Indicator-focussed technical assistance in South Africa's HIV programme: A stepped-wedge evaluation.

BACKGROUND: There is a lack of research on technical assistance (TA) interventions in low- and middle-income countries. Variation in local contexts requires tailor-made approaches to TA that are structured and replicable across intervention sites whilst retaining the flexibility to adapt to local contexts. We developed a systematic process of TA using multidisciplinary roving teams to provide support across the various elements comprising local HIV services. OBJECTIVES: To examine the effectiveness of targeting specific HIV and TB programme indicators for improvement using roving teams. METHOD: We conducted a cluster-randomised stepped-wedge evaluation of a TA support package focussing on clinical, managerial and pharmacy services in the Mopani district of the Limpopo province, South Africa (SA). Three roving teams delivered the intervention. Seventeen primary and community healthcare centres that had 400-600 patients on antiretroviral therapy (ART) were selected for inclusion. The TA package was implemented for six consecutive months across facilities until all had received the same level of support. Data were collected from the relevant health management information systems for 11 routine indicators. RESULTS: The mean proportion of PLWH screened for tuberculosis (TB) at ART initiation increased from 85.2% to 87.2% (P = 0.65). Rates of retention in care improved, with the mean proportion of patients retained in care at three months post-ART initiation increasing from 79.9% to 87.4% (P < 0.001) and from 70.3% to 77.7% (P < 0.01) after six months. Finally, the mean proportion of patients with TB who completed their treatment increased from 80.6% to 82.1% (P = 0.75). CONCLUSION: Tailored TA interventions in SA using a standardised structure and process led to a significant improvement in retention-in-care rates and to non-significant improvements in the proportion of PLWH screened for TB and of those who completed their treatment.

Contextual factors affecting the integration of community health workers into the health system in Limpopo Province, South Africa.

BACKGROUND: Community health workers (CHWs) are an essential cadre in the health systems of many low- and middle-income countries. These workers provide a wide variety of services and are key to ongoing processes of task shifting within human immunodeficiency virus programmes in particular. Ward-based outreach teams (WBOTs) are South Africa's latest iteration of the CHW programme and have been introduced as part of the National Department of Health's Primary Health Care Re-engineering programme. METHODS: In order to assess the perceived effectiveness of the WBOTs in supporting the ongoing rollout of antiretroviral therapy, tuberculosis care and patient support, we conducted a qualitative investigation focusing on the perceived successes and challenges of the programme among CHWs, community leaders, healthcare workers and community members in the Mopani district, Limpopo province, South Africa. RESULTS: The CHW programme operates across these contexts, each associated with its own set of challenges and opportunities. CONCLUSIONS: While these challenges may be interrelated, a contextual analysis provides a useful means of understanding the programme's implementation as part of ongoing decision-making processes.

Targeted mentoring for human immunodeficiency virus programme support in South Africa.

BACKGROUND: Mentoring is a required component of health systems strengthening technical assistance interventions in low- and middle-income countries (LMICs). Mentoring is useful because it does not necessarily compromise service delivery and promotes the sharing of newly acquired knowledge and skills. However, there is a lack of research on the implementation of mentoring in the context of the HIV epidemic in southern Africa. OBJECTIVES: This qualitative evaluation focussed on understanding the implementation process of targeted mentoring for clinical practice, data management and pharmacy management, at public health care facilities in South Africa; and on identifying critical factors influencing the effectiveness of mentoring as a technical assistance intervention in this context. METHODS: Purposive sampling was used to select participants from public health facilities in three South African Provinces. Participants were invited to take part in structured interviews. Datawere analysed using thematic analysis, and two core themes were identified: mentoring as knowledge and skills transfer; and mentoring as psychosocial support. RESULTS: In terms of knowledge and skills transfer, the sequential implementation of proactive and reactive mentoring was critical. Initial proactive mentoring involved mentors initiating training and developing professional relationships with mentees. Thereafter, a reactive mentoring phase allowed mentees to request support when required. This enabled mentors to leverage real-world problems faced by health workers to support their implementation of new knowledge and skills. The availability and accessibility of mentors alongside the relationships between mentors and mentees provided psychosocial support for health care workers which facilitated their self-efficacy in implementing new knowledge and skills. CONCLUSION: These findings suggest that the success of mentoring programmes in LMICs may require specific attention to both knowledge transfer and the management of interpersonal relationships.

