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Background: Breast cancer (BC) is the leading cause of cancer-related morbidity and mortality in women living in South Africa, a country with a high HIV burden. However, characteristics of the double burden of HIV and BC in South Africa have not been properly investigated. We described characteristics of BC cases by HIV status in South Africa. Methods: In this nationwide South African study, we obtained BC records for women aged ≥15 years diagnosed in the public health sector between January 2004 and December 2014. We included records from the National Cancer Registry that had been linked to HIV-related laboratory records from the National Health Laboratory Service. We assessed the odds of being HIV positive versus HIV negative in relation to patient-, cancer-, and municipality-related characteristics. Results: From 2004–2014, 40 520 BC cases were diagnosed in women aged ≥15 years. Of these, 73.5% had unknown HIV status, 18.7% were HIV negative, and 7.7% were HIV positive. The median age at BC diagnosis was 43 years (interquartile range [IQR]: 37–52) in HIV positive and 57 years (IQR: 46–68) in HIV negative women, respectively. The odds of being HIV positive was higher for women who were aged 30–34 years compared to women aged 35–39 years at cancer diagnosis (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.10–1.71), Black versus non-Black (OR 6.41, 95% CI 5.68–7.23), diagnosed with cancer in rural versus urban areas (OR 1.59, 95% CI 1.40–1.82) and diagnosed in municipalities with low and middle (OR 3.46, 95% CI 2.48–4.82) versus high socioeconomic position (OR 2.69, 95% CI 2.11–3.42). Conclusion: HIV status was unknown for the majority of BC patients. Among those with known HIV status, being HIV positive was associated with a younger age at cancer diagnosis, being Black and receiving care in municipalities of poor socioeconomic position. Future studies should examine opportunities to integrate HIV and BC control programs. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to map place of cancer diagnosis in relation to Human Immunodeficiency Virus (HIV) care centre among people living with HIV (PLHIV) within South Africa (SA) using national laboratory database. Design: We linked HIV and cancer laboratory data from 2004–2014 using supervised machine-learning algorithms. We performed a cross-sectional analysis comparing province where individuals accessed their HIV care versus where they had their cancer diagnosis. Setting: We used laboratory test records related to HIV diagnostics and care, such as CD4 cell counts and percentages, rapid tests, qualitative Polymerase Chain Reaction (PCR), antibody and antigen tests for HIV data that was documented as HIV positive and laboratory diagnosed cancer records from SA. Study population: Our study population consisted of HIV records from the National Health Laboratory Service (NHLS) that linked to cancer record at the National Cancer Registry (NCR) between 2004–2014. Primary and secondary outcomes: We linked HIV records from NHLS to cancer records at NCR in order to study the inherent characteristics of the population with both HIV and cancer. Results: The study population was 68,284 individuals with cancer and documented HIV related laboratory test. The median age at cancer diagnosis was 40 [IQR, 33–48] years for the study population with most cancers in PLHIV diagnosed in females 70.9% [n = 46,313]. Of all the PLHIV and cancer, 25% (n = 16,364 p < 0.001) sought treatment outside their province of residence with 60.7% (n = 10,235) travelling to Gauteng. KZN had 46.6% (n = 4,107) of its PLHIV getting cancer diagnosis in Gauteng. Western Cape had 95% (n = 6,200) of PLHIV getting cancer diagnosis within the province. Conclusions: Our results showed health systems inequalities across provinces in SA with respect to cancer diagnosis. KZN for example had nearly half of the PLHIV getting cancer diagnosis outside the province while Western Cape is able to offer cancer diagnostic services to most of the PLHIV in the province. Gauteng is getting over burdened with referral for cancer diagnosis from other provinces. More effort is required to ensure equitable access to cancer diagnostic services within the country. [ABSTRACT FROM AUTHOR]

