Seroprevalence of Severe Acute Respiratory Syndrome Coronavirus 2 After the Second Wave in South Africa in Human Immunodeficiency Virus-Infected and Uninfected Persons: A Cross-Sectional Household Survey.

BACKGROUND: Seroprevalence studies are important for quantifying the burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in resource-constrained countries. METHODS: We conducted a cross-sectional household survey spanning the second pandemic wave (November 2020 to April 2021) in 3 communities. Blood was collected for SARS-CoV-2 antibody (2 enzyme-linked immunosorbent assays targeting spike and nucleocapsid) and human immunodeficiency virus (HIV) testing. An individual was considered seropositive if testing positive on ≥1 assay. Factors associated with infection, and the age-standardized infection case detection rate, infection hospitalization rate, and infection fatality rate were calculated. RESULTS: Overall, 7959 participants were enrolled, with a median age of 34 years and an HIV prevalence of 22.7%. SARS-CoV-2 seroprevalence was 45.2% (95% confidence interval 43.7%-46.7%) and increased from 26.9% among individuals enrolled in December 2020 to 47.1% among those enrolled in April 2021. On multivariable analysis, seropositivity was associated with age, sex, race, being overweight/obese, having respiratory symptoms, and low socioeconomic status. Persons living with HIV with high viral load were less likely to be seropositive than HIV-uninfected individuals. The site-specific infection case detection rate, infection hospitalization rate, and infection fatality rate ranged across sites from 4.4% to 8.2%, 1.2% to 2.5%, and 0.3% to 0.6%, respectively. CONCLUSIONS: South Africa has experienced a large burden of SARS-CoV-2 infections, with <10% of infections diagnosed. Lower seroprevalence among persons living with HIV who are not virally suppressed, likely as a result of inadequate antibody production, highlights the need to prioritize this group for intervention.

Health and wellbeing needs and priorities in mining host communities in South Africa: a mixed-methods approach for identifying key SDG3 targets.

BACKGROUND: The global mining industry has an opportunity to mobilize resources to advance progress against the Sustainable Development Goals (SDGs). In 2018, the Anglo-American Group outlined aspirations for mining host communities to meet the SDG3 health targets. To progress from aspiration to action we designed and implemented a mixed-methods approach to attain a deeper understanding of the health and wellbeing priorities within the local context of host communities of fifteen mines in South Africa. METHODS: To identify local needs and priorities relating to SDG3 targets in host communities, stakeholder workshops and key informant interviews were conducted between June and August 2019. A baseline assessment of health data, related to each of the SDG3 targets and indicators and to each host community location, was also conducted. Findings emerging from the qualitative and quantitative baseline assessments were compared to identify the extent to which health issues aligned and health and wellbeing priority areas for action. RESULTS: A total of 407 people participated in the workshops, and 85 key informants were interviewed. Quantitative data were available at sub-national level for seven of the nine SDG3 targets and eleven of the 21 indicators. Key priority areas for action identified through alignment of the qualitative and quantitative data were maternal mortality (SDG3.1), HIV (SDG3.3.1), tuberculosis (SDG3.3.2), substance abuse (SDG3.5), and road traffic accidents (SDG3.6) We found consistency in the individual, interpersonal, community, societal, and structural factors underlying these priority areas. At a structural level, poor access to quality healthcare was raised at every workshop as a key factor underlying the achievement of all SDG3 targets. Of the five priority areas identified, HIV, TB and substance abuse were found to overlap in the study communities in terms of risk, burden, and underlying factors. CONCLUSIONS: We demonstrate a mixed method approach for identifying local health needs and prioritised SDG3 targets in mining host communities. Consistency in reporting suggests the need for effective, efficient and feasible interventions to address five priority areas. Given the prominent economic role of the mining sector in South Africa, it can play a critical role in implementing programmatic activities that further progress towards achieving the SDG3 targets.

The role and effectiveness of School-based Extra-Curricular Interventions on children's health and HIV related behaviour: the case study of Soul Buddyz Clubs Programme in South Africa.

