Household transmission of SARS-CoV-2 in a rural area in South Africa.

BACKGROUND: Patterns of SARS-CoV-2 spread have varied by geolocation, with differences in seroprevalence between urban and rural areas, and between waves. Household spread of SARS-CoV-2 is a known source of new COVID-19 infections, with rural areas in sub-Saharan Africa being more prone than urban areas to COVID-19 transmission because of limited access to water in some areas, delayed health- seeking behaviour and poor access to care. OBJECTIVES: To explore SARS-CoV-2 infection incidence and transmission in rural households in South Africa (SA). METHODS: We conducted a prospective household cluster investigation between 13 April and 21 July 2021 in the Matjhabeng subdistrict, a rural area in Free State Province, SA. Adults with SARS-CoV-2 confirmed by polymerase chain reaction (PCR) tests (index cases, ICs) and their household contacts (HCs) were enrolled. Household visits conducted at enrolment and on days 7, 14 and 28 included interviewer- administered questionnaires and respiratory and blood sample collection for SARS-CoV-2 PCR and SARS-CoV-2 immunoglobulin G serological testing, respectively. Co-primary cases were HCs with a positive SARS-CoV-2 PCR test at enrolment. The incidence rate (IR), using the Poisson distribution, was HCs with a new positive PCR and/or serological test per 1 000 person-days. Associations between outcomes and HC characteristics were adjusted for intra-cluster correlation using robust standard errors. The secondary infection rate (SIR) was the proportion of new COVID-19 infections among susceptible HCs. RESULTS: Among 23 ICs and 83 HCs enrolled, 10 SARS-CoV-2 incident cases were identified, giving an IR of 5.8 per 1 000 person-days (95% confidence interval (CI) 3.14 - 11.95). Households with a co-primary case had higher IRs than households without a co-primary case (crude IR 14.16 v. 1.75, respectively; p=0.054). HIV infection, obesity and the presence of chronic conditions did not materially alter the crude IR. The SIR was 15.9% (95% CI 7.90 - 29.32). Households with a lower household density (fewer household members per bedroom) had a higher IR (IR 9.58; 95% CI 4.67 - 21.71) than households with a higher density (IR 3.06; 95% CI 1.00 - 12.35). CONCLUSION: We found a high SARS-CoV-2 infection rate among HCs in a rural setting, with 48% of households having a co-primary case at the time of enrolment. Households with co-primary cases were associated with a higher seroprevalence and incidence of SARS-CoV-2. Sociodemographic and health characteristics were not associated with SARS-CoV-2 transmission in this study, and we did not identify any transmission risks inherent to a rural setting.

"Mothers get really exhausted!" The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya.

Heat exposure in pregnancy is associated with a range of adverse health and wellbeing outcomes, yet research on the lived experience of pregnancy in high temperatures is lacking. We conducted qualitative research in 2021 in two communities in rural Kilifi County, Kenya, a tropical savannah area currently experiencing severe drought. Pregnant and postpartum women, their male spouses and mothers-in-law, community health volunteers, and local health and environment stakeholders were interviewed or participated in focus group discussions. Pregnant women described symptoms that are classically regarded as heat exhaustion, including dizziness, fatigue, dehydration, insomnia, and irritability. They interpreted heat-related tachycardia as signalling hypertension and reported observing more miscarriages and preterm births in the heat. Pregnancy is conceptualised locally as a 'normal' state of being, and women continue to perform physically demanding household chores in the heat, even when pregnant. Women reported little support from family members to reduce their workload at this time, reflecting their relative lack of autonomy within the household, but also potentially the 'normalisation' of heat in these communities. Climate change risk reduction strategies for pregnant women in low-resource settings need to be cognisant of local household gender dynamics that constrain women's capacity to avoid heat exposures.

Quality of counselling and support provided by the South African National AIDS Helpline: Content analysis of mystery client interviews.

