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.

Small-area variation of cardiovascular diseases and select risk factors and their association to household and area poverty in South Africa: Capturing emerging trends in South Africa to better target local level interventions.

BACKGROUND: Of the total 56 million deaths worldwide during 2012, 38 million (68%) were due to noncommunicable diseases (NCDs), particularly cardiovascular diseases (17.5 million deaths) cancers (8.2 million) which represents46.2% and 21.7% of NCD deaths, respectively). Nearly 80 percent of the global CVD deaths occur in low- and middle-income countries. Some of the major CVDs such as ischemic heart disease (IHD) and stroke and CVD risk conditions, namely, hypertension and dyslipidaemia share common modifiable risk factors including smoking, unhealthy diets, harmful use of alcohol and physical inactivity. The CVDs are now putting a heavy strain of the health systems at both national and local levels, which have previously largely focused on infectious diseases and appalling maternal and child health. We set out to estimate district-level co-occurrence of two cardiovascular diseases (CVDs), namely, ischemic heart disease (IHD) and stroke; and two major risk conditions for CVD, namely, hypertension and dyslipidaemia in South Africa. METHOD: The analyses were based on adults health collected as part of the 2012 South African National Health and Nutrition Examination Survey (SANHANES). We used joint disease mapping models to estimate and map the spatial distributions of risks of hypertension, self-report of ischaemic heart disease (IHD), stroke and dyslipidaemia at the district level in South Africa. The analyses were adjusted for known individual social demographic and lifestyle factors, household and district level poverty measurements using binary spatial models. RESULTS: The estimated prevalence of IHD, stroke, hypertension and dyslipidaemia revealed high inequality at the district level (median value (range): 5.4 (0-17.8%); 1.7 (0-18.2%); 32.0 (12.5-48.2%) and 52.2 (0-71.7%), respectively). The adjusted risks of stroke, hypertension and IHD were mostly high in districts in the South-Eastern parts of the country, while that of dyslipidaemia, was high in Central and top North-Eastern corridor of the country. CONCLUSIONS: The study has confirmed common modifiable risk factors of two cardiovascular diseases (CVDs), namely, ischemic heart disease (IHD) and stroke; and two major risk conditions for CVD, namely, hypertension and dyslipidaemia. Accordingly, an integrated intervention approach addressing cardiovascular diseases and associated risk factors and conditions would be more cost effective and provide stronger impacts than individual tailored interventions only. Findings of excess district-level variations in the CVDs and their risk factor profiles might be useful for developing effective public health policies and interventions aimed at reducing behavioural risk factors including harmful use of alcohol, physical inactivity and high salt intake.

The Arts and Tools for Using Routine Health Data to Establish HIV High Burden Areas: The Pilot Case of KwaZulu-Natal South Africa.

Background: To optimally allocate limited health resources in responding to the HIV epidemic, South Africa has undertaken to generate local epidemiological profiles identifying high disease burden areas. Central to achieving this, is the need for readily available quality health data linked to both large and small geographic areas. South Africa has relied on national population-based surveys: the Household HIV Survey and the National Antenatal Sentinel HIV and Syphilis Prevalence Survey (ANC) amongst others for such data for informing policy decisions. However, these surveys are conducted approximately every 2 and 3 years creating a gap in data and evidence required for policy. At subnational levels, timely decisions are required with frequent course corrections in the interim. Routinely collected HIV testing data at public health facilities have the potential to provide this much needed information, as a proxy measure of HIV prevalence in the population, when survey data is not available. The South African District health information system (DHIS) contains aggregated routine health data from public health facilities which is used in this article. Methods: Using spatial interpolation methods we combine three "types" of data: (1) 2015 gridded high-resolution population data, (2) age-structure data as defined in South Africa mid-year population estimates, 2015; and (3) georeferenced health facilities HIV-testing data from DHIS for individuals (15-49 years old) who tested in health care facilities in the district in 2015 to delineate high HIV disease burden areas using density surface of either HIV positivity and/or number of people living with HIV (PLHIV). For validation, we extracted interpolated values at the facility locations and compared with the real observed values calculating the residuals. Lower residuals means the Inverse Weighted Distance (IDW) interpolator provided reliable prediction at unknown locations. Results were adjusted to provincial published HIV estimates and aggregated to municipalities. Uncertainty measures map at municipalities is provided. Data on major cities and roads networks was only included for orientation and better visualization of the high burden areas. Results: Results shows the HIV burden at local municipality level, with high disease burden in municipalities in eThekwini, iLembe and uMngundgudlovu; and around major cities and national routes. Conclusion: The methods provide accurate estimates of the local HIV burden at the municipality level. Areas with high population density have high numbers of PLHIV. The analysis puts into the hand of decision makers a tool that they can use to generate evidence for HIV programming. The method allows decision makers to routinely update and use facility level data in understanding the local epidemic.

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.