Understanding health worker data use in a South African antiretroviral therapy register.

OBJECTIVE: To evaluate how electronic data management systems affect data use practices in antiretroviral therapy (ART) programs within local health districts, and individual health facilities. METHODS: We used a data quality audit to establish a baseline of the quality of data in the electronic register alongside in-depth interviews with health workers and managers, to understand perceptions of data quality, data use by facility staff and challenges affecting data use. RESULTS: The findings provide a four-level continuum of data use that can be applied to other settings and recommendations for optimising facility-level data use. CONCLUSION: By defining four levels of data use our findings suggest the potential to encourage a structured process of moving from passive data use, to more active and engaged data use, where data could be used to anticipate patient behaviour and link that behaviour to differentiated care plans.

Qualitative assessment of facilitators and barriers to HIV programme implementation by community health workers in Mopani district, South Africa.

South Africa has implemented a community-based HIV programme (CBHP) in its primary healthcare (PHC) re-engineering strategy that aims to improve public healthcare delivery. This CBHP is delivered by ward-based outreach teams (WBOTs); provision of community HIV services comprises an important component of this programme. We conducted an exploratory study to determine the facilitators and barriers to successful implementation of this CBHP in rural Mopani District, South Africa. Focus group discussions were conducted with the community health workers (CHWs) and PHC nurses; participant interviews were conducted with community members who access these health services, community leaders, and social workers. We conducted a thematic content analysis and based on the key themes reported, we identified the Consolidated Framework for Implementation Research, consisting of five domains, as the most appropriate model to interpret our findings. First, in terms of intervention characteristics, community members generally valued the HIV services provided, but the variable needs impacted on programme implementation. Outer setting challenges include inability to meet the need of patients as a result of stigma, non-disclosure of HIV status and social factors. In terms of the inner setting, CHWs were grateful for the equipment and training received but expressed the need for better support of management and the provision of additional resources. With regard to characteristics of the implementers, the CHWs expressed the desire for further training despite reporting having sufficient knowledge to conduct their HIV work. Finally, in terms of the implementation process, the importance of relationship building between CHWs and community members was emphasised. In conclusion, these data underline the positive receipt and potential of the CBHP in this rural district and identify areas to further strengthen the programme. The success and sustainability of the CBHP requires ongoing commitment of resources, training, supervision, and organisational support in order to operate effectively and efficiently.

Making ward-based outreach teams an effective component of human immunodeficiency virus programmes in South Africa.

The implementation of ward-based outreach teams (WBOTs), comprised of community health workers (CHWs), is one of the three interventions of the South African National Department of Health's (NDoH) Primary Health Care (PHC) Re-engineering strategy for improving health outcomes. CHWs provide a necessary structure to contribute to successful implementation of the human immunodeficiency virus (HIV) programme in four ways: (1) prevention of HIV infection by health education, (2) linkage to care by health education and referrals, (3) adherence support and (4) identification of individuals who are failing treatment. However, CHW programme and HIV programme-specific barriers exist that need to be resolved in order to achieve maximum impact. These include a lack of stakeholder and community support for WBOTs, challenging work and operational environments, a lack of in-depth knowledge and skills, and socio-cultural barriers such as HIV-related stigma. Considering its promising structure, documentation of the WBOT contribution to healthcare overall, and the HIV programme in particular, is urgently warranted to successfully and sustainably incorporate it into the South African healthcare system.

Gender identity and HIV risk among men who have sex with men in Cape Town, South Africa.

