterogeneity of anaemia in children may result in certain sub-populations being excluded, limiting the effectiveness of the programmes. This study investigated the demographic and socio-economic determinants as well as the spatial variation of anaemia in children aged 6 to 59 months in Kenya, Malawi, Tanzania and Uganda. METHODS: The study made use of data collected from nationally representative Malaria Indicator Surveys (MIS) and Demographic and Health Surveys (DHS) conducted in all four countries between 2015 and 2017. During these surveys, all children under the age of five years old in the sampled households were tested for malaria and anaemia. A child's anaemia status was based on the World Health Organization's cut-off points where a child was considered anaemic if their altitude adjusted haemoglobin (Hb) level was less than 11 g/dL. The explanatory variables considered comprised of individual, household and cluster level factors, including the child's malaria status. A multivariable hierarchical Bayesian geoadditive model was used which included a spatial effect for district of child's residence. RESULTS: Prevalence of childhood anaemia ranged from 36.4% to 61.9% across the four countries. Children with a positive malaria result had a significantly higher odds of anaemia [AOR = 4.401; 95% CrI: (3.979, 4.871)]. After adjusting for a child's malaria status and other demographic, socio-economic and environmental factors, the study revealed distinct spatial variation in childhood anaemia within and between Malawi, Uganda and Tanzania. The spatial variation appeared predominantly due to unmeasured district-specific factors that do not transcend boundaries. CONCLUSIONS: Anaemia control measures in Malawi, Tanzania and Uganda need to account for internal spatial heterogeneity evident in these countries. Efforts in assessing the local district-specific causes of childhood anaemia within each country should be focused on.

Spatial-temporal patterns of malaria incidence in Uganda using HMIS data from 2015 to 2019.

BACKGROUND: As global progress to reduce malaria transmission continues, it is increasingly important to track changes in malaria incidence rather than prevalence. Risk estimates for Africa have largely underutilized available health management information systems (HMIS) data to monitor trends. This study uses national HMIS data, together with environmental and geographical data, to assess spatial-temporal patterns of malaria incidence at facility catchment level in Uganda, over a recent 5-year period. METHODS: Data reported by 3446 health facilities in Uganda, between July 2015 and September 2019, was analysed. To assess the geographic accessibility of the health facilities network, AccessMod was employed to determine a three-hour cost-distance catchment around each facility. Using confirmed malaria cases and total catchment population by facility, an ecological Bayesian conditional autoregressive spatial-temporal Poisson model was fitted to generate monthly posterior incidence rate estimates, adjusted for caregiver education, rainfall, land surface temperature, night-time light (an indicator of urbanicity), and vegetation index. RESULTS: An estimated 38.8 million (95% Credible Interval [CI]: 37.9-40.9) confirmed cases of malaria occurred over the period, with a national mean monthly incidence rate of 20.4 (95% CI: 19.9-21.5) cases per 1000, ranging from 8.9 (95% CI: 8.7-9.4) to 36.6 (95% CI: 35.7-38.5) across the study period. Strong seasonality was observed, with June-July experiencing highest peaks and February-March the lowest peaks. There was also considerable geographic heterogeneity in incidence, with health facility catchment relative risk during peak transmission months ranging from 0 to 50.5 (95% CI: 49.0-50.8) times higher than national average. Both districts and health facility catchments showed significant positive spatial autocorrelation; health facility catchments had global Moran's I = 0.3 (p < 0.001) and districts Moran's I = 0.4 (p < 0.001). Notably, significant clusters of high-risk health facility catchments were concentrated in Acholi, West Nile, Karamoja, and East Central - Busoga regions. CONCLUSION: Findings showed clear countrywide spatial-temporal patterns with clustering of malaria risk across districts and health facility catchments within high risk regions, which can facilitate targeting of interventions to those areas at highest risk. Moreover, despite high and perennial transmission, seasonality for malaria incidence highlights the potential for optimal and timely implementation of targeted interventions.

Reducing Physical Aggression in High School Students in KwaZulu-Natal: A Cluster Randomized Trial.

Youth violence is of public health and social concern. A South African cluster randomized trial (434 grade 10 students, 16 schools), used the Integrated Model for Behavior Change conceptual framework to implement a 20 module classroom-based intervention program. The study contributes to the literature and used a strong analytical technique since mixed effects linear regression assessed the impact of the intervention on physical violence endpoints and other socioeconomic confounders/factors. The intervention reduced students' experiencing physical violence compared to controls and social pressure for this, yet no differences were found for hitting others. Our results support findings that school programs against violence can reduce students' experience of physical violence, but translation of these findings to reduce the actual hitting of others may need further approaches and/or more time.