BACKGROUND: HIV education targeting children and adolescents is a key component of HIV prevention. This is especially important in the context of increasing HIV prevalence rates among adolescents and young people. The authors sought to examine the role and effectiveness of an extra-curricular school based programme, Soul Buddyz Clubs (SBC) on HIV knowledge, attitudes, behaviours and biomedical outcomes. METHODS: This paper employs a mixed methods approach drawing on data from independent qualitative and quantitative sources. Secondary data analysis was performed using survey data from a nationally representative sample that was restricted to 10-14 year-old males and females living in South Africa. Ten focus group discussions and ten in-depth interviews conducted with SBC members and facilitators from 5 provinces, as part of a process evaluation are used to triangulate the effectiveness of SBC intervention. RESULTS: The analysis of survey data from 2 198 children indicated that 12% of respondents were exposed to SBC with 4% reporting that they had ever belonged to a club. Children exposed to SBC were more likely to be medically circumcised (AOR 2.38; 95%CI 1.29 -4.40, p=0.006), had correct HIV knowledge (AOR 2.21; 95%CI 1.36 - 3.57, p<0.001) and had less HIV stigmatising attitudes (AOR 0.54; 95%CI 0.31-0.93, p=0.025), adjusting for age, sex, province and exposure to other media - in comparison to those not exposed. Propensity Score Matching findings were consistent with the regression findings. Qualitative findings also supported some of the quantitative results. SBC members reported having learnt about HIV prevention life skills, including condom use, positive attitudes towards people living with HIV, and alcohol abuse. CONCLUSIONS: Participation in SBC is associated with accessing biomedical HIV prevention services, specifically MMC, correct HIV prevention knowledge and less HIV stigmatizing attitudes. This paper demonstrates the effectiveness of a school-based extracurricular intervention using a club approach targeting boys and girls ages 10-14 years on some of the key HIV prevention biomarkers as well as knowledge and attitudes. The article suggests that extra-curricular interventions can form an effective component of school-based comprehensive sexuality education in preventing HIV and promoting medical male circumcision.

Alcohol Availability, Marketing, and Sexual Health Risk Amongst Urban and Rural Youth in South Africa.

South Africa has high rates of HIV prevalence and incidence and very high binge drinking rates amongst youth. GIS mapping of alcohol outlets and participatory research methods were used to explore and understand youth's perception of alcohol availability and marketing, and their associated risks for HIV and sexual violence. Twenty seven youth 18-24 years from an urban and rural area participated in the study. There was high density of alcohol outlets at both sites with 97% within 500 m radius to a school; 76% of outlets had alcohol advertising signage on the exterior. Youth reported that alcohol is easily accessible to them. Alcohol advertising and marketing are appealing and entice them to consume alcohol, including binge drinking. Young women reported exposure to unsafe and transactional sex, and sexual violence at alcohol outlets. Effective policies are needed to regulate alcohol availability and marketing to youth.

Using a cascade approach to assess condom uptake in female sex workers in India: a review of the Avahan data.

BACKGROUND: The Avahan India AIDS Initiative was implemented to provide HIV prevention services to key populations including female sex workers (FSWs) who carry the burden of India's concentrated HIV epidemic. Established in 2003 and handed over to the Indian government in 2009, the Initiative included peer-led outreach education, condom promotion and distribution and STI treatment. This study aimed to determine if HIV prevention cascades could be generated using routine monitoring and evaluation data from the Avahan program and to assess their value in identifying and responding to program gaps for FSWs. METHODS: Two data sources were used namely the Integrated Behavioural and Biological Assessment reports and the Centralized Management Information System dataset. Indicators selected for the cascades were: FSWs at risk, belief that HIV can be prevented, condom access and consistent condom use with an occasional partner. Six districts were selected and stratified by HIV prevalence at baseline and two cascades were generated per district reflecting changes over time. RESULTS: Consistent condom use with occasional partners in this population increased in all six districts during program implementation, with statistically significant increases in four of the six. No patterns in the cascades were detected according to HIV prevalence either at baseline (2005) or at follow-up (2009). Cascades were able to identify key programmatic bottlenecks at baseline that could assist with focusing program efforts and direct resources at district levels. In some districts the belief that HIV could not be prevented contributed to inconsistent condom use, while in others, low levels of condom access were a more important barrier to consistent condom use. CONCLUSION: This HIV prevention cascade analysis among FSWs in India suggests that cascades could assist in identifying program gaps, focus intervention efforts and monitor their effect. However, cascades cannot replace a detailed understanding of the multiple factors at individual, community and structural levels that lead to consistent condom use in this key population. Careful indicator selection coupled with innovative data collection methods will be required. Pilot projects are proposed to formally evaluate the value of HIV prevention cascades at district level.

Behavior change communication and mobile populations: the evaluation of a cross-border HIV/AIDS communication strategy amongst migrants from Swaziland.