Gender identity plays a potentially important role contributing to HIV risk among MSM in South Africa. Where studies have included a focus on gender identity, MSM reporting gender non-conformity have been found to have a higher risk of being HIV positive than other MSM. This article examines HIV risk among gender non-conforming MSM in a sample of 316 MSM in Cape Town, South Africa. Reporting gender non-conformity was associated with higher HIV prevalence and increased HIV risk behaviour. Gender non-conformity was also associated with a higher likelihood of being unemployed and reporting low household incomes. These findings highlight the importance of gender-identity as a factor affecting access to HIV treatment, care, and prevention in South Africa and this is an issue that needs to be addressed in interventions targeting MSM populations.

HIV risk and prevention among men who have sex with men in rural South Africa.

Rural South African men who have sex with men (MSM) are likely to be underserved in terms of access to relevant healthcare and HIV prevention services. While research in urban and peri-urban MSM populations has identified a range of factors affecting HIV risk in South African MSM, very little research is available that examines HIV risk and prevention in rural MSM populations. This exploratory study begins to address this lack by assessing perceptions of HIV risk among MSM in rural Limpopo province. Using thematic analysis of interview and discussion data, two overarching global themes that encapsulated participants' understandings of HIV risk and the HIV risk environment in their communities were developed. In the first theme, "community experience and the rural social environment", factors affecting HIV risk within the broad risk environment were discussed. These included perceptions of traditional value systems and communities as homophobic; jealousy and competition between MSM; and the role of social media as a means of meeting other MSM. The second global theme, "HIV/AIDS knowledge, risk and experience", focused on factors more immediately affecting HIV transmission risk. These included: high levels of knowledge of heterosexual HIV risk, but limited knowledge of MSM-specific risk; inconsistent condom and lubricant use; difficulties in negotiating condom and lubricant use due to uneven power dynamics in relationships; competition for sexual partners; multiple concurrent sexual partnerships; and transactional sex. These exploratory results suggest that rural South African MSM, like their urban and peri-urban counterparts, are at high risk of contracting HIV, and that there is a need for more in-depth research into the interactions between the rural context and the specific HIV risk knowledge and behaviours that affect HIV risk in this population.

Delivering HIV services in partnership: factors affecting collaborative working in a South African HIV programme.

BACKGROUND: The involvement of Global Health Initiatives (GHIs) in delivering health services in low and middle income countries (LMICs) depends on effective collaborative working at scales from the local to the international, and a single GHI is effectively constructed of multiple collaborations. Research is needed focusing on how collaboration functions in GHIs at the level of health service management. Here, collaboration between local implementing agencies and departments of health involves distinct power dynamics and tensions. Using qualitative data from an evaluation of a health partnership in South Africa, this article examines how organisational power dynamics affected the operation of the partnership across five dimensions of collaboration: governance, administration, organisational autonomy, mutuality, and norms of trust and reciprocity. RESULTS: Managing the tension between the power to provide resources held by the implementing agency and the local Departments' of Health power to access the populations in need of these resources proved critical to ensuring that the collaboration achieved its aims and shaped the way that each domain of collaboration functioned in the partnership. CONCLUSIONS: These findings suggest that it is important for public health practitioners to critically examine the ways in which collaboration functions across the scales in which they work and to pay particular attention to how local power dynamics between partner organisations affect programme implementation.

HIV risk and prevention among men who have sex with men in rural South Africa

Rural South African men who have sex with men (MSM) are likely to be underserved in terms of access to relevant healthcare and HIV prevention services. While research in urban and peri-urban MSM populations has identified a range of factors affecting HIV risk in South African MSM, very little research is available that examines HIV risk and prevention in rural MSM populations. This exploratory study begins to address this lack by assessing perceptions of HIV risk among MSM in rural Limpopo province. Using thematic analysis of interview and discussion data, two overarching global themes that encapsulated participants' understandings of HIV risk and the HIV risk environment in their communities were developed. In the first theme, "community experience and the rural social environment", factors affecting HIV risk within the broad risk environment were discussed. These included perceptions of traditional value systems and communities as homophobic; jealousy and competition between MSM; and the role of social media as a means of meeting other MSM. The second global theme, "HIV/AIDS knowledge, risk and experience", focused on factors more immediately affecting HIV transmission risk. These included: high levels of knowledge of heterosexual HIV risk, but limited knowledge of MSM-specific risk; inconsistent condom and lubricant use; difficulties in negotiating condom and lubricant use due to uneven power dynamics in relationships; competition for sexual partners; multiple concurrent sexual partnerships; and transactional sex. These exploratory results suggest that rural South African MSM, like their urban and peri-urban counterparts, are at high risk of contracting HIV, and that there is a need for more in-depth research into the interactions between the rural context and the specific HIV risk knowledge and behaviours that affect HIV risk in this population

Sexual behaviour of women in rural South Africa: a descriptive study.

