Reflections of volunteer counselors working remotely during the COVID-19 pandemic-Implications for policy and practice.

PURPOSE: We reflect on our experience of running a remote volunteer counseling service, known as the Counseling Collective, to support patients and their families during the second wave of the COVID-19 pandemic in Cape Town, South Africa, and the learning and implications for practice and policy regarding the effective utilization of volunteers during a crisis or disaster context. BACKGROUND: The Beta SARS-Co-2 variant dominated the second COVID-19 wave which gained momentum in December 2020, as public sector health teams prepared to deescalate services over the South African summer season. The ferocity with which the wave hit the city soon made it clear that volunteers would be needed to assist with counseling services as the Beta variant caused serious disease, resulting in a significant upswing in hospitalisations and deaths. METHODS: Four counselors and a colleague with oversight responsibilities of the volunteers reflected on the service we provided. This was done with the benefit of hindsight a year after the activities of the Counseling Collective were wrapped up. LESSONS LEARNED: Virtual volunteers are a largely untapped resource in the South African health care system. Much is to be gained by using this underutilized resource to deliver patient-centred services, especially in times of crisis. CONCLUSION: Networks of retired and self-employed health professionals, particularly nurses,-skilled volunteers-are a valuable resource and can be deployed for critical work using their versatile skillsets, in public health emergencies. Telephonic consultations are a useful modality for providing quality care and need to be built into the business of health services. Skills to conduct such consultations and for the provision of palliative care services need to be mainstreamed into the skillsets of health professionals. POLICY AND CLINICAL RELEVANCE: Public health disaster plans should include a blueprint for the rapid recruitment and deployment of volunteer counselors to assist permanent staff in providing crucial patient-centred care.

Health Sciences students' experience of COVID-19 case management and contact tracing in Cape Town, South Africa.

BACKGROUND: COVID-19 has challenged health and higher education systems globally. Managing the epidemic in Cape Town, South Africa (SA), required partnerships with universities and setting up of de novo systems for mass case and contact tracing (C&CT). Health sciences, predominantly medical students, as well as social work and psychology students formed the core of this telephone-based work over the 18 months when SARS-CoV-2 caused severe disease. METHODS: This qualitative study aimed to elicit students' motivations for becoming involved in C&CT, their experiences, and recommendations for C&CT and curricula. After Cape Town's first COVID-19 wave, six on-line focus groups comprising 23 students were conducted, and a further four were conducted with 13 students after the second wave. As the researchers were predominantly educators previously involved in undergraduate health sciences education, the study's purpose was to reflect on students' experiences to make educational and health system recommendations. RESULTS: Students were largely motivated to mitigate the impact of the epidemic on society and support people affected by COVID-19, as well as hone their professional skills. While these motivations were realised, students also needed to learn new skills - to autonomously work remotely, using novel communication strategies to engage those affected and use virtual groups to connect with colleagues. They managed responsibilities within the healthcare systems that did not always work smoothly, distressed cases who were financially insecure, difficult employers, and language barriers. They were prepared through training, and supported by virtual, yet effective teamwork and debriefing opportunities. Although the work was sometimes physically and emotionally exhausting, students found the work personally meaningful. They embraced public health's role to protect population and individuals' health. CONCLUSION: New teaching and learning practices adopted due to Covid-19 lockdowns enabled this digital C&CT project. It facilitated students to become confident, work autonomously and navigate challenges they will encounter as young professionals. The programme demonstrated that novel opportunities for rich student learning, such as in telehealth, can be embedded into public health and clinical functions of health services in contexts such as in SA, deepening partnerships between the health services and universities, to mutual benefit.

Investigating the disjoint between education and health policy for infant feeding among teenage mothers in South Africa: a case for intersectoral work.