There is a rapid spread of antibiotic resistance in the environment. However, the impact of antibiotic resistance in drinking water is relatively underexplored. Thus, this study aimed to quantify antibiotic resistance genes (ARGs) and antibiotic residues in two drinking water production facilities (NW-E and NW-C) in North West Province, South Africa and link these parameters to bacterial communities. Physicochemical and ARG levels were determined using standard procedures. Residues (antibiotics and fluconazole) and ARGs were quantified using ultra-high performance liquid chromatography (UHPLC) chemical analysis and real-time PCR, respectively. Bacterial community compositions were determined by high-throughput 16S rRNA sequencing. Data were analysed using redundancy analysis and pairwise correlation. Although some physicochemical levels were higher in treated than in raw water, drinking water in NW-E and NW-C was safe for human consumption using the South African Water Quality Guideline (SAWQG). ARGs were detected in raw and treated water. In NW-E, the concentrations of ARGs (sul1, intl1, EBC, FOX, ACC and DHA) were higher in treated water than in raw water. Regarding antimicrobial agents, antibiotic and fluconazole concentrations were higher in raw than in treated water. However, in NW-C, trimethoprim concentrations were higher in raw than in treated water. Redundancy analysis showed that bacterial communities were not significantly correlated (Monte Carlo simulations, p-value >0.05) with environmental factors. However, pairwise correlation showed significant differences (p-value <0.05) for Armatimonas, CL500-29 marine group, Clade III, Dickeya and Zymomonas genera with environmental factors. The presence of ARGs and antibiotic residues in the current study indicated that antibiotic resistance is not only a clinical phenomenon but also in environmental settings, particularly in drinking water niches. Consumption of NW-E and NW-C treated water may facilitate the spread of antibiotic resistance among consumers. Thus, regulating and monitoring ARGs and antibiotic residues in drinking water production facilities should be regarded as paramount. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) and COVID-19 co-infection poses a significant global health challenge with increased fatality rates and adverse outcomes. However, the existing evidence on the epidemiology and treatment of TB-COVID co-infection remains limited. Methods: This updated systematic review aimed to investigate the prevalence, fatality rates, and treatment outcomes of TB-COVID co-infection. A comprehensive search across six electronic databases spanning November 1, 2019, to January 24, 2023, was conducted. The Joanna Briggs Institute Critical Appraisal Checklist assessed risk of bias of included studies, and meta-analysis estimated co-infection fatality rates and relative risk. Results: From 5,095 studies screened, 17 were included. TB-COVID co-infection prevalence was reported in 38 countries or regions, spanning both high and low TB prevalence areas. Prevalence estimates were approximately 0.06% in West Cape Province, South Africa, and 0.02% in California, USA. Treatment approaches for TB-COVID co-infection displayed minimal evolution since 2021. Converging findings from diverse studies underscored increased hospitalization risks, extended recovery periods, and accelerated mortality compared to single COVID-19 cases. The pooled fatality rate among co-infected patients was 7.1% (95%CI: 4.0% ~ 10.8%), slightly lower than previous estimates. In-hospital co-infected patients faced a mean fatality rate of 11.4% (95%CI: 5.6% ~ 18.8%). The pooled relative risk of in-hospital fatality was 0.8 (95% CI, 0.18–3.68) for TB-COVID patients versus single COVID patients. Conclusion: TB-COVID co-infection is increasingly prevalent worldwide, with fatality rates gradually declining but remaining higher than COVID-19 alone. This underscores the urgency of continued research to understand and address the challenges posed by TB-COVID co-infection. Author summary: Tuberculosis (TB) and COVID-19, both highly infectious diseases, have posed significant global health challenges, particularly in low/middle-income countries (LMICs) with limited medical resources. Our research highlights that TB-COVID co-infection remains a substantial concern, impacting regions with varying TB burdens. The predominant treatment approach for TB-COVID co-infection has not notably evolved since our earlier study in 2021. It typically involves a combination of the recommended TB regimen and standard COVID-19 treatment. Our analysis consistently shows that individuals with TB-COVID co-infection are at heightened risk of hospitalization, protracted recovery periods, and accelerated mortality compared to those with sole COVID-19 infections. Remarkably, we found limited information on the post-COVID-19 condition of co-infected patients. One study indicated a higher prevalence of anxiety symptoms, highlighting the potential psychological toll of TB-COVID co-infection. Although the fatality rate has gradually decreased, it remains notably higher than that of COVID-19 alone. Our findings underscore the urgent need for global collaboration to address the complex challenges posed by TB-COVID co-infection, particularly in countries with limited medical resources. [ABSTRACT FROM AUTHOR]