This study investigates the effect of being exposed to the Soul City Southern Africa Regional OneLove campaign, a behavior change communication program, on sexual behavior and condom use among a mobile population in Swaziland. Data for this study come from a nationally representative sample of 845 individuals who reported traveling to neighboring countries for at least two weeks at any time in the previous two years. Respondents were asked about exposure to the campaign through television, radio, booklets, posters, and advertisements both in Swaziland and in the other countries where they had traveled in the previous two years. Odds ratios were used to estimate the relationships between the HIV/AIDS outcomes of interest and program exposure for the full sample as well as separately for males and females. The program had no effect on reducing known risky behaviors such as having multiple sexual partners. However, men exposed in Swaziland only (AOR = 3.4, CI 1.2-9.4) and in Swaziland and another country (AOR = 2.8, CI 1.0-7.7) were more likely to report using a condom at last sex. In the full sample, those exposed in Swaziland were more likely to report using a condom at last sex (AOR = 2.6, CI 1.3-5.3) and a condom at last sex with a regular partner (AOR = 2.3, CI 1.1-4.8). Men who reported multiple sexual partnerships and who were exposed in Swaziland and another country were nine times as likely to report condom at last sex than men with no exposure. Respondents exposed in Swaziland and another country were more likely to have been tested for HIV; this was true for the total population (AOR = 2.9, CI 1.1-7.9) and for men separately (AOR = 3.3, CI 1.1-10.1). These findings provide support for more regional HIV prevention programs in Southern Africa as a way to increase positive behaviors among mobile populations.

Understanding the role of the OneLove campaign in facilitating drivers of social and behavioral change in southern Africa: a qualitative evaluation.

In the wake of the HIV and AIDS pandemic, health communication has played an important role in social and behavior change in HIV prevention and treatment efforts. Despite this significant role, it is not always clear how health communication influences individuals and communities to facilitate social and behavior change. Guided predominantly by Lewin's theory of change in the context of complexity thinking, and supported by qualitative evidence from Soul City Institute's midterm evaluation of the OneLove multimedia campaign in 9 southern African countries, this article illustrates how carefully designed health edutainment communication materials facilitate drivers of social and behavior change. Thus, researched and theory-based health communication aimed at behavior and social change remains an important pillar in HIV prevention and treatment, where personal and social agency remain key.

Healthcare utilization during the first two waves of the COVID-19 epidemic in South Africa: A cross-sectional household survey.

Healthcare utilization surveys contextualize facility-based surveillance data for burden estimates. We describe healthcare utilization in the catchment areas for sentinel site healthcare facilities during the first year of the COVID-19 pandemic. We conducted a cross-sectional healthcare utilization survey in households in three communities from three provinces (KwaZulu-Natal, Western Cape and North West). Field workers administered structured questionnaires electronically with the household members reporting influenza-like illness (ILI) in the past 30 days or severe respiratory illness (SRI) since March 2020. Multivariable logistic regression was used to identify factors associated with healthcare utilization among individuals that reported illness. From November 2020 through April 2021, we enrolled 5804 households and 23,003 individuals. Any respiratory illness was reported by 1.6% of individuals; 0.7% reported ILI only, 0.8% reported SRI only, and 0.1% reported both ILI and SRI. Any form of medical care was sought by 40.8% (95% CI 32.9% - 49.6%) and 71.3% (95% CI 63.2% - 78.6%) of individuals with ILI and SRI, respectively. On multivariable analysis, respiratory illness was more likely to be medically attended for individuals at the Pietermaritzburg site (aOR 3.2, 95% CI 1.1-9.5, compared to Klerksdorp), that were underweight (aOR 11.5, 95% CI 1.5-90.2, compared to normal weight), with underlying illness (aOR 3.2, 95%CI 1.2-8.5), that experienced severe illness (aOR 4.8, 95% CI 1.6-14.3) and those with symptom duration of ≥10 days (aOR 7.9, 95% CI 2.1-30.2, compared to <5 days). Less than half of ILI episodes and only 71% of SRI episodes were medically attended during the first two COVID-19 waves in South Africa. Facility-based data may underestimate disease burden during the COVID-19 pandemic.

Knowledge, attitudes, practices and intention to get vaccinated against COVID-19: results from a cross-sectional survey in three peri-urban communities in South Africa.