BACKGROUND: Telephone helplines can facilitate referral, education and support for patients living with HIV or those concerned about the infection. The anonymity of helplines facilitates discussion of sensitive issues that are difficult to raise face to face. These services could support the expansion of HIV self-testing. However, maintaining quality and standardising messages in rapidly evolving fields such as HIV is challenging. OBJECTIVES: To evaluate the quality of the South African (SA) National AIDS Helpline. METHODS: Mystery clients posing as members of the public made 200 calls to the service in 2014. They presented several scenarios, including having received HIV-positive results from a doctor's secretary or through self-testing. Following the call, 'clients' completed a semistructured questionnaire on the information received and the caller-counsellor interaction. RESULTS: Calls were answered within a median of 5 seconds (interquartile range 2 - 14). Conversations took place in 8 of the 11 SA official languages, though mainly in English. Overall, 75% of callers felt that with the information they received they could locate a nearby clinic for further services. Counsellors expressed appropriate levels of concern about inadequate counselling that callers had received and confidentiality breaches in some scenarios. Eight counsellors incorrectly mentioned the need for a waiting period to confirm a positive result. Consistent with policy, almost all said that being foreign would not affect HIV treatment access. About 90% explained the need for CD4+ testing and antiretroviral therapy, but only 78% discussed HIV prevention. Counsellors were mostly empathetic (83%), though some adopted a neutral tone (10%) or were brusque (6%) or unhelpful (2%). CONCLUSIONS: Overall, helpline counsellors were proficient at providing information about local clinics, HIV testing and steps needed for initiating ART. Dissatisfaction with the caller-counsellor interactions, instances of incorrect information and the relatively low attention accorded to HIV prevention are worrying, however. Training for both refreshing and updating knowledge, and supervision and monitoring of calls, could target these areas.

UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis.

BACKGROUND: Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS: We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS: A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS: The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.

Contraception coverage and methods used among women in South Africa: A national household survey.

BACKGROUND: Globally, family planning services are being strengthened and the range of contraceptive choices expanded. Data on contraceptive coverage and service gaps could help to shape these initiatives. OBJECTIVE: To assess contraception coverage in South Africa (SA) and identify underserved populations and aspects of programming that require strengthening. METHODS: Data from a 2012 SA household survey assessed contraception coverage among 6 296 women aged 15 - 49 years and identified underserved populations. RESULTS: Two-thirds had an unintended pregnancy in the past 5 years, a quarter of which were contraceptive failures. Most knew of injectable (92.0%) and oral contraception (89.9%), but fewer of intrauterine devices (56.1%) and emergency contraception (47.3%). Contraceptive prevalence was 49.1%, and 41.8% women used modern non-barrier methods. About half had ever used injectable contraception. Contraception was lower in black Africans and younger women, who used a limited range of methods. CONCLUSION: Contraception coverage is higher than many previous estimates. Rates of unintended pregnancy, contraceptive failure and knowledge gaps, however, demonstrate high levels of unmet need, especially among black Africans and young women.

Uptake and early removals of Implanon NXT in South Africa: Perceptions and attitudes of healthcare workers

Background. The South African (SA) government introduced Implanon NXT, a long-acting subdermal contraceptive implant, in 2014 to expand contraceptive choice. Following an initial high uptake, its use declined considerably amid reports of early removals and frequent side-effects. We examine providers' perceptions of training and attitudes towards Implanon NXT, as well as their views on the causes of early removals and the impact on the implant service. Objective. To assess healthcare providers' perceptions and attitudes towards implant services in SA. Methods. In-depth interviews were conducted with eight nurses providing implant services in public facilities in Gauteng and North West Province. Emerging themes were identified, manually coded and thematically analysed following an interpretivism approach. Results. Nurses lacked confidence in providing implant services effectively, particularly removals, which they ascribed to the brief, cascade-type training received. Nurses generally held negative views towards the method. They also reported that side-effects are the most common reason for early removals ­ particularly irregular bleeding ­ and that men often do not support their partners who use the method. Lastly, it was found that providers require guidance on counselling regarding the method and standardised guidelines on the management of side-effects. Conclusion. Retraining and support of providers are needed to address competency gaps and negative attitudes towards the method. Assessment of providers' readiness to perform removal procedures is also important. Finally, effective plans are necessary to improve implant continuation rates, especially among women whose partners are unsupportive.