Background: The traditional HIV treatment cascade aims to visualise the journey of each person living with HIV from diagnosis, through initiation on antiretroviral therapy (ART) to treatment success, represented by virological suppression. This representation has been a pivotal tool in highlighting and quantifying sequential gaps along the care continuum. There is longstanding recognition, however, that this may oversimplify the complexity of real-world engagement with HIV services in settings with mature high-burden HIV epidemics. A complementary "cyclical" cascade has been proposed to represent the processes of disengagement at different points on the care continuum, with multiple pathways to re-engagement, although the feasibility of implementing this at scale has been uncertain. This study aimed to populate, refine, and explore the utility of a cyclical representation of the HIV cascade, using routine data from a high-burden HIV setting. Methods and findings: This observational cohort study leveraged person-level data on all people living with HIV in the Western Cape (WC), South Africa, who accessed public health services in the 2 years prior to 31 December 2023. Programme data from disease registers were complemented by data from pharmacy and laboratory systems. At study closure, 494 370 people were included, constituting 93% of those of those estimated to be living with HIV in the province, of whom 355 104 were on ART. Substantial disengagement from HIV care was evident at every point on the cascade. Early treatment emerged as a period of higher risk of disengagement, but it did not account for the majority of disengagement. Almost all those currently disengaged had prior experience of treatment. While re-engagement was also common, overall treatment coverage had increased slowly over 5 years. The transition to dolutegravir-based regimens was dramatic with good virological outcomes for those in care, notwithstanding a clearly discernible impact of the Coronavirus Disease 2019 (COVID-19) pandemic on viral load (VL) testing. People currently engaged and disengaged in care are similar with respect to age and gender. Those who died or disengaged recently were previously distributed across a range of cascade statuses, and a substantial proportion of those newly initiating and re-initiating treatment were no longer on treatment 6 months later. The main limitation of this study was incomplete evidence of HIV testing, linkage to HIV-specific services, and out-of-facility mortality. Conclusions: Using routine data, it was possible to populate and automate a cyclical cascade of HIV care that continuously captured the nonlinear care journeys of individuals living with HIV. In this generalised mature HIV epidemic, most people are treatment experienced. Disengagement is common and occurs at various points along the cascade, making it challenging to identify high-impact intervention opportunities. While historical HIV cascades remain valuable for target setting and service monitoring, they can be complemented with insights from more detailed cyclical cascades. Jonathan Euvrard and colleagues leverage routinely collected data from a high-burden HIV setting to demonstrate the feasibility of populating a cyclical HIV care cascade as part of routine service provision and to identify care gaps and temporal trends and changes to cascade statuses. Author summary: Why was this study done?: While there had been broad enthusiasm for cyclical representations of the HIV care cascade, the feasibility and utility of populating such representations using routine data in high-burden settings like South Africa are unknown. What did the researchers do and find?: The researchers used routine person-level data from 494 370 people who recently accessed public health services in the Western Cape (WC), South Africa, to adapt and populate a cyclical cascade of HIV care. The study uncovered complex patterns of engagement, disengagement, and re-engagement at various cascade points. Early treatment emerged as a period of higher risk of disengagement, but it did not account for the majority of disengagement. Trends over time demonstrated the shift among those starting ART from first-ever HIV engagement to re-engagement and service disruptions resulting from the Coronavirus Disease 2019 (COVID-19) pandemic. What do these findings mean?: With an appropriate data consolidation environment within the health services, it is readily feasible to continuously populate a cyclical representation of the HIV cascade of care using routine administrative and clinical data. The findings provide insights into the complex nature of engagement with HIV care. The identification of disengagement at multiple points on the care journey suggests the need for scalable, inclusive interventions. While historical cascades remain important tools, the cyclical cascade offers a complementary understanding of engagement patterns, contributing to ongoing efforts to refine public health strategies and improve HIV care outcomes. The main limitation of this study was incomplete evidence of HIV testing, linkage to HIV-specific services and out-of-facility mortality. [ABSTRACT FROM AUTHOR]