Overall survival for neuroblastoma in South Africa between 2000 and 2014.

BACKGROUND: Outcome data for neuroblastoma in sub-Saharan Africa are minimal, whereas poor outcome is reported in low- and middle-income countries. A multi-institutional retrospective study across South Africa was undertaken to determine outcome. METHODS: Patients treated between January 2000 and December 2014 in nine South African pediatric oncology units were included. Kaplan-Meier curves and Cox regression models were employed to determine two-year survival rates and to identify prognostic factors. RESULTS: Data from 390 patients were analyzed. The median age was 39.9 months (range, 0-201 months). The majority presented with stage 4 disease (70%). The main chemotherapy regimens were OPEC/OJEC (44.8%), St Jude NB84 protocol (28.96%), and Rapid COJEC (22.17%). Only 44.4% had surgery across all risk groups, whereas only 16.5% of high-risk patients received radiotherapy. The two-year overall survival (OS) for the whole cohort was 37.6%: 94.1%, 81.6%, and 66.7%, respectively, for the very-low-risk, low-risk, and intermediate-risk groups and 27.6% for the high-risk group (P < 0.001, 95% CI). The median survival time for the whole group was 13 months (mean, 41.9 months; range, 0.1-209 months). MYCN-nonamplified patients had a superior two-year OS of 51.3% in comparison with MYCN-amplified patients at 37.3% (P = 0.002, 95% CI). CONCLUSIONS: Limited disease had an OS comparable with high-income countries, but advanced disease had a poor OS. South Africa should focus on early diagnosis and implementation of a national protocol with equitable access to treatment.

A decade of sustained geographic spread of HIV infections among women in Durban, South Africa.

BACKGROUND: Fine scale geospatial analysis of HIV infection patterns can be used to facilitate geographically targeted interventions. Our objective was to use the geospatial technology to map age and time standardized HIV incidence rates over a period of 10 years to identify communities at high risk of HIV in the greater Durban area. METHODS: HIV incidence rates from 7557 South African women enrolled in five community-based HIV prevention trials (2002-2012) were mapped using participant household global positioning system (GPS) coordinates. Age and period standardized HIV incidence rates were calculated for 43 recruitment clusters across greater Durban. Bayesian conditional autoregressive areal spatial regression (CAR) was used to identify significant patterns and clustering of new HIV infections in recruitment communities. RESULTS: The total person-time in the cohort was 9093.93 years and 613 seroconversions were observed. The overall crude HIV incidence rate across all communities was 6·74 per 100PY (95% CI: 6·22-7·30). 95% of the clusters had HIV incidence rates greater than 3 per 100PY. The CAR analysis identified six communities with significantly high HIV incidence. Estimated relative risks for these clusters ranged from 1.34 to 1.70. Consistent with these results, age standardized HIV incidence rates were also highest in these clusters and estimated to be 10 or more per 100 PY. Compared to women 35+ years old younger women were more likely to reside in the highest incidence areas (aOR: 1·51, 95% CI: 1·06-2·15; aOR: 1.59, 95% CI: 1·19-2·14 and aOR: 1·62, 95% CI: 1·2-2·18 for < 20, 20-24, 25-29 years old respectively). Partnership factors (2+ sex partners and being unmarried/not cohabiting) were also more common in the highest incidence clusters (aOR 1.48, 95% CI: 1.25-1.75 and aOR 1.54, 95% CI: 1.28-1.84 respectively). CONCLUSION: Fine geospatial analysis showed a continuous, unrelenting, hyper HIV epidemic in most of the greater Durban region with six communities characterised by particularly high levels of HIV incidence. The results motivate for comprehensive community-based HIV prevention approaches including expanded access to PrEP. In addition, a higher concentration of HIV related services is required in the highest risk communities to effectively reach the most vulnerable populations.

The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care.

