Informing comprehensive HIV prevention: a situational analysis of the HIV prevention and care context, North West Province South Africa

COVID-19 Vaccination Hesitancy among Youths in Soweto, South Africa

In combatting COronaVIrus Disease 2019 (COVID-19), immunization is the most prominent strategy. However, vaccination hesitancy-meaning delays in accepting or denying inoculation regardless of availability-has been identified as an essential threat to global health. Attitudes and perceptions play a pivotal role in vaccine acceptability. Meanwhile, uptake in South Africa's rollout has been particularly disappointing among youths. For that reason, we explored attitudes and perceptions of COVID-19 in 380 youths in Soweto and Thembelihle, South Africa, between April and June 2022. A staggering hesitancy rate of 79.2 percent was recorded (301/380). We found negative attitudes and confounded perceptions of COVID-19 to be fueled by medical mistrust and misinformation, with online channels as the main sources of non- and counterfactual claims stemming mostly from unregulated social media popular with youths. Understanding its underpinnings-and enhancing means of curbing vaccine hesitancy-will be paramount in boosting uptake in South Africa's immunization program, particularly among youths.

Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa

INTRODUCTION

Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses.

METHODS

In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care.

RESULTS

Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records.

CONCLUSION

At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics.

TRIAL REGISTRATION

The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa

Background

We reviewed a combination prevention program to strengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR's country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives.

Results

Cost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs).

Conclusions

Labor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention's composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

Sexual and Physical Violence in Childhood Is Associated With Adult Intimate Partner Violence and Nonpartner Sexual Violence in a Representative Sample of Rural South African Men and Women

Intimate partner violence, nonpartner sexual violence, and physical and sexual violence against children are significant public health issues in South Africa. Theory suggests that experiencing violence in childhood plays a role in propensity to perpetrate violence or vulnerability to violence in adulthood. Most research to date on this topic has been conducted in high-resource countries or within urban or high-risk populations. We explore the relationship between violence in childhood and violence in adulthood in a community-based sample of 18- to 49-year-old adults in rural South Africa using data from a population-based survey (N = 1,044) in North West province in 2014. We measured childhood violence before age 15 years, experience of nonpartner sexual violence in adulthood, and IPV victimization and perpetration in the last 12 months. We conducted multivariate logistic regression; gender was tested as an effect modifier. All estimates are weighted to the subdistrict population. More women (2.7%) than men (0.8%) reported childhood forced sex, whereas fewer women (2.0%) than men (7.9%) reported childhood physical violence. Women and men reported similar rates of IPV victimization (6.8% vs. 5.4%), IPV perpetration (3.3% vs. 4.8%), and forced sex by a nonpartner (1.6% vs. 1.2%). We found that men and women who experienced childhood violence (combined physical and/or sexual) were significantly more likely to experience forced sex by a nonpartner (men: adjusted odds ratio [aOR] = 5.53, 95% confidence interval [CI] = [1.27, 24.0], p < .05; women: aOR = 51.1, 95% CI = [10.58, 246.3], p < .01) compared with those who did not experience childhood violence. They were also 2.5 times as likely to perpetrate recent IPV (aOR = 2.5, 95% CI = [0.97, 6.7], p = .06) or experience recent IPV (aOR = 2.5, 95% CI = [0.9, 6.9], p = .07), although this finding was marginally significant. These results align with the literature from other settings and population groups.

'We are the change' - An innovative community-based response to address self-stigma: A pilot study focusing on people living with HIV in Zimbabwe

Introduction

Self-stigma–negative self-judgements resulting in shame, worthlessness and self-blame–may play a crucial role in emotional reactions and cause emotional distress among many people living with HIV and other chronic illnesses. Furthermore, self-stigma negatively impacts on self-agency, quality of life, adherence to treatment, and access to services. High levels of self-stigma have been reported across many countries, however few programmes or interventions exist to specifically tackle this phenomenon. This paper reports the findings of a pilot study carried out in Zimbabwe using a programme incorporating “Inquiry-Based Stress Reduction (IBSR): The Work of Byron Katie”–a guided form of self-inquiry which helps users to overcome negative thoughts and beliefs.

Objectives

The primary objective of this uncontrolled pilot study was to examine the potential role of the IBSR intervention in helping people living with HIV to overcome self-stigma and associated states.

Methods

23 people living with HIV (17 Female, 6 male, average age 41 years) were recruited from a local HIV support network, via open call for volunteers. All participants received the intervention, consisting of a 12-week facilitated programme using techniques derived from IBSR: The Work of Byron Katie. Qualitative and quantitative data were collected and analysed pre- and post-programme.

Results

After taking part in the intervention, participants reported significant improvements in factors including self-stigma (1-month follow-up vs baseline Z = 2.1, p = 0.039; 3-month follow-up vs baseline Z = 3.0, p = 0.003, n = 23, Wilcoxon Matched Pairs Signed Rank Test) and depression (1mo vs baseline Z = 3.7, p = <0.001; 3mo vs baseline Z = 3.3, p = 0.001). Qualitatively, participants reported improvements including lessened fears around disclosure of their HIV status, reduced feelings of life limitations due to HIV, and greater positive mentality. Improvements persisted at three-month follow-up.

Conclusion

With further development and larger comparative studies to confirm effects, the IBSR programme could become a novel tool to enable people living with HIV to support themselves in overcoming self-stigma.