Background: Contraceptive use has complex effects on sexual behaviour and mood, including those related to reduced concerns about unintended pregnancy, direct hormonal effects and effects on endogenous sex hormones. We set out to obtain robust evidence on the relative effects of three contraceptive methods on sex behaviours, which is important for guiding contraceptive choice and future contraceptive developments. Methods: This is a secondary analysis of data from the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial in which 7,829 HIV-uninfected women from 12 sites in Eswatini, Kenya, South Africa and Zambia seeking contraception were randomly assigned to intramuscular depot-medroxyprogesterone acetate (DMPA-IM), the copper intrauterine device (Cu-IUD) or the levonorgestrel (LNG) implant. Data collected for 12 to 18 months using 3-monthly behavioural questionnaires that relied on recall from the preceding 3 months, were used to estimate relative risk of post-baseline sex behaviours, as well as sexual desire and menstrual bleeding between randomized groups using modified Poisson regression. Results: We observed small but generally consistent effects wherein DMPA-IM users reported lower prevalence of specified high risk sexual behaviours than implant users than Cu-IUD users (the '>' and '<' symbols indicate statistically significant differences): multiple sex partners 3.6% < 4.8% < 6.2% respectively; new sex partner 3.0% < 4.0% <5.3%; coital acts 16.45, 16.65, 17.12 (DMPA-IM < Cu-IUD); unprotected sex 65% < 68%, 70%; unprotected sex past 7 days 33% <36%, 37%; sex during vaginal bleeding 7.1%, 7.1% < 8.9%; no sex acts 4.1%, 3.8%, 3.4% (DMPA-IM > Cu-IUD); partner has sex with others 10% < 11%, 11%. The one exception was having any sex partner 96.5%, 96.9% < 97.4% (DMPA-IM < Cu-IUD). Decrease in sexual desire was reported by 1.6% > 1.1% >0.5%; amenorrhoea by 49% > 41% >12% and regular menstrual pattern by 26% <35% < 87% respectively. Conclusions: These findings suggest that women assigned to DMPA-IM may have a modest decrease in libido and sexual activity relative to the implant, and the implant relative to the Cu-IUD. We found more menstrual disturbance with DMPA-IM than with the implant (and as expected, both more than the Cu-IUD). These findings are important for informing the contraceptive choices of women and policymakers and highlight the need for robust comparison of the effects of other contraceptive methods as well. [ABSTRACT FROM AUTHOR]

Background: Monitoring Caesarean Section (CS) rates is essential to ensure optimal use of the procedure. Information on CS rates in the South African private sector is limited and information from this study will assist in planning for the proposed NHI in South Africa. Objectives: The objectives of this paper are to assess mode of delivery patterns and to determine CS rates amongst South African private health insurance scheme members; and to assess the extent to which CS rates are influenced by age and health status of the mother. Methods: The 2015 claims for members of 10 health insurance schemes were analysed to assess delivery type patterns. Mode of delivery patterns were assessed by 6 delivery types: emergency, elective and “other” for caesarean deliveries; and non-assisted, assisted and “other” for vaginal deliveries; as well as by age and health condition of the mother. Results: Of a total of 6,542 births analysed, 4,815 were CS giving a CS rate of 73·6% (95% CI 72·5%;74·7%). Emergency CS were the most common mode of delivery (39·7%), followed by elective CS (39·5%). CS rates increased with increasing maternal age and were higher for women with a medical condition. Conclusions: CS rates for the South African private sector are considerably higher than the safe rates recommended by the WHO. The high CS rates is a cause for concern for the health system under the proposed NHI. To support initiatives encouraging evidence based practice, further research is required to understand the drivers for the high CS rates. [ABSTRACT FROM AUTHOR]

Introduction: HIV self-testing (HIVST) offers a useful addition to HIV testing services and enables individuals to test privately. Despite recommendations to the contrary, repeat HIV testing is frequent among people already on anti-retroviral treatment (ART) and there are concerns that oral self-testing might lead to false negative results. A study was conducted in Khayelitsha, South Africa, to assess feasibility and uptake of HIVST and linkage-to-care following HIVST. Methods: Participants were recruited at two health facilities from 1 March 2016 to 31 March 2017. People under 18 years, or with self-reported previously-diagnosed HIV infection, were excluded. Participants received an OraQuick Rapid HIV-1/2 Antibody kit, and reported their HIVST results by pre-paid text message (SMS) or by returning to the facility. Those not reporting within 7 days were contacted by phone. Electronic and paper-based clinical and laboratory records were retrospectively examined for all participants to identify known HIV outcomes, after matching for name, date of birth, and sex. These findings were compared with self-reported HIVST results where available. Results: Of 639 participants, 401 (62.8%) self-reported a negative HIVST result, 27 (4.2%) a positive result, and 211 (33.0%) did not report. The record search identified that of the 401 participants self-reporting a negative HIVST result, 19 (4.7%) were already known to be HIV positive; of the 27 self-reporting positive, 12 (44%) were known HIV positive. Overall, records showed 57/639 (8.9%) were HIV positive of whom 39/57 (68.4%) had previously-diagnosed infection and 18/57 (31.6%) newly-diagnosed infection. Of the 428 participants who self-reported a result, 366 (85.5%) reported by SMS. Conclusions: HIVST can improve HIV testing uptake and linkage to care. SMS is acceptable for reporting HIVST results but negative self-reports by participants may be unreliable. Use of HIVST by individuals on ART is frequent despite recommendations to the contrary and its implications need further consideration. [ABSTRACT FROM AUTHOR]