BACKGROUND: Many low-and-middle-income countries, including South Africa, have high rates of teenage pregnancy. Following the World Health Organisation recommendations, South African health policy on infant feeding promotes exclusive breastfeeding until six months of age, with gradual weaning. At the same time, South Africa's education department, in the interest of learners, promotes adolescents' early return to school post-partum. Yet infant feeding at school is currently not perceived as a realistic option. METHODS: Recognising his this policy tension, we aimed to explore how policies are interpreted and implemented by the health and education sectors through interviews with key informants who produce, interpret and implement these policies. Using an interview guide developed for this study, we conducted in-depth interviews with 24 health policy makers, managers in both sectors, school principals and nursing staff who manage adolescent mothers (aged 16-19) and their babies. Data was analysed using thematic analysis. RESULTS: Informants from both sectors expressed discomfort at pregnant learners remaining in school late in pregnancy and were uncertain about policy regarding when to return to school and how long to breast-feed. Educators reported that new mothers typically returned to school within a fortnight after delivery and that breastfeeding was not common. While health professionals highlighted the benefits of extended breastfeeding for infants and mothers, they recognised the potential conflict between the need for the mother to return to school and the recommendation for longer breastfeeding. Additionally, the need for ongoing support of young mothers and their families was highlighted. CONCLUSIONS: Our findings suggest educators should actively encourage school attendance in a healthy pregnant adolescent until delivery with later return to school, and health providers should focus attention on breastfeeding for the initial 4-6 weeks postpartum, followed by guided support of formula-feeding. We encourage the active engagement of adolescents' mothers and extended families who are often involved in infant feeding and care decisions. Education and health departments must engage to facilitate the interests of both the mother and infant: some exclusive infant feeding together with a supported return to school for the adolescent mother.

What happens to misunderstandings of biomedical concepts across a medical curriculum?

Research on the extent and nature of commonly misunderstood fundamental biomedical concepts across a medical curriculum is scarce. These misunderstandings could point toward robust misconceptions. We examined first whether common misunderstandings persist throughout a medical curriculum, followed by a fine-grained analysis to identify their nature. We designed and administered a 2-tier test to 987 medical students across our curriculum, with 8 questions covering the respiratory and cardiovascular systems, cell division, and homeostatic processes. Proportions of incorrect responses were computed. Four questions where misunderstandings persisted were further qualitatively analyzed. A one-way ANOVA showed the proportion of incorrect responses decreased significantly by students' academic year [F(6, 986) = 96.05, P < 0.001]. While novices and end-of -first-year students showed similar proportion of incorrect responses (P > 0.05), incorrect responses decreased significantly between first years and second years (P < 0.001). Thereafter, the proportion of incorrect responses remained stable from second to final year (P > 0.05), with ∼35% of incorrect responses. Five questions showed no decrease of incorrect responses between second and final years, with two questions where final year students performed marginally better than novices. A Chi-square analysis, with Bonferroni post hoc test, showed certain misunderstandings appeared frequently across the curriculum. The qualitative analysis of the open-ended questions yielded 15 categories of common misunderstandings of fundamental biomedical concepts in all years of training. If educators become aware of commonly misunderstood biomedical concepts, preventative measures could be taken to prevent robust misconceptions.

Routine Health Information System (RHIS) improvements for strengthened health system management.

BACKGROUND: A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management. OBJECTIVES: To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed. SELECTION CRITERIA: Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence). AUTHORS' CONCLUSIONS: The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems.

BACKGROUND: The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries. METHODS: Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature. RESULTS: The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting. CONCLUSION: This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice.

Adolescent girls' perceptions of breastfeeding in two low-income periurban communities in South Africa.

In South Africa, exclusive breastfeeding rates are low, and rates of teenage pregnancy are high. Educational policy enables mothers' return to school, which conflicts with policy emphasizing exclusive breastfeeding. We elicited adolescent women's perceptions and experiences of infant feeding choices, and conducted six focus groups (N = 57) in two periurban settlements. Participants knew arguments in favor of and against breast and formula-feeding, but in practice, mixed feeding occurred early after birth. While completion of high school was emphasized, exclusive breastfeeding was viewed as impractical. Congruent education policies and infant feeding policies/guidelines must address the constraints and contexts of adolescent mothers.

General practitioners' perceptions on management of epilepsy in primary care settings in Cape Town, South Africa: an exploratory pilot study.

In a context where there are few neurologists, excellent management of patients with epilepsy at a primary care level is imperative. In South Africa, most uninsured patients suffering from epilepsy and other chronic illnesses are managed by general practitioners in state-provided primary care settings. We conducted a qualitative pilot study to explore perceptions of doctors working in primary care settings in Cape Town regarding the quality of epilepsy management. Our analysis revealed that these clinicians believe that epilepsy is poorly managed. Attributing factors were consistent with those found in literature. Although study findings cannot be generalized, we conclude that lack of attention to factors impacting on management of epilepsy is a serious concern and may lead to violations of health rights. Urgent prioritization, advocacy, collaboration, and empowerment of healthcare professionals, patients, lay carers, and the general public are needed to improve the management and quality of care of PWE.

Sexual health behavior, health status, and knowledge among queer womxn and trans men in Kenya: An online cross-sectional study.