Gaps in monitoring systems for Implanon NXT services in South Africa: An assessment of 12 facilities in two districts

Background. Implanon NXT, a long-acting subdermal contraceptive implant, was introduced in South Africa (SA) in early 2014 as part of an expanded contraceptive method mix. After initial high levels of uptake, reports emerged of frequent early removals and declines in use. Monitoring of progress and challenges in implant service delivery could identify aspects of the programme that require strengthening. Objectives. To assess data management and record keeping within implant services at primary care facilities. Methods. We developed a checklist to assess the tools used for monitoring implant services and data reporting to district offices. The checklist was piloted in seven facilities. An additional six high-volume and six low-volume implant insertion clinics in the City of Johannesburg (CoJ), Gauteng Province, and the Dr Kenneth Kaunda District, North West Province, were selected for assessment. Results. All 12 facilities completed a Daily Head Count Register, which tallied the number of clients attending the clinic, but not information about implant use. A more detailed Tick Register recorded services that clinic attendees received, with nine documenting number of implant insertions and six implant removals. A more specific tool, an Insertion Checklist, collected data on insertion procedures and client characteristics, but was only used in CoJ (five of six facilities). Other registers, which were developed de novo by staff at individual facilities, captured more detailed information about insertions and removals, including reasons. Five of six low-volume insertion facilities used these registers, but only three of six high-volume facilities. No facilities used the form specifically developed by the National Department of Health for implant pharmacovigilance. Nine of 12 clinics reported data on numbers of insertions to the district office, six reported removals and none provided data on reasons for removals. Conclusion. For data to inform effective decision-making and quality improvement in implant services in SA, standardised reporting guidelines and data collection tools are needed, reinforced by staff training and quality assessment of data collection. Staff often took the initiative to fill gaps in reporting systems. Current systems are unable to accurately monitor uptake or discontinuation, or identify aspects of services requiring strengthening. Lack of pharmacovigilance data is especially concerning. Deficiencies noted in these monitoring systems may be common to family planning services more broadly, which warrants investigation.

Lessons learnt from the introduction of the contraceptive implant in South Africa

In 2014, South Africa (SA) introduced the subdermal contraceptive implant with the aim of expanding the contraceptive method mix and availability of long-acting reversible methods in the public sector. Three years on, concerns have been raised about the decline in uptake, early implant removals and challenges in service delivery. This article explores the lessons learnt from the introduction of contraceptive technologies elsewhere and applies these to the SA context. Drawing on the World Health Organization's conceptual framework for the introduction of new contraceptive methods, and subsequent literature on the topic, lessons are classified into six cross-cutting themes. Recommendations highlight the need for SA to review and explore strategies to strengthen current implant services, including the provision of improved provider training aimed at sensitive, client-centred approaches; increased community engagement; and improved systems for programmatic monitoring and evaluation. With implementation of these recommendations, worrying trends in the provision of implants could be reversed.

