An HIV-1 risk assessment tool for women aged 15-49 in African countries: A pooled analysis across 15 nationally representative surveys.

BACKGROUND: Women in Africa disproportionately acquire HIV-1. Understanding which women are most likely to acquire HIV-1 can guide focused prevention with pre-exposure prophylaxis (PrEP). Our objective is to identify women at highest risk of HIV-1 and estimate PrEP efficiency at different sensitivity levels. METHODS: Nationally representative data were collected from 2015-2019 from 15 population-based household surveys. This analysis included women aged 15-49 who tested HIV-1 sero-negative or had recent HIV-1. Least absolute shrinkage and selection operator regression models were fit with 28 variables to predict recent HIV-1. Models were trained on the full population and internally cross-validated. Performance was evaluated using area under the receiver-operating-characteristic curve (AUC), sensitivity, and number needed to treat (NNT) with PrEP to avert one infection. RESULTS: Among 209,012 participants 248 had recent HIV-1 infection, representing 118 million women and 402,000 (95% CI: 309,000-495,000) new annual infections. Two variables were retained in the model: living in a subnational area with high HIV-1 viremia and having a sexual partner living outside the home. Full-population AUC was 0.80 (95% CI: 0.76-0.84); cross-validated AUC was 0.79 (95% CI: 0.75-0.84). At a sensitivity of 33%, up to 130,000 cases could be averted if 7.9 million women were perfectly adherent to PrEP; NNT would be 61. At a sensitivity of 67%, up to 260,000 cases could be averted if 25.1 million women were perfectly adherent to PrEP; the NNT would be 96. CONCLUSIONS: This risk assessment tool was generalizable, predictive, and parsimonious with tradeoffs between reach and efficiency.

Social distancing behaviour: avoidance of physical contact and related determinants among South Africans: twelve days into the COVID-19 lockdown.

Social distancing behaviour is a primary preventive measure for reducing COVID-19 transmission. Improved understanding of factors associated with adherence to social distancing is vital for mitigating the impact of COVID-19 in South Africa. The study assessed adherence to social distancing and its associated factors during the state-implemented lockdown in South Africa. Data was analysed from a large-scale public survey conducted in South Africa from 8 to 29 April 2020, which was administered online and telephonically. Invitations to participate were distributed widely on local websites and social media networks, including on a data-free platform. Adherence to social distancing was measured by self-report of having engaged in close physical contact with someone outside the home. Simple and multiple logistic regression models examined the association between social distancing and potential explanatory variables. Of the 17,586 participants, 9.2% came into close physical contact with a person outside their home by hugging, kissing, or shaking hands during the past 7 days. The odds of coming into close physical contact with other people were significantly higher for males, students, and those with incorrect knowledge on physical distancing, angry attitudes about the lockdown, lack of confidence in the government response, high-risk perception, movement out of the local area, travelling to shops using public transport, households with communal water facilities and higher household size. The 25-59-year olds compared to 18-24-year olds, and the White and Indian/Asian compared to the African population groups had significantly lower odds of close physical contact with others outside the home. The study identifies subgroups of individuals for whom public health interventions to improve adherence to social distancing should be prioritised and tailored. Interventions and policies should take cognisance of the social determinants of health as well as culturally accepted greeting practices like hand shaking.

HIV Prevalence and Associated Factors Among Men in South Africa 30 Years into the Epidemic: The Fifth Nationwide Cross-Sectional Survey.

We investigated HIV prevalence and associated factors among men ≥ 15 years in South Africa using data from a 2017 nationwide cross-sectional survey. HIV prevalence was 10.5% among 6 646 participants. Prevalence increased from 4.1% in the younger men (15-24 years), 12.5% in young men (25-34 years) to 12.7% in older men (≥ 35 years). Odds of being infected with HIV were lower among younger men who had secondary level education and those who reported poor/fair self-rated health. Young and older men of other race groups had lower odds of HIV infection. Odds of infection were lower among young men who had moderate/high exposure to HIV communication programmes. Men not aware of their HIV status had higher odds of HIV infection, including older men who never married. Improved access to education, behavioral change programmes, and awareness of HIV status are necessary to reduce the risk of HIV infection among Black African men.