Improving estimates of district HIV prevalence and burden in South Africa using small area estimation techniques.

Many countries, including South Africa, have implemented population-based household surveys to estimate HIV prevalence and the burden of HIV infection. Most household HIV surveys are designed to provide reliable estimates down to only the first subnational geopolitical level which, in South Africa, is composed of nine provinces. However HIV prevalence estimates are needed down to at least the second subnational level in order to better target the delivery of HIV care, treatment and prevention services. The second subnational level in South Africa is composed of 52 districts. Achieving adequate precision at the second subnational level therefore requires either a substantial increase in survey sample size or use of model-based estimation capable of incorporating other pre-existing data. Our purpose is demonstration of the efficacy of relatively simple small-area estimation of HIV prevalence in the 52 districts of South Africa using data from the South African National HIV Prevalence, Incidence and Behavior Survey, 2012, district-level HIV prevalence estimates obtained from testing of pregnant women who attended antenatal care (ANC) clinics in 2012, and 2012 demographic data. The best-fitting model included only ANC prevalence and dependency ratio as out-of-survey predictors. Our key finding is that ANC prevalence was the superior auxiliary covariate, and provided substantially improved precision in many district-level estimates of HIV prevalence in the general population. Inclusion of a district-level spatial simultaneously autoregressive covariance structure did not result in improved estimation.

Prevalence of non-communicable diseases (NCDs) and associated factors among HIV positive educators: Findings from the 2015/6 survey of Health of Educators in Public Schools in South Africa.

INTRODUCTION: In many sub-Saharan African countries, confronting the dual epidemic of HIV and NCDs is a public health priority especially in high HIV burden countries such as South Africa. Evidence shows that poor health as a consequence of NCDs and HIV among the workforce increases absenteeism and leads to decrease in productivity. However, the prevalence of these co-occurring chronic conditions and associated factors is unknown in the educator workforce. Improved understanding has implications for their management and wellbeing of educators. This paper reports the prevalence of selected NCDs and associated factors among HIV positive educators in South Africa using the 2015/6 survey of Educators in Public Schools in South Africa. METHODS: This was a second-generation surveillance undertaken among educators in selected public schools in all nine provinces in South Africa. A multi-stage stratified cluster design with probability proportional to size sampling was used to draw a random sample of schools. Factors associated with presence of NCDs were determined using a multivariate backward stepwise logistic regression analysis. RESULTS: A total of 1 365 schools were sampled within which 21 495 (85.5%) educators were interviewed. Out of 2691, HIV Positive educators that responded to the questions on NCDs, 36.9% reported having NCDs. The most commonly reported NCDs were high blood pressure (17.4%), and stomach ulcers (13.5%). The increased odds of reporting the presence of NCDs was significantly associated with being female than male [aOR = 1.5: 95% CI (1.1-1.9), p<0.002], age 45 to 54 years [aOR = 1.8: 95% CI (1.4-2.2), p = p<0.001], and age 55 years and older than those 18 to 24 years [aOR = 2.7: 95% CI (1.8-3.9), p<0.001). The decreased odds of reporting the presence of NCDs was significantly associated with not being absent from school for health reasons [aOR = 0.7: 95% CI (0.6-0.9), p = 0.003]. CONCLUSION: NCDs care and active screening should be an integral part of HIV programmes including interventions such as prevention, treatment, care and support amongst public school educators in SA. The education department will need to invest in health promotion intervention programmes to prevent and mitigate the negative impact of NCDs and HIV on the sector.

Growing inequities in maternal health in South Africa: a comparison of serial national household surveys.

BACKGROUND: Rates of maternal mortality and morbidity vary markedly, both between and within countries. Documenting these variations, in a very unequal society like South Africa, provides useful information to direct initiatives to improve services. The study describes inequalities over time in access to maternal health services in South Africa, and identifies differences in maternal health outcomes between population groups and across geographical areas. METHODS: Data were analysed from serial population-level household surveys that applied multistage-stratified sampling. Access to maternal health services and health outcomes in 2008 (n = 1121) were compared with those in 2012 (n = 1648). Differences between socio-economic quartiles were quantified using the relative (RII) and slope (SII) index of inequality, based on survey weights. RESULTS: High levels of inequalities were noted in most measures of service access in both 2008 and 2012. Inequalities between socio-economic quartiles worsened over time in antenatal clinic attendance, with overall coverage falling from 97.0 to 90.2 %. Nationally, skilled birth attendance remained about 95 %, with persistent high inequalities (SII = 0.11, RII = 1.12 in 2012). In 2012, having a doctor present at childbirth was higher than in 2008 (34.4 % versus 27.8 %), but inequalities worsened. Countrywide, levels of planned pregnancy declined from 44.6 % in 2008 to 34.7 % in 2012. The RII and SII rose over this period and in 2012, only 22.4 % of the poorest quartile had a planned pregnancy. HIV testing increased substantially by 2012, though remains low in groups with a high HIV prevalence, such as women in rural formal areas, and from Gauteng and Mpumalanga provinces. Marked deficiencies in service access were noted in the Eastern Cape ad North West provinces. CONCLUSIONS: Though some population-level improvements occurred in access to services, inequalities generally worsened. Low levels of planned pregnancy, antenatal clinic access and having a doctor present at childbirth among poor women are of most concern. Policy makers should carefully balance efforts to increase service access nationally, against the need for programs targeting underserved populations.