INTRODUCTION: District hospitals are key to providing universal coverage of essential surgery and for strengthening surgical care in general. This audit set out to quantify the surgical output of all the district hospitals in KwaZulu-Natal Province (KZN) over a 6-month period to see whether district hospitals were delivering the surgical care they are expected to deliver. RESULTS: There were a total of 18,871 operations performed at 37 district hospitals in KwaZulu-Natal from July to December 2015. The number of operations per hospital varied widely between 2150 at a single large district hospital and 68 at a small district hospital, respectively. Surgical operations for obstetrical conditions made up by far the majority of operations at 57%, with gynecological operations making up the second highest at 15%. Only 12% of operations were for general surgical conditions. With regards to the bellwether procedures, 96.1% of these were cesarean sections, 2.1% were laparotomies and 1.8% were ORIFs. For almost all the 37 hospitals, the percentage of laparotomies and ORIFs performed was small to negligible, while the percentage of cesarean sections performed was high. The number of bellwether operations performed per 100,000 population was much higher than the number of general surgical or orthopedic operations performed, primarily because of the preponderance of cesarean sections conducted in each hospital. We observed a strong and significant positive correlation (+0.691, 95% CI +0.538 to +0.800, p < 0.001) between increasing distance to nearest regional referral hospital and rate of laparotomies and ORIF procedures performed. CONCLUSIONS: The surgical output of district hospitals in KZN is heavily skewed toward obstetrics and gynecology. Further work is required to understand the reasons for this, but the current data imply that district hospitals are not delivering surgical and orthopedic care at district hospitals in KwaZulu-Natal.

Sub national variation and inequalities in under-five mortality in Kenya since 1965.

BACKGROUND: Despite significant declines in under five mortality (U5M) over the last 3 decades, Kenya did not achieve Millennium Development Goal 4 (MDG 4) by 2015. To better understand trends and inequalities in child mortality, analysis of U5M variation at subnational decision making units is required. Here the comprehensive compilation and analysis of birth history data was used to understand spatio-temporal variation, inequalities and progress towards achieving the reductions targets of U5M between 1965 and 2013 and projected to 2015 at decentralized health planning units (counties) in Kenya. METHODS: Ten household surveys and three censuses with data on birth histories undertaken between 1989 and 2014 were assembled. The birth histories were allocated to the respective counties and demographic methods applied to estimate U5M per county by survey. To generate a single U5M estimate for year and county, a Bayesian spatio-temporal Gaussian process regression was fitted accounting for variation in sample size, surveys and demographic methods. Inequalities and the progress in meeting the goals set to reduce U5M were evaluated subnationally. RESULTS: Nationally, U5M reduced by 61·6%, from 141·7 (121·6-164·0) in 1965 to 54·5 (44·6-65·5) in 2013. The declining U5M was uneven ranging between 19 and 80% across the counties with some years when rates increased. By 2000, 25 counties had achieved the World Summit for Children goals. However, as of 2015, no county had achieved MDG 4. There was a striking decline in the levels of inequality between counties over time, however, disparities persist. By 2013 there persists a 3·8 times difference between predicted U5M rates when comparing counties with the highest U5M rates against those with the lowest U5M rates. CONCLUSION: Kenya has made huge progress in child survival since independence. However, U5M remains high and heterogeneous with substantial differences between counties. Better use of the current resources through focused allocation is required to achieve further reductions, reduce inequalities and increase the likelihood of achieving Sustainable Development Goal 3·2 on U5M by 2030.

A health system framework for perinatal care in South African district hospitals: a Delphi technique.

BACKGROUND: The majority of perinatal deaths occurring in low- and middle- income countries are preventable. South Africa is a middle-income country with consistently high perinatal mortality rates and most factors contributing to preventable deaths are linked to the functioning of the health system. Particularly of concern in South Africa is the high perinatal mortality in district hospitals, where most births occur and where intrapartum care is provided to women of low and intermediate risk. Therefore, it is crucial to strengthen the health system for perinatal care in district hospitals. There is currently no consolidated documented framework outlining contextual health system domains and indicators that are key to providing effective perinatal care in district hospitals. The purpose of this study was to derive key health system domains and indicators necessary to measure the performance of the health system for perinatal care in South African district hospitals. METHODS: The Delphi technique was used in collecting data from a panel with experts drawn from disciplines connected with the functioning of the health system for perinatal care in South Africa. The study enrolled thirteen experts from whom data on key health system domains and indicators for perinatal care were derived. The project reference group gave guidance to the development of the framework and ascertained its relevance to the South African setting. RESULTS: The Facility Based Health System Framework for Perinatal Care comprising domains and indicators necessary to measure health system performance in South African district hospitals was derived from data. The broad structure of the proposed framework aligns with the WHO Health Systems Framework. Each critical building block has detailed domains and indicators that illuminate essential facility-level and programme-specific elements that require attention for strengthening the health system for perinatal care. CONCLUSION: The proposed framework can enable district hospital management teams to identify gaps in the health system for perinatal care, which need to be strengthened in order to alleviate the burden of perinatal deaths in district hospitals.