Association Between ART Adherence and Mental Health: Results from a National HIV Sero-Behavioural Survey in South Africa.

This paper assesses the levels of antiretroviral treatment (ART) adherence and mental health distress among study participants in a national behavioural HIV-sero prevalence study South Africa. The study was a cross-sectional population-based multi-stage stratified cluster random survey, (SABSSM V, 2017). Structured questionnaires were used to collect information on socio-demographics, HIV knowledge, perceptions, HIV testing and HIV treatment history. Study participants were tested for HIV infection, antiretroviral use, viral suppression, and ART drug resistance. A total of 2155 PLHIV aged 15 years or older who were on ART were included in the study. Incidence of either moderate or severe mental health distress was 19.7%. Self-reported ART adherence among study participants with no, mild, moderate, or severe mental distress was 82%, 83%, 86% and 78%, respectively. The adjusted odds ratio for ART non-adherence was 0.58 (95% CI 0.24; 1.40) for mild mental distress, 0.82 (95% CI 0.35; 1.91) for moderate mental distress and 2.19 (95% CI 1.14; 4.19) for severe mental distress groups compared to the no mental health distress group. The other factors that were associated with ART non-adherence in adjusted models included education level, alcohol use and province/region of residence. The study revealed that mental health remains a challenge to ART adherence in South Africa. To improve ART adherence, HIV continuum of care programs should include screening for mental health among people living with HIV.

Factors associated with age-disparate sexual partnerships among males and females in South Africa: a multinomial analysis of the 2012 national population-based household survey data.

BACKGROUND: In South Africa, age-disparate to sexual relationships where the age difference between partners is 5 years or greater is an important contributor to the spread of HIV. However, little is known about the predictors of age-disparate sexual relationships. This study investigates factors associated with age-disparate sexual relationships among males and females in South Africa. METHODS: This analysis used the 2012 nationally representative population-based household survey conducted using multi-stage stratified cluster sampling design. Multivariate multinomial stepwise logistic regression models were used to determine factors associated with age-disparate sexual relationships. RESULTS: Of 15,717 participants, who responded to the question on age-disparate sexual relationships, 62% males versus 58.5% females had partners within 5 years older or younger, 34.7% of males versus 2.7% of females had partners at least 5 years younger and 3.3% of males versus 38.8% of females had partners at least 5 years older. Among both males and females predictors of age-disparate sexual relationships were education, employment, socioeconomic status, locality type, age at sexual debut, condom use at last sexual act and HIV status while race was also an additional predictor for among females. Including unprotected sex and risk of HIV infection among adolescent girls and young women with sexual partners 5 years older their age. CONCLUSIONS: This study suggest that there is a need for reprioritizing the combination of behavioural and structural interventions to address risky sexual behaviours, unprotected sex, poverty, limited education and gender inequitable norms related to age-disparate sexual relationships and HIV.

Short-term real-time prediction of total number of reported COVID-19 cases and deaths in South Africa: a data driven approach.