INTRODUCTION: Little research has been conducted on the sexual health needs and risk behaviors of queer womxn and trans men, making it difficult to identify specific health needs and disparities. This is especially the case in the Global South, where their needs are poorly understood. This study presents findings on demographics, sources of information, sexual (risk) behaviors, and substance use in Kenyan queer womxn and trans men. METHODS: An online survey among 335 Kenyan queer womxn and trans men was used to collect data on sexual health, risk behavior, health information sources, and substance use. The participants needed to have had at least one self-identified female sexual partner. RESULTS: The sample presented young, highly-educated queer womxn and trans men. A high incidence of childhood sexual trauma found was found. Risk behaviors included sexual activities with partners of multiple genders, violence, and low use of barrier methods. One in three participants had been treated for an STD in the previous year. The incidences of smoking and drinking were high, and a quarter of participants indicated having taken drugs at least once a month or more. The internet was either the first or second most important source of sexual health information for 44.1% of the participants, followed by schools (30.9%). DISCUSSION AND CONCLUSION: Our findings indicate that queer womxn and trans men are at risk of negative sexual health outcomes due to a lack of appropriate information, risk behavior, substance use, and low uptake of sexual health services. Kenya's Penal Code still criminalizes consensual same-sex activities and may play a role in perpetuating barriers that prohibit them from making healthier choices. Developing tailored programming and policies require local, national, and global stakeholders to engage with the inclusion of queer womxn and trans men's sexual health needs within strategic planning and healthcare delivery.

Using online spaces to recruit Kenyan queer womxn and trans men in restrictive offline settings.

BACKGROUND: Understanding and addressing healthcare and service delivery inequalities is essential to increase equity and overcome health disparities and service access discrimination. While tremendous progress has been made towards the inclusion of sexual and gender minorities in health and other research, gaps still exist. Innovative methods are needed to close these. This case study describes and reflects on using online-based data collection to ascertain sexual health decision-making and health service utilisation among Kenyan queer womxn and trans men. METHODS: Case study The study used a mixed-methods approach in two phases with triangulated quantitative and qualitative elements. Both elements used web-based technology to gather data. RESULTS: Using online spaces to recruit and collect data from queer womxn and trans men exceeded expectations. A total of 360 queer womxn and trans men responded to the digitally distributed survey, and 33 people, queer womxn and trans men, as well as key informants, participated in the interviews, which were primarily conducted on Zoom and Skype. The case study analyses the risks and benefits of this approach and concludes that online sampling approaches can mitigate risks and enable effective and safe sampling of a marginalised group in a restrictive legal setting: Kenyan queer womxn and trans men. CONCLUSION: Using online spaces when researching marginalised populations could effectively overcome risks around stigma, discrimination and violence. It could be an effective way to understand these populations' healthcare needs better. Factors contributing to success included building trusting relationships with key members of the community, strategic and opportune timing, a nuanced understanding of the mobile landscape, and carefully chosen safety and security measures. However, it should be noted that conducting research online could increase the risk of further marginalising and excluding those without access to web-based technology.

Providers' approaches to contraceptive provision in Cape Town.

Background: Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs. Methods: Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach. Results: Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services. Discussion: Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

TB and HIV integration: obstacles and possible solutions to implementation in South Africa.

OBJECTIVES: To identify key obstacles to operational integration of TB and HIV services and to suggest strategies to promote integration in the prevention, treatment and care of patients with TB and HIV. METHODS: This is a health systems research case study of operational integration of TB and HIV in South Africa. Peer-reviewed and grey literature together with the experiences of the authors were used to identify key obstacles to integration in service implementation practices and community-level care. Relevant legislation, policies and guidelines were analysed to determine whether they facilitated or undermined the integration of TB and HIV services. RESULTS: Obstacles to integration exist at contextual and epidemiological levels as well as at intervention design and implementation levels. Importantly, integration at an operational level is undermined by fundamentally different principles underpinning the design of TB and HIV programmes and national policies and legislation which mitigate against integration. CONCLUSION: South Africa has an opportunity to effect changes that will facilitate TB/HIV integration and improve care for all those infected with TB, HIV or both conditions. An analytic approach necessary to understand the obstacles to and ensure effective strategies facilitating integration is required. This needs to be followed by mobilisation of clinical and health systems expertise, health infrastructure, commitment and experience in creative and appropriate ways for the variety of health care settings.

Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa.