Patterns of Online and Offline Connectedness Among Gay, Bisexual, and Other Men Who Have Sex with Men

This study examined patterns of connectedness among 774 sexually-active gay, bisexual, and other men who have sex with men (GBM), aged ≥ 16 years, recruited using respondent-driven sampling in Metro Vancouver. Latent class analysis examined patterns of connectedness including: attendance at gay venues/events (i.e., bars/clubs, community groups, pride parades), social time spent with GBM, use of online social and sex seeking apps/websites, and consumption of gay media. Multinomial regression identified correlates of class membership. A three-class LCA solution was specified: Class 1 "Socialites" (38.8%) were highly connected across all indicators. Class 2 "Traditionalists" (25.7%) were moderately connected, with little app/website-use. Class 3 "Techies" (35.4%) had high online connectedness and relatively lower in-person connectedness. In multivariable modelling, Socialites had higher collectivism than Traditionalists, who had higher collectivism than Techies. Socialites also had higher annual incomes than other classes. Techies were more likely than Traditionalists to report recent serodiscordant or unknown condomless anal sex and HIV risk management practices (e.g., ask their partner's HIV status, get tested for HIV). Traditionalists on the other hand were less likely to practice HIV risk management and had lower HIV/AIDS stigma scores than Socialites. Further, Traditionalists were older, more likely to be partnered, and reported fewer male sex partners than men in other groups. These findings highlight how patterns of connectedness relate to GBM's risk management.

Community engagement practices in Southern Africa: Review and thematic synthesis of studies done in Botswana, Zimbabwe and South Africa

Community Engagement (CE) is intended to enhance the participation of community stakeholders in research. CE is usually mentioned in publications as researchers discuss how they carried out community entry, consent and retained study participants but the actual CE activities are not always well documented. This paper reviews CE strategies employed in health research in Botswana, South Africa and Zimbabwe with reference to the development of a CE strategy for a multi-centre study to be conducted in these countries. The search was conducted using JANE (Journal/Author Name Estimator), Google Scholar and PubMed with known institutions and researchers providing context-specific material. The final synthesis includes 35 publications, 2 reports and 2 abstracts. There is evidence of CE being practiced in health research and eight closely related CE strategies were revealed. We conclude that since communities are heterogeneous and unique, CE activities will not have similar results in different settings. Even though there was insufficient evidence to determine which CE strategy is most effective, the review provides sufficient information to develop a CE strategy for a multi-centre study using the various strategies and activities described.

Pre/post evaluation of a pilot prevention with positives training program for healthcare providers in North West Province, Republic of South Africa

BACKGROUND

Prevention interventions for people living with HIV/AIDS are an important component of HIV programs. We report the results of a pilot evaluation of a four-hour, clinic-based training for healthcare providers in South Africa on HIV prevention assessments and messages. This pre/post pilot evaluation examined whether the training was associated with providers delivering more prevention messages.

METHODS

Seventy providers were trained at four public primary care clinics with a high volume of HIV patients. Pre- and post-training patient exit surveys were conducted using Audio-Computer Assisted Structured Interviews. Seven provider appropriate messaging outcomes and one summary provider outcome were compared pre- and post-training using Poisson regression.

RESULTS

Four hundred fifty-nine patients pre-training and 405 post-training with known HIV status were interviewed, including 175 and 176 HIV positive patients respectively. Among HIV positive patients, delivery of all appropriate messages by providers declined post-training. The summary outcome decreased from 56 to 50%; adjusted rate ratio 0.92 (95% CI = 0.87-0.97). Sensitivity analyses adjusting for training coverage and time since training detected fewer declines. Among HIV negative patients the summary score was stable at 32% pre- and post-training; adjusted rate ratio 1.05 (95% CI = 0.98-1.12).

CONCLUSIONS

Surprisingly, this training was associated with a decrease in prevention messages delivered to HIV positive patients by providers. Limited training coverage and delays between training and post-training survey may partially account for this apparent decrease. A more targeted approach to prevention messages may be more effective.

Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa

BACKGROUND

Stigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted.

METHODS

We conducted a "situational analysis"--a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services.

RESULTS

Findings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services.

CONCLUSIONS

We conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths' accessing health care.

A situational analysis methodology to inform comprehensive HIV prevention and treatment programming, applied in rural South Africa

Successful HIV prevention programming requires engaging communities in the planning process and responding to the social environmental factors that shape health and behaviour in a specific local context. We conducted two community-based situational analyses to inform a large, comprehensive HIV prevention programme in two rural districts of North West Province South Africa in 2012. The methodology includes: initial partnership building, goal setting and background research; 1 week of field work; in-field and subsequent data analysis; and community dissemination and programmatic incorporation of results. We describe the methodology and a case study of the approach in rural South Africa; assess if the methodology generated data with sufficient saturation, breadth and utility for programming purposes; and evaluate if this process successfully engaged the community. Between the two sites, 87 men and 105 women consented to in-depth interviews; 17 focus groups were conducted; and 13 health facilities and 7 NGOs were assessed. The methodology succeeded in quickly collecting high-quality data relevant to tailoring a comprehensive HIV programme and created a strong foundation for community engagement and integration with local health services. This methodology can be an accessible tool in guiding community engagement and tailoring future combination HIV prevention and care programmes.

Design and implementation of an external quality assessment program for HIV viral load measurements using dried blood spots

An external quality assurance program was developed for HIV-1 RNA viral load measurements taken from dried blood spots using a reference panel and field-collected specimens. The program demonstrated that accurate and reproducible quantitation can be obtained from field-collected specimens. Residual proviral DNA may confound interpretation in virologically suppressed subjects.