BACKGROUND: The rising burden of the ongoing COVID-19 epidemic in South Africa has motivated the application of modeling strategies to predict the COVID-19 cases and deaths. Reliable and accurate short and long-term forecasts of COVID-19 cases and deaths, both at the national and provincial level, are a key aspect of the strategy to handle the COVID-19 epidemic in the country. METHODS: In this paper we apply the previously validated approach of phenomenological models, fitting several non-linear growth curves (Richards, 3 and 4 parameter logistic, Weibull and Gompertz), to produce short term forecasts of COVID-19 cases and deaths at the national level as well as the provincial level. Using publicly available daily reported cumulative case and death data up until 22 June 2020, we report 5, 10, 15, 20, 25 and 30-day ahead forecasts of cumulative cases and deaths. All predictions are compared to the actual observed values in the forecasting period. RESULTS: We observed that all models for cases provided accurate and similar short-term forecasts for a period of 5 days ahead at the national level, and that the three and four parameter logistic growth models provided more accurate forecasts than that obtained from the Richards model 10 days ahead. However, beyond 10 days all models underestimated the cumulative cases. Our forecasts across the models predict an additional 23,551-26,702 cases in 5 days and an additional 47,449-57,358 cases in 10 days. While the three parameter logistic growth model provided the most accurate forecasts of cumulative deaths within the 10 day period, the Gompertz model was able to better capture the changes in cumulative deaths beyond this period. Our forecasts across the models predict an additional 145-437 COVID-19 deaths in 5 days and an additional 243-947 deaths in 10 days. CONCLUSIONS: By comparing both the predictions of deaths and cases to the observed data in the forecasting period, we found that this modeling approach provides reliable and accurate forecasts for a maximum period of 10 days ahead.

Trends and correlates of HIV prevalence among adolescents in South Africa: evidence from the 2008, 2012 and 2017 South African National HIV Prevalence, Incidence and Behaviour surveys.

BACKGROUND: Adolescents are at increased risk of HIV infection compared to other age groups. There is an urgent need for strategic information that will inform programmes to reduce risk and vulnerability to HIV and reverse the pattern of increasing HIV infection as they transition to adulthood. This paper analysed trends and factors associated with HIV prevalence among adolescents in South Africa using the national HIV population-based household surveys conducted in 2008, 2012 and 2017. METHODS: All three surveys used a multistage cross-sectional design. A trend analysis was conducted to assess the differences in HIV prevalence and covariates overtime using P-trend Chi-squared statistic. Univariate and multivariate logistic regression models were used to determine factors associated with HIV prevalence. RESULTS: Overall there was a significant increase in HIV prevalence among adolescents aged 12-19 years from 3.0% (n = 2892) in 2008 to 3.2% (n = 4829) in 2012 and 4.1% (n = 3937) in 2017 (p = 0.031). The odds of being HIV positive among adolescents aged 12-19 years was significantly higher among females [AOR = 2.24; 95% CI (1.73-2.91); p < 0.001] than males, those residing in KwaZulu-Natal province [AOR = 2.01; 95% CI (1.-3.99); p = 0.027] than Northern Cape, and those who did not attend an educational institution and were unemployed [AOR = 2.66; 95% CI (1.91-3.67); p < 0.001] compared to those attending an educational institution. The odds were significantly lower among Whites [AOR = 0.29; 95% CI (0.09-0.93); p = 0.037], Coloureds [AOR = 0.21; 95% CI (0.11-0.37); p ≤ 0.001] and Indian/Asian [AOR = 0.08; 95% CI (0.02-0.34); p = 0.001] population groups than Black Africans. CONCLUSION: The observed increasing trend and gender disparities in HIV prevalence suggests an urgent need for age appropriate and gender specific HIV interventions tailored and targeted at identified drivers of HIV infection among adolescents.

Prevalence and factors associated with intimate partner violence among the adolescent girls and young women in South Africa: findings the 2017 population based cross-sectional survey.