Strengthening implant provision and acceptance in South Africa with the 'Any woman, any place, any time' approach: An essential step towards reducing unintended pregnancies

Progress in reducing unintended pregnancies in South Africa is slow. The implant, introduced in 2014, expanded the range of available longacting reversible contraceptives (LARCs) and held much promise. Uptake, however, has declined precipitously, in spite of its 'unmatched effectiveness' and high levels of satisfaction for most users. We propose policy and provider interventions to raise implant use, underscored by a 'LARC-first' approach. Contraceptive counselling should focus on the particular benefits of LARCs and methods be presented in order of effectiveness. Moreover, implants hold particular advantages for certain groups, especially adolescents and young women, in whom it is considered first-line contraception. Provision of immediate postpartum and post-abortion implants is safe and highly acceptable, yet remains under-utilised. Implant services at HIV and tuberculosis clinics are a key priority, as is inclusion of LARC provision within school health services. Implants could also be delivered by existing mobile outreach services, for example in sex worker programmes. Services could be built around nurses dedicated solely to providing implants, with other health workers receiving brief refresher training. Women who experience side-effects, especially abnormal bleeding, require timely interventions, following a standardised protocol, including use of medications. Encouraging return for side-effects, follow-up phone calls and home visits would raise continuation rates. Removal services require doctor support or designated nurses at specific centres. Limited access to removal services, health workers' resistance or botched procedures will further undermine implant provision. Rapid implant demonstration projects in postpartum wards, schools, outreach services and by dedicated providers may rapidly advance the field. Together, the actions outlined here will ensure that the implant fulfils its potential and reinvigorates family planning services.

Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries.

BACKGROUND: Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants. OBJECTIVES: To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. METHODS: Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries. RESULTS: Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. CONCLUSIONS: Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health.

Addressing the intersection between alcohol consumption and antiretroviral treatment: needs assessment and design of interventions for primary healthcare workers, the Western Cape, South Africa.

BACKGROUND: At the points where an infectious disease and risk factors for poor health intersect, while health problems may be compounded, there is also an opportunity to provide health services. Where human immunodeficiency virus (HIV) infection and alcohol consumption intersect include infection with HIV, onward transmission of HIV, impact on HIV and acquired immunodeficiency syndrome (AIDS) disease progression, and premature death. The levels of knowledge and attitudes relating to the health and treatment outcomes of HIV and AIDS and the concurrent consumption of alcohol need to be determined. This study aimed to ascertain the knowledge, attitudes and practices of primary healthcare workers concerning the concurrent consumption of alcohol of clinic attendees who are prescribed antiretroviral drugs. An assessment of the exchange of information on the subject between clinic attendees and primary healthcare providers forms an important aspect of the research. A further objective of this study is an assessment of the level of alcohol consumption of people living with HIV and AIDS attending public health facilities in the Western Cape Province in South Africa, to which end, the study reviewed health workers' perceptions of the problem's extent. A final objective is to contribute to the development of evidence-based guidelines for AIDS patients who consume alcohol when on ARVs. The overall study purpose is to optimise antiretroviral health outcomes for all people living with HIV and AIDS, but with specific reference to the clinic attendees studied in this research. METHODS: Overall the research study utilised mixed methods. Three group-specific questionnaires were administered between September 2013 and May 2014. The resulting qualitative data presented here supplements the results of the quantitative data questionnaires for HIV and AIDS clinic attendees, which have been analysed and written up separately. This arm of the research study comprised two, separate, semi-structured sets of interviews: one face-to-face with healthcare workers at the same primary healthcare clinics from which the clinic attendees were sampled, and the other with administrators from the local government health service via email. The qualitative analysis from the primary healthcare worker interviews has been analysed using thematic content analysis. RESULTS: The key capacity gaps for nurses include the definition of different patterns and volumes of alcohol consumption, resultant health outcomes and how to answer patient questions on alcohol consumption while on antiretroviral treatment. Not only did the counsellors lack knowledge regarding alcohol abuse and its treatment, but they were also they were unclear on their role and rights in relation to their patients. Doctors highlighted the need for additional training for clinicians in diagnosing alcohol use disorders and information on the pharmacological interventions to treat alcoholism. CONCLUSION: Pertinent knowledge regarding patient alcohol consumption while taking ARVs needs to be disseminated to primary healthcare workers.

Cutting the cost of South African antiretroviral therapy using newer, safer drugs.