Introduction: South Africa has the largest number of confirmed cases of COVID-19 in Africa. Data to inform public health strategies to mitigate the spread of new variants and severity of disease is needed, including information on knowledge, attitudes and practices (KAP) regarding COVID-19, factors associated with intention to get vaccinated, and viewpoints on reliable sources of data. Methods: we investigated these topics as part of the COVID-19 healthcare utilization and seroprevalence (HUTS) cross-sectional survey in three communities in South Africa: Mitchell´s Plain (Western Cape Province), Pietermaritzburg (KwaZulu-Natal Province) and Klerksdorp (North West Province) during and after the second wave of COVID-19 prior to vaccine availability. Results: primary caregivers from 5799 households participated in the study, 41.1% from Pietermaritzburg, 34.2% from Klerksdorp and 24.7% from Mitchells Plain. Two-thirds and 94.7% of respondents had correct knowledge on the cause and spread of COVID-19, respectively. Knowledge measures were significantly associated with age less than 65 years, the highest level of education and site (Mitchells Plain). Desired preventive behaviors were associated with higher socio-economic status. While 64.7% of people intended to get vaccinated, those over 64 years of age were more likely to intend to vaccinate (aOR: 1.25, 95% CI: 1.06-1.47). Vaccine intention related to protection of self (58.4%) and family (40.0%). The most trusted source of COVID-19 information was television (59.3%) followed by radio (20.0%). Conclusion: these data can be used to design targeted public health campaigns for the current COVID-19 and future epidemics, ensuring that socio-economic constraints and preference for trusted information are considered.

Investing in African research training institutions creates sustainable capacity for Africa: the case of the University of the Witwatersrand School of Public Health masters programme in epidemiology and biostatistics.

BACKGROUND: Improving health in Africa is a high priority internationally. Inadequate research capacity to produce local, relevant research has been identified as a limitation to improved population health. Increasing attention is being paid to the higher education sector in Africa as a method of addressing this; evidence that such investment is having the desired impact is required. A 1998 3-year investment by the Special Programme for Research and Training in Tropical Diseases (TDR) in research training at the School of Public Health, University of the Witwatersrand, South Africa was reviewed to assess its' impact. METHODS: A descriptive cross-sectional survey of the 70 students registered for the masters programme in epidemiology & biostatistics from 2000-2005 was conducted. Data were collected from self-administered questionnaires. RESULTS: Sixty percent (42/70) of students responded. At the time of the survey 19% of respondents changed their country of residence after completion of the masters course, 14% migrated within Africa and 5% migrated out of Africa. Approximately half (47%) were employed as researchers and 38% worked in research institutions. Sixty percent reported research output, and four graduates were pursuing PhD studies. Government subsidy to higher education institutions, investments of the University of the Witwatersrand in successful programmes and ongoing bursaries for students to cover tuition fees were important for sustainability. CONCLUSIONS: Investing in African institutions to improve research training capacity resulted in the retention of graduates in Africa in research positions and produced research output. Training programmes can be sustained when national governments invest in higher education and where that funding is judiciously applied. Challenges remain if funding for students bursaries is not available.

The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models.

Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.

Coming home to die? The association between migration and mortality in rural South Africa.

BACKGROUND: Studies on migration often ignore the health and social impact of migrants returning to their rural communities. Several studies have shown migrants to be particularly susceptible to HIV infection. This paper investigates whether migrants to rural households have a higher risk of dying, especially from HIV, than non-migrants. METHODS: Using data from a large and ongoing Demographic Surveillance System, 41,517 adults, enumerated in bi-annual rounds between 2001 and 2005, and aged 18 to 60 years were categorized into four groups: external in-migrants, internal migrants, out-migrants and residents. The risk of dying by migration status was quantified by Cox proportional hazard regression. In a sub-group analysis of 1212 deaths which occurred in 2000 - 2001 and for which cause of death information was available, the relationship between migration status and dying from AIDS was examined in logistic regression. RESULTS: In all, 618 deaths were recorded among 7,867 external in-migrants, 255 among 4,403 internal migrants, 310 among 11,476 out-migrants and 1900 deaths were registered among 17,771 residents. External in-migrants were 28% more likely to die than residents [adjusted Hazard Ratio (aHR) = 1.28, P < 0.001, 95% Confidence Interval (CI) (1.16, 1.41)]. In the sub-group analysis, the odds of dying from AIDS was 1.79 [adjusted Odd ratio (aOR) = 1.79, P = 0.009, 95% CI (1.15, 2.78)] for external in-migrants compared to residents; there was no statistically significant difference in AIDS mortality between residents and out-migrants, [aOR = 1.25, P = 0.533, 95% CI (0.62-2.53)]. Independently, females were more likely to die from AIDS than males [aOR = 2.35, P < 0.001, 95% CI (1.79, 3.08)]. CONCLUSION: External in-migrants have a higher risk of dying, especially from HIV related causes, than residents, and in areas with substantial migration this needs to be taken into account in evaluating mortality statistics and planning health care services.