BACKGROUND: Evidence indicate that intimate partner violence (IPV) is disturbingly high among South African adolescent girls and young women (AGYW). Understanding prevalence and risk factors for IPV among these emerging adults is critical for developing appropriate interventions to prevent adverse health outcomes later in life. This study investigates the prevalence and factors associated with lifetime physical IPV experience among AGYW, aged 15-24 years, using the South African national HIV prevalence, incidence, behaviour and communication survey conducted in 2017. METHODS: The data used in this secondary analysis was obtained from a cross-sectional, population-based household survey data, conducted using a multi-stage stratified random cluster sampling approach. Multivariate stepwise backward logistic regression modelling was used to determine factors associated with IPV. RESULTS: Of 716 AGYW that responded to the two commonly answered questions on IPV, 13.1% (95% CI: 9.6-17.6) indicated that they experienced IPV. The odds of reporting experiences of IPV were significantly lower among AGYW residing in high SES households [AOR = 0.09 (95% CI: 0.02-0.47), p = 0.004] than low SES households, and those residing in rural informal/tribal areas [AOR = 0.01 (95% CI: 0.00-0.22), p = 0.004] than urban areas. AGYW experiencing IPV had higher odds of reporting psychological distress compared to their counterparts [AOR = 4.37 (95% CI, 0.97-19.72), p = 0.054]. CONCLUSION: The findings highlight the need for targeted structural and psychosocial interventions in low SES households and especially in urban areas.

Preparedness for self-isolation or quarantine and lockdown in South Africa: results from a rapid online survey.

BACKGROUND: The World Health Organization (WHO) declared the COVID-19 pandemic a public health emergency of international concern. South Africa, like many other countries, initiated a multifaceted national response to the pandemic. Self-isolation and quarantine are essential components of the public health response in the country. This paper examined perceptions and preparedness for self-isolation or quarantine during the initial phase of the pandemic in South Africa. METHODS: The analysis used data obtained from an online quantitative survey conducted in all nine provinces using a data-free platform. Descriptive statistics and multivariable logistic regression models were used to analyse the data. RESULTS: Of 55,823 respondents, 40.1% reported that they may end up in self-isolation or quarantine, 32.6% did not think that they would and 27.4% were unsure. Preparedness for self-isolation or quarantine was 59.0% for self, 53.8% for child and 59.9% for elderly. The odds of perceived possibility for self-isolation or quarantine were significantly higher among Coloureds, Whites, and Indians/Asians than Black Africans, and among those with moderate or high self-perceived risk of contracting COVID-19 than those with low risk perception. The odds were significantly lower among older age groups than those aged 18-29 years, and those unemployed than fully employed. The odds of preparedness for self-isolation or quarantine were significantly less likely among females than males. Preparedness for self, child and elderly isolation or quarantine was significantly more likely among other population groups than Black Africans and among older age groups than those aged 18-29 years. Preparedness for self, child and elderly isolation or quarantine was significantly less likely among those self-employed than fully employed and those residing in informal dwellings than formal dwellings. In addition, preparedness for self-isolation or quarantine was significantly less likely among those with moderate and high self-perceived risk of contracting COVID-19 than low risk perception. CONCLUSION: The findings highlight the challenge of implementing self-isolation or quarantine in a country with different and unique social contexts. There is a need for public awareness regarding the importance of self-isolation or quarantine as well as counter measures against contextual factors inhibiting this intervention, especially in impoverished communities.

Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey.

BACKGROUND: Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90-90-90 targets for the country stratified by a variety of key factors. METHODS: To evaluate progress towards achievement of the 90-90-90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90). RESULTS: Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one's positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15-24 years old, 25-49 years old and 50-64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25-49 years old, 82.9% of those aged 50-64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90-90-90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%. CONCLUSIONS: South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15-24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90-90-90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.

Determinants of HIV infection among adolescent girls and young women aged 15-24 years in South Africa: a 2012 population-based national household survey.