Women remain highly vulnerable to HIV infection in sub-Saharan Africa, with female sex workers (FSWs) facing some of the highest rates of HIV. Oral pre-exposure prophylaxis (PrEP) has the potential to reduce new infections among populations at highest risk and end-user perspectives of actual use in ‘real-world’ settings are critical to informing PrEP implementation. This paper presents findings from serial in-depth interviews (IDIs) conducted with FSW participants during the course of the Treatment And Prevention for Sex workers (TAPS) Demonstration Project in South Africa, exploring the lived experiences and perceptions of taking up and using PrEP. This research provides insight into risks and responsibilities facing FSWs perceived as prominent drivers in taking up and using PrEP, how PrEP was adopted to mitigate risk or ameliorate realities, and the characteristics of PrEP most valued, all of which are critical to consider in scale-up. Overall, distrust in the existence and/or efficacy of PrEP affected the motivation of women to come to the clinic and to maintain use. As one of the first reports of PrEP use among FSWs outside of a clinical trial setting, this research shows that it will be important to ensure accurate, relevant, and widespread messaging in communities to generate demand and support for PrEP. [ABSTRACT FROM AUTHOR]

Introduction: In many sub-Saharan African countries, confronting the dual epidemic of HIV and NCDs is a public health priority especially in high HIV burden countries such as South Africa. Evidence shows that poor health as a consequence of NCDs and HIV among the workforce increases absenteeism and leads to decrease in productivity. However, the prevalence of these co-occurring chronic conditions and associated factors is unknown in the educator workforce. Improved understanding has implications for their management and wellbeing of educators. This paper reports the prevalence of selected NCDs and associated factors among HIV positive educators in South Africa using the 2015/6 survey of Educators in Public Schools in South Africa. Methods: This was a second-generation surveillance undertaken among educators in selected public schools in all nine provinces in South Africa. A multi-stage stratified cluster design with probability proportional to size sampling was used to draw a random sample of schools. Factors associated with presence of NCDs were determined using a multivariate backward stepwise logistic regression analysis. Results: A total of 1 365 schools were sampled within which 21 495 (85.5%) educators were interviewed. Out of 2691, HIV Positive educators that responded to the questions on NCDs, 36.9% reported having NCDs. The most commonly reported NCDs were high blood pressure (17.4%), and stomach ulcers (13.5%). The increased odds of reporting the presence of NCDs was significantly associated with being female than male [aOR = 1.5: 95% CI (1.1–1.9), p<0.002], age 45 to 54 years [aOR = 1.8: 95% CI (1.4–2.2), p = p<0.001], and age 55 years and older than those 18 to 24 years [aOR = 2.7: 95% CI (1.8–3.9), p<0.001). The decreased odds of reporting the presence of NCDs was significantly associated with not being absent from school for health reasons [aOR = 0.7: 95% CI (0.6–0.9), p = 0.003]. Conclusion: NCDs care and active screening should be an integral part of HIV programmes including interventions such as prevention, treatment, care and support amongst public school educators in SA. The education department will need to invest in health promotion intervention programmes to prevent and mitigate the negative impact of NCDs and HIV on the sector. [ABSTRACT FROM AUTHOR]

Background: Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa. Methods: We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories. Results: A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care. Conclusion: This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts. [ABSTRACT FROM AUTHOR]

The South African Middle Stone Age (MSA) has in recent years become increasingly important for our understanding of the emergence of ‘modern human behaviours’. Several key innovations appeared in this context for the first time, significantly pre-dating their re-invention in the European Upper Palaeolithic. One of these innovations was heat treatment of stone to improve its quality for the production of stone tools. Heat treatment may even be the oldest well-documented technique used to intentionally alter the properties of materials in general. It is commonly thought of as requiring the skilled use of fire, a high degree of planning depth and complex cognitive abilities. However, to work on these fundamental concepts we need to analyse the techniques and procedures used to heat-treat and we need to understand what they imply. In this paper, we present a direct and expedient comparison between the technical complexities of four alternative heat treatment procedures by coding the behaviours required for their set-up in so-called cognigrams, a relatively new method for understanding complexity based on the problem-solution distance. Our results show that although the techniques significantly differ in complexity, the techniques used in the MSA fall within the range of complexities known from other MSA techniques. Heat treatment in above-ground fires, as it was practised during this period in South Africa, was even one of the most complex techniques at the time of its invention. Early heat treatment can therefore be considered an important behavioural proxy that may shed light on the behaviour and socioeconomic structure of past groups. The implications of this are highlighted by the ongoing debate about ‘modernity’, ‘behavioural flexibility’ and ‘complex cognition’ of early anatomically modern humans in Africa. [ABSTRACT FROM AUTHOR]