Antiretrovirals are a significant cost driver for HIV programmes. Current first-line regimens have performed well in real-life programmes, but have a low barrier to virological resistance and still carry toxicity that limits adherence. New drug developments may mean that we have access to safer, more robust and cheaper regimens, but only if the appropriate clinical trials are conducted. We briefly discuss these trials, and demonstrate the large cost savings to the South African HIV programme if these are successful.

Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review.

BACKGROUND: High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care. METHODS: Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded. FINDINGS: Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients' attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being. CONCLUSIONS: The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Declining maternal mortality in the face of persistently high HIV prevalence in a middle-income country.

OBJECTIVE: To estimate maternal mortality ratio (MMR) and determine maternal death causes and trends in Greater Soweto, Johannesburg, South Africa. DESIGN: Cross-sectional study. SETTING: Chris Hani Baragwanath Maternity Hospital (CHBMH) in Greater Soweto. POPULATION: Maternal deaths at CHBMH. METHODS: Record review of maternal deaths from 1997 to 2012, using hospital death records, with denominator data from the district health information system and the hospital. MAIN OUTCOME MEASURES: Maternal mortality ratio per 100,000 live births, and causes of death classified as in the South African confidential enquiries. RESULTS: There were 479 deaths, with a peak MMR of 139 in 2004 and a decline to 86 in 2012. Of 332 women tested, 245 (74%) were HIV-infected. Nonpregnancy-related infection (40%) was the most frequent cause of death, followed by hypertension (16%) and obstetric haemorrhage (13%). HIV infection rates in these groups were 92%, 30% and 61%, respectively. Previous caesarean section was associated with obstetric haemorrhage death (odds ratio [OR] 3.2, 95% confidence interval [95% CI] 1.7-6.0), maternal age ≥35 years with hypertension death (OR 2.2, 95% CI 1.2-3.7) and antenatal anaemia with nonpregnancy-related infection death (OR 4.0, 95% CI 2.3-6.9), compared with other causes of death. CONCLUSION: There is evidence of a decline in MMR since HIV treatment for pregnant women was introduced in 2004. Previous caesarean section, advanced maternal age, and anaemia were associated with death from obstetric haemorrhage, hypertensive disorders of pregnancy and nonpregnancy-related infections, respectively. MMR may be further reduced with accelerated initiation of HIV treatment during pregnancy.

Burden of fetal alcohol syndrome in a rural West Coast area of South Africa.

BACKGROUND: Fetal alcohol syndrome (FAS) is common in parts of South Africa; rural residence is a frequently cited risk factor. We conducted a FAS school prevalence survey of an isolated rural community in a West Coast village of Western Cape Province, so obtaining the first directly measured rate, focusing specifically on a South African rural area, of FAS and partial FAS (PFAS). METHODS: The study area (Aurora village), a community of about 2 500 people in a grain-producing region, has one primary school. All learners were eligible for study inclusion. Initial anthropometry screening was followed by a diagnostic stage entailing examination by a dysmorphologist for features of FAS, neurodevelopmental assessment, and an interview assessing maternal alcohol consumption. RESULTS: Of 160 learners screened, 78 (49%) were screen-positive, of whom 63 (81%) were clinically assessed for FAS. The overall FAS/PFAS rate among the screened learners was 17.5% (95% confidence interval 12.0 - 24.2%), with 16 (10.0%) children having FAS and 12 (7.5%) PFAS. High rates of stunting, underweight and microcephaly were noted in all learners, especially those with FAS or PFAS. Five (18%) mothers of affected children were deceased by the time of assessment. CONCLUSION: We describe very high rates of FAS/PFAS in an isolated rural part of the Western Cape that is not located in a viticultural region. Our study suggests that the prevalence of FAS may be very high in isolated communities, or in particular hot-spots. It adds to the growing evidence that FAS/PFAS is a significant, and underestimated, health problem in South Africa. Expanded screening and surveillance programmes, and preventive interventions, are urgently needed.