"There's evidence that this really works and anything that works is good": views on the introduction of medical male circumcision for HIV prevention in South Africa.

Three clinical trials have demonstrated the partial efficacy (40-60%) of surgically conducted medical male circumcision (MMC) in preventing HIV transmission to circumcised men. This research formed part of a larger study exploring the importance of integration of sexual and reproductive health with HIV services. The objective was to elicit key informant views on the introduction of MMC for HIV prevention in South Africa. Twenty-one key informants representing the South African Health Department, local and international NGOs and universities, were asked, via semi-structured interviews about their views on introducing MMC as an HIV prevention strategy in South Africa. Interviews were transcribed and all discussions on MMC were coded for analysis using NVivo 8. The majority of the key informants were knowledgeable about MMC for HIV prevention and felt that making MMC available in South Africa was a good idea, with some recommending immediate introduction. Others felt that MMC should be introduced with caution. Various factors were recommended for consideration, including culture, the impact of circumcision on women, possible increase in sexual risk behaviour from behavioural disinhibition and that MMC may become another vertical health service programme. Most felt that MMC should be undertaken in neonates, however, acknowledged concerns about cultural responses to this. Recommendations on the implementation of MMC ranged from integrating services at primary health care level, to provision by private medical practitioners. In conclusion, MMC is viewed as a key HIV prevention strategy. However, there are numerous factors which could hinder introduction and uptake in South Africa and in the region. It is important to explore and understand these factors and for these to be aligned in the national MMC policy.

Voluntary medical male circumcision in selected provinces in South Africa: Outcomes from a programmatic setting.

INTRODUCTION: Voluntary medical male circumcision (VMMC) remains an effective biomedical intervention for HIV prevention in high HIV prevalence countries. In South Africa, United States Agency for International Development VMMC partners provide technical assistance to the Department of Health, at national and provincial levels in support of the establishment of VMMC sites as well as in providing direct VMMC services at site level since April 2012. We describe the outcomes of the Right to Care (RTC) VMMC program implemented in South Africa from 2012 to 2017. METHODS: This retrospective study was undertaken at RTC supported facilities across six provinces. Young males aged ≥10 years who presented at these facilities from 1 July 2012 to 31 September 2017 were included. Outcomes were VMMC uptake, HIV testing uptake and rate of adverse events (AEs). Using a de-identified observational database of these clients, summary statistics of the demographic characteristics and outcomes were calculated. RESULTS: There were a total 1,001,226 attendees of which 998,213 (99.7%) were offered VMMC and had a median age of 15 years (IQR = 12-23 years). Of those offered VMMC, 99.6% (994,293) consented, 96.7% (965,370) were circumcised and the majority (46.3%) were from Gauteng province. HIV testing uptake was 71% with a refusal rate of 15%. Of the newly diagnosed HIV positives, 64% (6,371 / 9,972) referrals were made. The rate of AEs, defined as bleeding, infection, and insufficient skin removal) declined from 3.26% in 2012 to 1.17% in 2017. There was a reduction in infection-related AEs from 2,448 of the 2,602 adverse events (94.08%) in 2012 to 129 of the 2,069 adverse events (6.23%) in 2017. CONCLUSION: There was a high VMMC uptake with a decline in AEs over time. Adolescent men contributed the most to the circumcised population, an indication that the young population accesses medical circumcision more. VMMC programs need to implement innovative demand creation strategies to encourage older males (20-34 years) at higher risk of HIV acquisition to get circumcised for immediate impact in reduction of HIV incidence. HIV prevalence in the total population increased with increasing age, notably in clients above 25 years.

Using a file audit to evaluate retention in care and patient outcomes in a programme to decentralise antiretroviral treatment to primary health care facilities in a high prevalence setting in KwaZulu-Natal, South Africa.