BACKGROUND: Sexual behaviour is a core determinant of the HIV and sexually transmitted infection (STI) epidemics in women living in rural South Africa. Knowledge of sexual behaviour in these areas is limited, but constitutes essential information for a combination prevention approach of behavioural change and biomedical interventions. METHODS: This descriptive study was conducted in rural Mopani District, South Africa, as part of a larger study on STI. Women of reproductive age (18-49 years) who reported sexual activity were included regardless of the reason for visiting the facility. Questionnaires were administered to 570 women. We report sexual behaviour by age group, ethnic group and self-reported HIV status. RESULTS: Young women (<25 years) were more likely to visit bars, practice fellatio, have concurrent sexual partners and report a circumcised partner than older women (>34 years); there was no difference for condom use during last sex act (36 % overall). Sotho women were more likely to report concurrent sexual partners whereas Shangaan women reported more frequent intravaginal cleansing and vaginal scarring practice in our analysis. HIV-infected women were older, had a higher number of lifetime sexual partners, reported more frequent condom use during the last sex act and were more likely to have a known HIV-infected partner than women without HIV infection; hormonal contraceptive use, fellatio, and a circumcised partner were less often reported. CONCLUSIONS: This study provides insight into women's sexual behaviour in a rural South African region. There are important differences in sexual behaviour by age group and ethnicity and HIV status; these should be taken into account when designing tailor-made prevention packages.

"In the fell clutch of circumstance": HIV and men who have sex with men in sub-Saharan Africa.

Men who have sex with men (MSM) in sub-Saharan Africa (SSA) have been repeatedly found to have high risk of HIV infection, and in spite of the differing nature of the HIV epidemic in the general population between East and Southern Africa, and West and Central Africa, MSM are disproportionately affected by HIV across the entire region. Recent research has examined the drivers of HIV risk, and the dynamics of the MSM HIV epidemic in greater detail. However, this growing knowledge has generally not been translated into effective HIV prevention interventions. In part, this is due to the highly stigmatised and frequently criminalised nature of same-sex sexualities in much of the region. Without human-rights-based advocacy targeting governments and interventions aiming to decrease stigma and homophobia, translating research into effective HIV interventions for MSM in SSA at the scale needed to reduce HIV transmission in this population remains highly unlikely.

Minority stress in the lives of men who have sex with men in Cape Town, South Africa.

The mental health outcomes of men who have sex with men (MSM) living in sub-Saharan Africa are understudied, despite evidence that discrimination and stigma are widespread. This article examines the occurrence and mental health effects of minority stress in a sample of diverse South African MSM. Twenty-two MSM living in Cape Town took part in exploratory qualitative in-depth interviews and completed mental health questionnaires. Results indicate that the majority of participants experienced minority stress, which affected their sexual relationships and coping strategies. Concealment behaviors and perceived discrimination levels were high and were associated with race, religion, SES, and geographical location.

Homophobic stigma, depression, self-efficacy and unprotected anal intercourse for peri-urban township men who have sex with men in Cape Town, South Africa: a cross-sectional association model.

While research now highlights that men who have sex with men (MSM) in places such as South Africa are at particular risk of HIV infection, left relatively unexplored are potential relationships between one of the most pressing social issues affecting peri-urban MSM - namely homophobic stigma - and sexual risk-taking behaviour. Drawing on research from the Ukwazana baseline study of 316 township MSM in Cape Town we examine how homophobic stigma relates to psychosocial factors such as depression and self-efficacy and the risk activity of unprotected anal intercourse (UAI). By deploying cross-sectional association models, we examine a series of relationships between these variables and offer evidence to suggest that HIV prevention programmes aimed at sexual minority groups should be mindful of potentially complex relationships between social stigmas such as homophobia and sexual risk-taking behaviour.