Alcohol Use and Transactional Sex among Women in South Africa: Results from a Nationally Representative Survey.

BACKGROUND: Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa. METHODS: A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16-55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex. RESULTS: About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1-4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5-6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex. CONCLUSION: Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.

Impact of Place of Delivery on Neonatal Mortality in Rural Tanzania.

OBJECTIVES: Studies on factors affecting neonatal mortality have rarely considered the impact of place of delivery on neonatal mortality. This study provides epidemiological information regarding the impact of place of delivery on neonatal deaths. METHODS: We analyzed data from the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania. A total of 5,124 live births and 166 neonatal deaths were recorded from January 2005 to December 2006. The place of delivery was categorized as either in a health facility or outside, and the neonatal mortality rate (NMR) was calculated as the number of neonatal deaths per 1,000 live births. Univariate and multivariate logistic regression models were used to assess the association between neonatal mortality and place of delivery and other maternal risk factors while adjusting for potential confounders. RESULTS: Approximately 67% (111) of neonatal deaths occurred during the first week of life. There were more neonatal deaths among deliveries outside health facilities (NMR = 43.4 per 1,000 live births) than among deliveries within health facilities (NMR = 27.0 per 1,000 live births). The overall NMR was 32.4 per 1,000 live births. Mothers who delivered outside a health facility experienced 1.85 times higher odds of experiencing neonatal deaths (adjusted odds ratio = 1.85; 95% confidence interval = 1.33-2.58) than those who delivered in a health facility. CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS: Place of delivery is a significant predictor of neonatal mortality. Pregnant women need to be encouraged to deliver at health facilities and this should be done by intensifying education on where to deliver. Infrastructure, such as emergency transport, to facilitate health facility deliveries also requires urgent attention.

Where have all the doctors gone? Career choices of Wits medical graduates.

OBJECTIVES: To assess the distribution of University of the Witwatersrand (Wits) medical graduates from 1960 to 1994 with regard to private or public sector work, chosen specialist or generalist careers, and work in urban or rural areas, looking for secular trends and gender differences. DESIGN: A cross-sectional analysis of the register of what was then the South African Medical and Dental Council (SAMDC) and a telephone interview survey of a sample of medical graduates, collecting retrospective career histories. RESULTS: Thirty-six per cent of the sample was working predominantly in the public sector, while 47% of all years worked by graduates were in the public sector. Women graduates spent 68% of their years working in the public sector, compared with 36% for men. The majority (55%) of graduates in the sample who were working in the public sector cited academic and training aspects as the main reason for this choice. Conversely, nearly half (47%) gave income as the main reason for moving to the private sector. Forty per cent of graduates had specialised (46% of men, 22% of women), while 76% were working in the large urban areas. CONCLUSIONS: The findings highlight methodological problems with standard cross-sectional analysis of distribution of personnel. They also challenge several assumptions about the likelihood of Wits graduates working as generalists (60%), the voluntary contribution of graduates to the public sector, and in particular the value of women doctors to public service and primary care.

Labour complications remain the most important risk factors for perinatal mortality in rural Kenya.

OBJECTIVES: To identify and quantify risk factors for perinatal mortality in a Kenyan district hospital and to assess the proportion of perinatal deaths attributable to labour complications, maternal undernutrition, malaria, anaemia and human immunodeficiency virus (HIV). METHODS: A cross-sectional study of 910 births was conducted between January 1996 and July 1997 and risk factors for perinatal mortality were analysed. FINDINGS: The perinatal mortality rate was 118 per 1000 births. Complications of labour such as haemorrhage, premature rupture of membranes/premature labour, and obstructed labour/ malpresentation increased the risk of death between 8- and 62-fold, and 53% of all perinatal deaths were attributable to labour complications. Placental malaria and maternal HIV, on the other hand, were not associated with perinatal mortality. CONCLUSIONS: Greater attention needs to be given to the quality of obstetric care provided in the rural district-hospital setting.