HIV care and antiretroviral treatment (ART) provision is largely hospital-based with an over-reliance on doctors. Existing ART sites are reaching capacity and are increasingly unable to initiate new patients and also see follow up patients. In response, the Reproductive Health and HIV Research Unit (RHRU), has supported the KwaZulu-Natal provincial Department of Health with developing a model to decentralise services to primary health care (PHC) level. The programme has been in operation since 2006, and currently nine ART initiation sites down refer stable patients to 24 PHC clinics. Data on patient numbers, treatment outcomes and patient retention rates were collected through a file audit of 2071 adult patient files and analyzed. Results indicate that a file audit is a feasible mechanism to provide this data and can be used to identify gaps and improve quality of care. PHC sites in resource-constrained settings are able to manage stable patients on ART; however, sites need support with monitoring and evaluation and with tracking patients that have been down referred. In terms of quality of care, PHC sites need to ensure that clients receive CD4 count tests and viral load monitoring at six monthly intervals to ensure that treatment failure does not go undetected. Patients suspected of experiencing adverse events or treatment failure appear to be managed according to standard operating procedures, but there is a need to ensure that adverse events are clearly documented in patient files.

Birth outcomes following antiretroviral exposure during pregnancy: Initial results from a pregnancy exposure registry in South Africa.

BACKGROUND: In 2013, a pregnancy exposure registry and birth defects surveillance (PER/BDS) system was initiated in eThekwini District, KwaZulu-Natal (KZN), to assess the impact of antiretroviral treatment (ART) on birth outcomes. OBJECTIVES: At the end of the first year, we assessed the risk of major congenital malformations (CM) and other adverse birth outcomes (ABOs) detected at birth, in children born to women exposed to ART during pregnancy. METHOD: Data were collected from women who delivered at Prince Mshiyeni Memorial Hospital, Durban, from 07 October 2013 to 06 October 2014, using medicine exposure histories and birth outcomes from maternal interviews, clinical records and neonatal surface examination. Singleton births exposed to only one ART regimen were included in bivariable analysis for CM risk and multivariate risk analysis for ABO risk. RESULTS: Data were collected from 10 417 women with 10 517 birth outcomes (4013 [38.5%] HIV-infected). Congenital malformations rates in births exposed to Efavirenz during the first trimester (T1) (RR 0.87 [95% CI 0.12-6.4; p = 0.895]) were similar to births not exposed to ART during T1. However, T1 exposure to Nevirapine was associated with the increased risk of CM (RR 9.28 [95% CI 2.3-37.9; p = 0.002]) when compared to the same group. Other ABOs were more frequent in the combination of HIV/ART-exposed births compared to HIV-unexposed births (29.9% vs. 26.0%, adjusted RR 1.23 [1.14-1.31; p < 0.001]). CONCLUSION: No association between T1 use of EFV-based ART regimens and CM was observed. Associations between T1 NVP-based ART regimen and CM need further investigation. HIV- and ART-exposed infants had more ABOs compared to HIV-unexposed infants.

Mapping indicators of sexually transmitted infection services in the South African public health sector.

BACKGROUND: Prevention and early treatment of sexually transmitted infections (STIs) is a high public health priority in South Africa. In 2002 a national survey of public health care (PHC) facilities was conducted to develop measurable indicators for monitoring and evaluation of the National STI programme. In this paper we present maps of key indicators obtained from the survey, and discuss their programmatic implications. We also address some methodological issues that arise in the context of producing appropriate maps. METHODS: A national sample, stratified by subdistrict/municipality, of 962 PHC facilities was randomly selected. In each facility the senior nurse was telephonically contacted and interviewed to answer questions related to the implementation of STI prevention and management from a structured questionnaire. Responses were validated through a second phone call, and inconsistencies recorded. The following key variables were mapped: stock-outs of drugs and condoms, knowledge of correct treatment procedures, consistent record keeping, number of STI clients seen per month per 1000 adult population, number of condoms distributed per adult male, and number of trained nurses per 1000 population. Using conditional autoregressive models and Markov Chain Monte Carlo (MCMC) simulation, smoothed subdistrict level clinic responses were computed and 95% confidence limits estimated. RESULTS AND DISCUSSION: Drug stock-outs were reported by 13% [95% CI 10-15%] and condom stock-outs were reported by 4% [95% CI 2-5%] of facilities. Underlying geographical patterns of risk were more clearly observed when maps had been smoothed and were not dominated by sampling error. Smoothed maps show that there is a finite, low risk of drug stock-outs in all areas with higher risk regions more clearly identified. The maps of indicators of STI services at PHC facilities show that there are important differences in quality of service within South Africa and underscore the usefulness of facility level routine data both for local programme monitoring and planning and for providing a national "bird's eye view" of programme performance.