OBJECTIVE: To assess the quality of pre-antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART. METHODS: The scale-up of the HCT, pre-ART and ART service platform and programmatic support in Cape was described. Data from the August 2010 routine annual HIV/TB/STI evaluation, which included interviews with 133 facility managers and folder reviews of 634 HCT clients who tested positive and 1115 clients receiving pre-ART HIV care, were analysed. RESULTS: Historically, the implementation and management of pre-ART care has been relatively neglected compared with the scale-up of HCT and ART. CD4 counts were carried out for 77.5% of positive HCT clients, and 46.6% were clinically staged - crucial steps that determine the care path. There were gaps in quality of care (32.2% of women had a PAP smear), missed opportunities for integrated care (67% were symptomatically screened for tuberculosis) and positive prevention (48.3% had contraceptive needs assessed). Breaks in the continuity of care of pre-ART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service. CONCLUSION: While a package of pre-ART care is clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality of service delivered that undermine the programme objectives of provision of positive prevention and timely access to ART.

Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services.

Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with women's fertility intentions. Gender differences were also apparent in participants' key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations.

Stakeholders' perspectives on Public Health Medicine in South Africa.

South Africa (SA) is reforming its health system in preparation for an anticipated national health insurance (NHI) scheme that aims to improve the delivery of affordable, equitable, accessible health care. Public health (PH) language is explicit in the policy and skilled PH professionals would be expected to play a key role in its implementation. In South Africa, training of doctors as Public Health Medicine (PHM) specialists is funded by the state, yet there are few positions for PHM specialists in the health services. We explored stakeholders' perspectives about this absence, and their views on PHM specialist' roles and contribution in an era of health reform. A qualitative study was conducted in 2012-13, using in-depth interviews with thematic analysis, which elicited perspectives of 31 key stakeholders nationally reflecting diverse employer and institutional backgrounds. While some were surprised by the absence of PH professionals in SA's health system, most agreed the reason was due to factors internal to the profession, such as its low profile and uncertain identity. External factors such as legislation and political preferences for health managers impacted on the employment of PH professionals. However, given the competencies required to implement an ambitious restructuring of the health sector, all believed that PH and PHM personnel were vital. In view of the health system's dominant curative orientation, embedding PH personnel in the services should ensure that health protection, promotion and prevention strategies will inform health priorities. This study, the first known from a low and middle-income country, contributes to the international literature about the identity and roles of PHM physicians, who are versatile professionals with broad skills-sets. In SA, through consultation with health sector employers about potential roles, curricular redesign and trainee recruitment, PHM can graduate fit-for-purpose specialists to work in a range of institutions to address health system reform.

Career Paths of Public Health Medicine Specialists in South Africa.

Public health (PH) skills are core to building responsive and appropriate health systems, and PH personnel including medical specialists are embedded in many countries' health systems. In South Africa, the medical specialty in PH, Public Health Medicine (PHM), has existed for over 40 years. Four years of accredited training plus success in a single national exit exam allows specialist registration with the Health Professions Council of South Africa (HPCSA). However, there are few posts designated specifically for PHM specialists in SA's health system. In view of uncertain roles, this research was designed to determine specialists' career paths, their work, job satisfaction, and perspectives on the future of the specialty. We combined three databases to generate the study population and invited all specialists to participate in an online or hard-copy survey. We found that in 2010, PHM was a small specialty of less 200 physicians. Of the 151 contactable, eligible physicians, 55.6% completed the questionnaire. Participants represented an aging group (median age = 49) of specialists and recent graduates were increasingly women. They largely worked in academic institutions (as managers, teachers, and researchers) and in the public sector health system; were motivated by a sense of social justice and their training was formative, exposing them to work settings which they later entered; were largely highly satisfied at work, but many worked in non-specialist positions. Indeed, one fifth had not registered with the HPCSA as specialists. They were concerned about the specialty's poor visibility and identity, but did not see other PH professionals as a threat. They believed that the specialty should refine its competencies, demonstrate its value and advocate for service positions at all levels of the public sector health service. PHM has a contribution to make-reorienting services to protect communities, preventing ill health, analyzing disease burdens locally, identifying innovations in a resource-constrained health service, largely preoccupied with curative care services.

Antiretroviral therapy and early mortality in South Africa.

OBJECTIVE: To describe province-wide outcomes and temporal trends of the Western Cape Province antiretroviral treatment (ART) programme 5 years since inception, and to demonstrate the utility of the WHO monitoring system for ART. METHODS: The treatment programme started in 2001 through innovator sites. Rapid scaling-up of ART provision began early in 2004, located predominantly in primary-care facilities. Data on patients starting ART were prospectively captured into facility-based registers, from which monthly cross-sectional activity and quarterly cohort reports were aggregated. Retention in care, mortality, loss to follow-up and laboratory outcomes were calculated at 6-monthly durations on ART. FINDINGS: By the end of March 2006, 16 234 patients were in care. The cohort analysis included 12 587 adults and 1709 children. Women accounted for 70% of adults enrolled. After 4 and 3 years on ART respectively, 72.0% of adults (95% confidence interval, CI: 68.0-75.6) and 81.5% (95% CI: 75.7-86.1) of children remained in care. The percentage of adults starting ART with CD4 counts less than 50 cells/microl fell from 51.3% in 2001 to 21.5% in 2005, while mortality at 6 months fell from 12.7% to 6.6%, offset in part by an increase in loss to follow-up (reaching 4.7% at 6 months in 2005). Over 85% of adults tested had viral loads below 400 copies/ml at 6-monthly durations until 4 years on ART. CONCLUSION: The location of care in primary-care sites in this programme was associated with good retention in care, while the scaling-up of ART provision was associated with reduced early mortality.