BACKGROUND: South Africa is making tremendous progress in the fight against HIV, however, adolescent girls and young women aged 15-24 years (AGYW) remain at higher risk of new HIV infections. This paper investigates socio-demographic and behavioural determinants of HIV infection among AGYW in South Africa. METHODS: A secondary data analysis was undertaken based on the 2012 population-based nationally representative multi-stage stratified cluster random household sample. Multivariate stepwise backward and forward regression modelling was used to determine factors independently associated with HIV prevalence. RESULTS: Out of 3092 interviewed and tested AGYW 11.4% were HIV positive. Overall HIV prevalence was significantly higher among young women (17.4%) compared to adolescent girls (5.6%). In the AGYW model increased risk of HIV infection was associated with being young women aged 20-24 years (OR = 2.30, p = 0.006), and condom use at last sex (OR = 1.91, p = 0.010), and decreased likelihood was associated with other race groups (OR = 0.06, p < 0.001), sexual partner within 5 years of age (OR = 0.53, p = 0.012), tertiary level education (OR = 0.11, p = 0.002), low risk alcohol use (OR = 0.19, p = 0.022) and having one sexual partner (OR = 0.43, p = 0.028). In the adolescent girls model decreased risk of HIV infection was associated with other race groups (OR = 0.01, p < 0.001), being married (OR = 0.07), p = 0.016], and living in less poor household (OR = 0.08, p = 0.002). In the young women's models increased risk of HIV infection was associated with condom use at last sex (OR = 2.09, p = 0.013), and decreased likelihood was associated with other race groups (OR = 0.17, p < 0.001), one sexual partner (OR = 0.6, p = 0.014), low risk alcohol use (OR = 0.17, p < 0.001), having a sexual partner within 5 years of age (OR = 0.29, p = 0.022), and having tertiary education (OR = 0.29, p = 0.022). CONCLUSION: These findings support the need to design combination prevention interventions which simultaneously address socio-economic drivers of the HIV epidemic, promote education, equity and access to schooling, and target age-disparate partnerships, inconsistent condom use and risky alcohol consumption.

HIV Serostatus Disclosure to Sexual Partners Among Sexually Active People Living with HIV in South Africa: Results from the 2012 National Population-Based Household Survey.

This paper explores the prevalence and correlates of HIV seropositive status disclosure to sexual partners by people living with HIV (PLHIV) in South Africa. Secondary analysis of the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey was conducted on data obtained from 934 sexually active PLHIV aged 15 years and older who responded to the question about HIV seropositive status disclosure. Overall, a large majority of respondents (77.1 %) reported disclosing their HIV-positive status to all their current sex partners. Multiple regression analysis, after adjustments for sex, marital status and locality type, revealed that those who were living together, going steady, and those who were single were all 60 % [adjusted odds ratio (AOR) = 0.4, 95 % CIs 0.20-0.78; AOR = 0.4, 95 % CIs 0.24-0.77; and AOR = 0.4, 95 % CIs 0.19-1.00, all ps < 0.05] less likely to disclose their HIV positive status to their partners compared to those who were married. Those who lived in rural formal areas were 70 % less likely to disclose their HIV status to their partners compared to those who stayed in urban formal areas (AOR = 0.3, 95 % CI 0.17-0.69, p < 0.001). Those who had correct HIV knowledge and rejection of myths were 2.0 times more likely to disclose their HIV status to their partners compared to those who did not have correct HIV knowledge and rejection of myths (AOR = 2.0, 95 % CI 1.04-3.68, p < 0.05). In conclusion, intervention programmes which help improve HIV seropositive status disclosure are needed by PLHIV who are not married, live in rural formal areas, and have incorrect HIV knowledge and rejection of myths.

New insights into HIV epidemic in South Africa: key findings from the National HIV Prevalence, Incidence and Behaviour Survey, 2012.