Assessing the spatial nonstationarity in relationship between local patterns of HIV infections and the covariates in South Africa: A geographically weighted regression analysis.

Beyond the structural drivers such as distance from the road, rural/urban divide or demographic profiles, not much is known about the spatial relationship between HIV and social covariates. Spatial relations between social covariates and HIV infection of persons above 15 years were explored and mapped using geographically weighted regression model using data from a national HIV household survey conducted in 2008 and comprising 23 369 individuals from approximately 1000 enumeration areas that were randomly selected from the national census. The maps show spatial non-stationarity in relationship between local patterns of HIV prevalence and the social covariates across South Africa. The high prevalence districts have very homogeneous population defined by the following characteristics: Black origin, unfavorable sex ratio (high proportion of females), low socioeconomic status, being single or low marriage rates, multiple sexual partners and intergenerational sex. Markedly, intergenerational sex compounds the risk of acquiring HIV infection for females in poor districts. Identification of key social drivers of HIV and how they vary from location to location can help to effectively guide and focus intervention programs to areas of particular need.

Covariates of condom use in South Africa: findings from a national population-based survey in 2008.

Condom use has increased significantly over the past decade among all adult age groups in South Africa, and it is widely believed to have played a major role in the recent significant decline in HIV incidence in the country, especially among young people. This study investigated the demographic, behavioural and psychosocial correlates of condom use at last sex among a national random probability sample of sexually experienced respondents aged 15 years and older (n = 7817, 42.9% males and 57.1% females) using data from the 2008 South African national HIV population-based household survey. Multivariate logistic regression analyses revealed that for both sexes, being aged 15-24 years and 25-49 years old, Black African, never married and unemployed were significantly associated with condom use at last sex. In addition, for males, condom use was associated with having had two or more sexual partners, whereas for females it was associated with living in urban formal, urban informal and rural informal areas, and having been in a current relationship for less than a year. Based on these findings, it was concluded that there is a need to further promote condom use especially among the subgroups of people with lower rates of condom use in order to reduce their risk of HIV infection.

Socio-economic inequality and HIV in South Africa.

BACKGROUND: The linkage between the socio-economic inequality and HIV outcomes was analysed using data from a population-based household survey that employed multistage-stratified sampling. The goal is to help refocus attention on how HIV is linked to inequalities. METHODS: A socio-economic index (SEI) score, derived using Multiple Correspondence Analysis of measures of ownership of durable assets, was used to generate three SEI groups: Low (poorest), Middle, and Upper (no so poor). Distribution of HIV outcomes (i.e. HIV prevalence, access to HIV/AIDS information, level of stigma towards HIV/AIDS, perceived HIV risk and sexual behaviour) across the SEI groups, and other background characteristics was assessed using weighted data. Univariate and multivariate logistic regression was used to assess the covariates of the HIV outcomes across the socio-economic groups. The study sample include 14,384 adults 15 years and older. RESULTS: More women (57.5%) than men (42.3%) were found in the poor SEI [P<0.001]. HIV prevalence was highest among the poor (20.8%) followed by those in the middle (15.9%) and those in the upper SEI (4.6%) [P<0.001]. It was also highest among women compared to men (19.7% versus 11.4% respectively) and among black Africans (20.2%) compared to other races [P<0.001]. Individuals in the upper SEI reported higher frequency of HIV testing (59.3%) compared to the low SEI (47.7%) [P< 0.001]. Only 20.5% of those in poor SEI had "good access to HIV/AIDS information" compared to 79.5% in the upper SEI (P<0.001). A higher percentage of the poor had a stigmatizing attitude towards HIV/AIDS (45.6%) compared to those in the upper SEI (34.8%) [P< 0.001]. There was a high personal HIV risk perception among the poor (40.0%) and it declined significantly to 10.9% in the upper SEI. CONCLUSIONS: Our findings underline the disproportionate burden of HIV disease and HIV fear among the poor and vulnerable in South Africa. The poor are further disadvantaged by lack of access to HIV information and HIV/AIDS services such as testing for HIV infection. There is a compelling urgency for the national HIV/AIDS response to maximizing program focus for the poor particularly women.

Equity in maternal health in South Africa: analysis of health service access and health status in a national household survey.

BACKGROUND: South Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources. METHODS: Analysis draws on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data. FINDINGS: Poorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2-6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group. CONCLUSIONS: Aside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.