An exploration into the role of depression and self-efficacy on township men who have sex with men's ability to engage in safer sexual practices.

Men who have sex with men (MSM) in South Africa remain at particular risk of HIV infection. The Ukwazana baseline survey is the first to explore this risk in relation to psychological factors associated with unprotected anal intercourse (UAI). A cohort of 316 MSM from township peri-urban Cape Town took part in the survey. The survey found that 55.2% had engaged in UAI over the preceding 6 months. Depression was significantly associated with UAI. Respondents with self-efficacy scores less than two standard deviations above the mean were also more likely to have engaged in UAI. A Sobel test for mediation highlighted that the depression-UAI association was partially mediated by self-efficacy, indicating that most of the effect of depression on UAI was not covarying with self-efficacy. This study, therefore, highlights that both depression and self-efficacy should be considered factors to be addressed in HIV-prevention programmes aimed at peri-urban MSM.

HIV risk and prevention among men who have sex with men (MSM) in peri-urban townships in Cape Town, South Africa.

Current guidelines on HIV prevention for MSM emphasise the need for 'combination prevention' based on context-specific understandings of HIV risk. MSM in South Africa are a population with a high risk of HIV infection, however there is little research available on the drivers of this risk. In the context of a focus on combination prevention, this paper argues that effective HIV prevention for MSM in South Africa requires an understanding of the factors at multiple 'distances' from individuals that contribute to HIV risk. Based on qualitative research with MSM in Cape Town, South Africa, we situate HIV risk using a socio-ecological framework and identify factors at distal, proximal, and personal, levels that contribute to MSM's high risk of HIV infection. By understanding the interactions and linkages between risk environments and the risk situations in which HIV is transmitted, HIV prevention programmes will be more effectively able to address the multiple drivers of HIV risk in this population.

Transgender in Africa: invisible, inaccessible, or ignored?

Transgender people are an important key population for HIV risk globally, and several studies have found HIV prevalence rates in transgender populations that are significantly higher than those among other key populations such as men who have sex with men (MSM). There is a lack of research on transgender populations in Africa, and at present, there is almost no data available on HIV prevalence and risk among transgender people on the continent. It is possible that the invisibility of transgender people in epidemiological data from Africa is related to the criminalisation of same-sex behaviour in many countries and the subsequent fear of negative repercussions from participation in research. Alternatively, transgender people may be being overlooked in research due to confusion among researchers about how to ask questions about gender identity. It is also possible that transgender populations have simply been ignored in research to date. Without research on transgender-specific HIV prevalence and risk, it is very difficult to know what interventions and services are needed for this risk population. Therefore, it is important that researchers, governments, Non Governmental Organisations (NGOs) and donor organisations begin to pay explicit attention to transgender people in their HIV-related research and programmes in Africa.

Changing masculinities: land-use, family communication and prospects for working with older men towards gender equality in a livelihoods intervention.

Engaging men in work towards gender equality is a critical aspect of gender and development. However, there are few documented grassroots-level approaches to undertaking such work. This paper argues that context specific stresses on local constructions of masculinity, such as unemployment, poverty and high HIV prevalence, may provide useful entry points for work with men towards gender equality. While these stresses may act to undermine men's ability to 'achieve' the requirements of traditional constructions of masculinity, particularly the role of men as providers, they simultaneously create spaces for change. In this research, land-use provided a basis from which to engage with a group of older men (45-75 years) around a range of issues, including HIV and AIDS and health. Increases in levels of communication around HIV, household resources and health are used as indicative of the men's moves towards gender-equal behaviour. The paper argues that this was achieved by supporting positive aspects of traditional masculine identities, particularly the role of men as breadwinners, in a social and economic context where these roles are threatened or placed under pressure, while simultaneously working around 'sensitive' issues.