This article presents key findings from the 2012 HIV prevalence, incidence and behaviour survey conducted in South Africa and explores trends in the HIV epidemic. A representative household based survey collected behavioural and biomedical data among people of all ages. Chi-squared test for association and formal trend tests (2002, 2005, 2008 and 2012) were used to test for associations and trends in the HIV epidemic across the four surveys. In 2012 a total of 38 431 respondents were interviewed from 11 079 households; 28 997 (67.5%) of 42 950 eligible individuals provided blood specimens. HIV prevalence was 12.2% [95% CI: 11.4-13.1] in 2012 with prevalence higher among females 14.4% than males 9.9%. Adults aged 25-49 years were most affected, 25.2% [95% CI: 23.2-27.3]. HIV prevalence increased from 10.6% [95%CI: 9.8-11.6] in 2008 to 12.2% [95% CI: 11.4-13.1] in 2012 (p < 0.001). Antiretroviral treatment (ART) exposure doubled from 16.6% in 2008 to 31.2% in 2012 (p < 0.001). HIV incidence in 2012 among persons 2 years and older was 1.07% [95% CI: 0.87-1.27], with the highest incidence among Black African females aged 20-34 years at 4.5%. Sexual debut before 15 years was reported by 10.7% of respondents aged 15-24 years, and was significantly higher among male youth than female (16.7% vs. 5.0% respectively, p < 0.001). Reporting of multiple sexual partners in the previous 12 months increased from 11.5% in 2002 to 18.3% in 2012 (p < 0.001). Condom use at last sex dropped from 45.1% in 2008 to 36.2% in 2012 (p < 0.001). Levels of accurate HIV knowledge about transmission and prevention were low and had decreased between 2008 and 2012 from 31.5% to 26.8%. South Africa is on the right track with scaling up ART. However, there have been worrying increases in most HIV-related risk behaviours. These findings suggest that there is a need to scale up prevention methods that integrate biomedical, behavioural, social and structural prevention interventions to reverse the tide in the fight against HIV.

Determinants of multiple sexual partnerships in South Africa.

BACKGROUND: This paper aims to examine determinants of multiple sexual partnerships (MSPs) among South African men and women using a nationally representative sample. METHODS: Quantitative and qualitative data from a 2008 population-based cross-sectional survey were used. The analysis focused on the 6990 (33.6% of total sample) who were 15 years and older and reported sexual activity in the prior 12 months. The qualitative component consisted of 15 focus group interviews investigating values underlying MSP behaviors. RESULTS: Predictors of MSP common across gender were race, having a history of STI, being in a short relationships (<1 year) and suspecting the current partner of infidelity. MSP among men enjoyed greater community acceptance and was mainly done for social status. Furthermore, men reporting MSP were mostly younger (15-24 years old) and use condom at last sex. Among women, determinants of MSP included economic vulnerability, younger age at sexual debut and living in formal urban rather than formal rural areas. CONCLUSIONS: The data presented in this paper reinforces the importance of MSP as a risk factor for HIV and outline factors that should strongly be considered in strengthening condom use promotion and of partner reduction programs messaging in South Africa.

Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence. METHODS: We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019. RESULTS: Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices. CONCLUSION: South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.

Voluntary medical male circumcision reduces the risk of male HIV acquisition. Programmes to provide circumcisions for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Estimates of circumcision coverage are needed for planning and delivering circumcisions to meet targets and evaluate their impacts on HIV incidence. We developed a model to integrate date from both household surveys and health systems on the number of circumcisions conducted, and applied it to understand how the practices and coverage of circumcision are changing in South Africa. National circumcision coverage increased considerably between 2008 and 2019, however, there remains a substantial subnational variation across districts and age groups. Further progress is needed to reach national and international targets.

Screening and brief interventions for hazardous and harmful alcohol use among patients with active tuberculosis attending primary public care clinics in South Africa: results from a cluster randomized controlled trial.