Clients' perspectives on HIV/AIDS care and treatment and reproductive health services in South Africa.

Qualitative research was conducted with HIV-positive women and men of reproductive age attending HIV/AIDS care and treatment services at a public health clinic in Cape Town, South Africa. Focus group discussions were held with women (n = 4) and men (n = 4), and in-depth interviews were held with four men to explore perceptions and experiences of HIV/AIDS care and treatment and sexual and reproductive health (SRH) care. Respondents praised their HIV/AIDS care and treatment, reflected on how it improved their quality of life and contrasted this with suboptimal care at other public health facilities, including SRH services. Women wanted integrated services, especially for contraception and to reduce stigma. HIV-positive men's lack of experience with SRH services and antipathy towards attending "women's" health services were highlighted. Challenges to involving men in HIV/AIDS care and treatment and SRH services and measures to address this were identified.

Motivations of South African physicians specialising in public health.

BACKGROUND: South African physicians can specialise in public health through a four-year 'registrar' programme. Despite national health policies that seemingly value public health (PH) approaches, the Public Health Medicine (PHM) speciality is largely invisible in the health services. Nevertheless, many physicians enrol for specialist training. OBJECTIVES: This study investigated physicians' motivations for specialising in PHM, their intended career paths, perceptions of training, and perspectives about the future of the speciality. METHODS: Focus groups and in-depth interviews were conducted with specialists-in-training and newly qualified specialists, and thematic analysis of transcripts was performed. RESULTS: Motivations, often driven by difficult experiences as young physicians in poorly resourced clinical settings, stemmed from a commitment to improving communities' health and desire to impact on perceived failing health systems. Rather than 'exiting' the South African health service, selecting PHM specialist training enacted participants' 'loyalty' to population health. Participants anticipated carving out their own careers due to an absence of public sector career paths. They believed specialists' contribution centred on providing 'public health intelligence' - finding and interpreting information; supporting services through management and leadership; and inputting into policymaking and planning. CONCLUSIONS: Competencies of PHM specialists should be refined to inform and improve management of this scarce human resource for health. This is particularly important given the proposed major health reforms towards universal health coverage in South Africa presently. In addition, findings highlight the importance of physicians' early work experiences where avenues for expressing 'voice', mediated by 'loyalty', could be utilised to improve public sector health systems.

"Life is still going on": reproductive intentions among HIV-positive women and men in South Africa.

This article reports on qualitative research investigating HIV positive individuals' reproductive intentions and their influencing factors in Cape Town, South Africa. In-depth interviews were held with 61 HIV positive women and men; at the time of interview, half had been receiving antiretroviral treatment (ART) for over 6 months and half were not receiving ART. Being HIV positive modified but did not remove reproductive desires, and diversity existed in reproductive intentions. Some HIV positive individuals wished to avoid pregnancy. Fears of partner and infant infection and having a previously infected baby were important factors deterring some individuals from considering having children. There was also strongly perceived community disapproval associated with HIV and reproduction. Strong desires to experience parenthood, mediated by prevailing social and cultural norms that encouraged childbearing in society more broadly, were reported by others. Motherhood was an important component of married women's identity and important for women's social status. Family, husbands' and societal expectations for childbearing were important influences on women's reproductive intentions, for some counterbalancing HIV as a factor discouraging reproduction. There was evidence that prevention of perinatal transmission programs in combination with ART may alter women and men's attitudes in favour of childbearing. Most HIV positive women had not discussed their reproductive desires and intentions with health care providers in HIV care or general health services because of anticipated negative reactions. The few who had done so perceived the counselling environment to be mostly unsupportive of open discussion on these issues. The findings highlight the need for explicit policies recognizing reproductive rights and choice. They support the need for health counselling and service interventions that advance safer and healthier reproductive options for HIV positive individuals in this region of the world which is experiencing a generalised and advanced HIV/AIDS pandemic.