BACKGROUND: In 2008 the World Health Organization (WHO) reported that South Africa had the highest tuberculosis (TB) incidence in the world. This high incidence rate is linked to a number of factors, including HIV co-infection and alcohol use disorders. The diagnosis and treatment package for TB and HIV co-infection is relatively well established in South Africa. However, because alcohol use disorders may present more insidiously, making it difficult to diagnose, those patients with active TB and misusing alcohol are not easily cured from TB. With this in mind, the primary purpose of this cluster randomized controlled trial was to provide screening for alcohol misuse and to test the effectiveness of brief interventions in reducing alcohol intake in those patients with active TB found to be misusing alcohol in primary public health care clinics in three districts in South Africa. METHODS: Within each of the three provinces targeted, one district with the highest TB burden was selected. Furthermore, 14 primary health care facilities with the highest TB caseload in each district were selected. In each district, 7 of the 14 (50%) clinics were randomly assigned to a control arm and another 7 of the 14 (50%) clinics assigned to intervention arm. At the clinic level systematic sampling was used to recruit newly diagnosed and retreatment TB patients. Those consenting were screened for alcohol misuse using the Alcohol Use Disorder Identification Test (AUDIT). Patients who screened positive for alcohol misuse over a 6-month period were given either a brief intervention based on the Information-Motivation-Behavioural Skills (IMB) Model or an alcohol use health education leaflet. RESULTS: Of the 4882 tuberculosis patients screened for alcohol and agreed to participate in the trial, 1196 (24.6%) tested positive for the AUDIT. Among the 853 (71%) patients who also attended the 6-month follow-up session, the frequency of positive screening results at baseline/follow-up were 100/21.2% for the AUDIT (P < 0.001) for the control group and 100/16.8% (P < 0.001) for the intervention group. The intervention effect on the AUDIT score was statistically not significant. The intervention effect was also not significant for hazardous or harmful drinkers and alcohol dependent drinkers ( AUDIT: 7-40), alcohol dependent drinkers and heavy episodic drinking, while the control group effect was significant for hazardous drinkers ( AUDIT: 7-19) (P = 0.035). CONCLUSION: The results suggest that alcohol screening and the provision of a health education leaflet on sensible drinking performed at the beginning of anti-tuberculosis treatment in public primary care settings may be effective in reducing alcohol consumption. TRIAL REGISTRATIONS: PACTR201105000297151.

Heterogeneity in COVID-19 infection among older persons in South Africa: Evidence from national surveillance data.

Background: The 2021 World Health Organization study on the impact of COVID-19 on older people (≥60 years) in the African region highlighted the difficulties they faced as the virus spread across borders and dominated the way of life. These difficulties included disruptions to both essential health care services and social support, as well as disconnections from family and friends. Among those who contracted COVID-19, the risks of severe illness, complications, and mortality were highest among near-old and older persons. Objective: Recognizing that older persons are a diverse group including younger- and older-aged individuals, a study was conducted to track the epidemic among near-old (50-59 years) and older persons (≥60 years) in South Africa covering the 2 years since the epidemic emerged. Methods: Using a quantitative secondary research approach, data for near-old and older persons were extracted for comparative purposes. COVID-19 surveillance outcomes (confirmed cases, hospitalizations, and deaths) and vaccination data were compiled up to March 5th, 2022. COVID-19 surveillance outcomes were plotted by epidemiological week and epidemic waves to visualize the overall growth and trajectory of the epidemic. Means for each age-group and by COVID-19 waves, together with age-specific rates, were calculated. Results: Average numbers of new COVID-19 confirmed cases and hospitalizations were highest among people aged 50-59- and 60-69-years. However, average age-specific infection rates showed that people aged 50-59 years and ≥80 years were most vulnerable to contracting COVID-19. Age-specific hospitalization and death rates increased, with people aged ≥ 70 years most affected. The number of people vaccinated was slightly higher among people aged 50-59 years before Wave Three and during Wave Four, but higher among people aged ≥ 60 years during Wave Three. The findings suggest that uptake of vaccinations stagnated prior to and during Wave Four for both age groups. Discussion: Health promotion messages and COVID-19 epidemiological surveillance and monitoring are still needed, particularly for older persons living in congregate residential and care facilities. Prompt health-seeking should be encouraged, including testing and diagnosis as well as taking up vaccines and boosters, particularly for high-risk older persons.

Healthcare seeking patterns for TB symptoms: Findings from the first national TB prevalence survey of South Africa, 2017-2019.

BACKGROUND: Although tuberculosis (TB) symptoms have limited sensitivity they remain an important entry point into the TB care cascade. OBJECTIVES: To investigate self-reported healthcare seeking for TB symptoms in participants in a community-based survey. METHODS: We compared reasons for not seeking care in participants reporting ≥1 of four TB screening symptoms (cough, weight loss, night sweats, fever) in the first South African national TB prevalence survey (2017-2019). We used logistic regression analyses to identify sociodemographic and clinical characteristics associated with healthcare seeking. RESULTS: 5,168/35,191 (14.7%) survey participants reported TB symptoms and 3,442/5168 had not sought healthcare. 2,064/3,442(60.0%) participants intended to seek care, 912 (26.5%) regarded symptoms as benign, 399 (11.6%) reported access barriers(distance and cost), 36 (1.0%) took other medications and 20(0.6%) reported health system barriers. Of the 57/98 symptomatic participants diagnosed with bacteriologically confirmed TB who had not sought care: 38(66.7%) intended to do so, 8(14.0%) regarded symptoms as benign, and 6(10.5%) reported access barriers. Among these 98, those with unknown HIV status(OR 0.16 95% CI 0.03-0.82), p = 0.03 and those who smoked tobacco products(OR 0.39, 95% CI 0.17-0.89, p = 0.03) were significantly less likely to seek care. CONCLUSIONS: People with TB symptoms delayed seeking healthcare, many regarded symptoms as benign while others faced access barriers. Those with unknown HIV status were significantly less likely to seek care. Strengthening community-based TB awareness and screening programmes together with self-screening models could increase awareness of the significance of TB symptoms and contribute to improving healthcare seeking and enable many people with TB to enter the TB care cascade.

Adult HIV-1 incidence across 15 high-burden countries in sub-Saharan Africa from 2015 to 2019: a pooled analysis of nationally representative data.

BACKGROUND: Harmonised population-based surveys with recent HIV-1 infection testing algorithms permit pooled cross-sectional estimation of HIV incidence across multiple countries. We aimed to estimate adult HIV-1 incidence rates and number of new infections by sex, age, and subregion in sub-Saharan Africa. METHODS: We analysed data from 13 Population-Based HIV Impact Assessment (PHIA) surveys and two additional population-based surveys done between 2015 and 2019 in 15 sub-Saharan African countries. HIV-seropositive samples from adults aged 15-59 years were tested for recent HIV-1 infection by use of an algorithm consisting of the HIV-1 limiting antigen avidity enzyme immunoassay, HIV-1 viral load, and qualitative detection of antiretroviral agents. Data were pooled across countries; sampling weights were incorporated to represent all adults in the 15 national populations. Analyses accounted for the complex sample designs. HIV incidence rates, incidence rate differences, and number of new annual infections were estimated. FINDINGS: Among 445 979 adults sampled, 382 had recent HIV-1 infection. The estimated HIV-1 incidence rate was 3·3 per 1000 person-years (95% CI 2·6-4·0) among women and 2·0 per 1000 person-years (1·2-2·7) among men (incidence rate difference 1·3 per 1000 person-years, 95% CI 0·3-2·3). Among adults aged 15-24 years, the incidence rate was higher for women (3·5 per 1000 person-years) than men (1·2 per 1000 person-years; difference 2·3, 95% CI 0·8-3·8), but infection rates were similar between sexes in all other age groups. The HIV-1 incidence rate was 7·4 per 1000 person-years (95% CI 5·0-9·7) in southern sub-Saharan Africa, 2·3 per 1000 person-years (1·7-2·9) in the eastern subregion, and 0·9 per 1000 person-years (0·6-1·2) in the western and central subregion. 689 000 (95% CI 546 000-833 000) new HIV cases were estimated annually among the 265 million susceptible adults (61·6% in women). INTERPRETATION: HIV-1 incidence and number of new infections differed by age, sex, and subregion. Approaches for risk stratification are needed to guide comprehensive HIV-1 prevention. FUNDING: National Institutes of Health.