Introduction: The increasing number of people requiring HIV treatment in South Africa calls for efficient use of its human resources for health in order to ensure optimum treatment coverage and outcomes. This paper describes an innovative public-private partnership model which uses private sector doctors to treat public sector patients and ascertains the model’s ability to maintain treatment outcomes over time. Methods: The study used a retrospective design based on the electronic records of patients who were down-referred from government hospitals to selected private general medical practitioners (GPs) between November 2005 and October 2012. In total, 2535 unique patient records from 40 GPs were reviewed. The survival functions for mortality and attrition were calculated. Cumulative incidence of mortality for different time cohorts (defined by year of treatment initiation) was also established. Results: The median number of patients per GP was 143 (IQR: 66–246). At the time of down-referral to private GPs, 13.8% of the patients had CD4 count <200 cell/mm3, this proportion reduced to 6.6% at 12 months and 4.1% at 48 months. Similarly, 88.4% of the patients had suppressed viral load (defined as HIV-1 RNA <400 copies/ml) at 48 months. The patients’ probability of survival at 12 and 48 months was 99.0% (95% CI: 98.4%–99.3%) and 89.0% (95% CI: 87.1%–90.0%) respectively. Patient retention at 48 months remained high at 94.3% (95% CI: 93.0%–95.7%). Conclusions: The study findings demonstrate the ability of the GPs to effectively maintain patient treatment outcomes and potentially contribute to HIV treatment scale-up with the relevant support mechanism. The model demonstrates how an assisted private sector based programme can be effectively and efficiently used to either target specific health concerns, key populations or serve as a stop-gap measure to meet urgent health needs. [ABSTRACT FROM AUTHOR]

This paper is a response to the growing reference to archaeological evidence by linguists and geneticists interested in the spread of early farmers and pastoralists in southern Africa. It presents two databases. The first contains the archaeological evidence for pastoralism and farming in southern Africa, for the period 550 BC to AD 1050. This is the first time that the seven different types of archaeological evidence that have traditionally been used to identify both spread events are presented together at this scale. This was stimulated by our interest in investigating the antiquity of an early ‘Iron Age package’ relative to the spread of single archaeological traits. The analysis shows that the package appears approximately 700 years after sites containing pottery, cattle and sheep, without agriculture, appear in the drier parts of the sub-continent. It post-dates the appearance of earlier sites with pottery associated with farmers, metal-working and cultivation in the eastern half of the sub-continent. While poor preservation undoubtedly explains the absence of some parts of the package, the analysis suggests that other explanations should be considered. The second database is a quantitative, spatial study of archaeological publications on southern African farming and pastoralism for the period 1950 to 2016, covering the same geographical area and archaeological timeframe. This is presented as a proxy for research-intensive areas in attempt to show the gaps in archaeological fieldwork and knowledge. [ABSTRACT FROM AUTHOR]

Introduction: Health Care Workers (HCWs) are among the highest risk groups for contracting tuberculosis (TB), which is ranked the third most common occupational health disease in South Africa. Little is known about the true extent of the burden of TB among South African HCWs and current surveillance approaches are inadequate. The study aimed to determine the feasibility of using postal and web-based surveys accessed through registries of registered professionals to estimate the prevalence of TB among HCWs in South Africa. Materials and methods: We conducted a cross sectional survey on a sample of professional nurses and doctors (general practitioners) registered on the Medpages database platform; a subscription based registry for practising health care professionals. The survey included professionals who were actively involved in the clinical management of patients, either in public or private health care facilities. The paper based survey, including pre-paid return envelopes, was distributed via the post office and web-based surveys were distributed via e-mail through a hyperlink. Descriptive statistics were used to summarize the data and the Chi-square test to determine associations between categorical variables. Active TB was defined as any history of TB Results: Out of a total of 3,400 health care professionals contacted, 596 (18%) responses were received: 401 (67%) web-based and 195 (33%) postal. A significantly higher percentage of complete forms were from postal compared to web-based (97% [189/195] versus 87% [348/401], p<0.001). Younger (<60 years) professionals were more likely to use the web-based compared to postal (87% [236/270] versus 71% [134/189], p<0.001). Overall, the prevalence of active TB infection was 8.7%, (95%CI: 6.3%–11.7%) and there was no difference observed between doctors and nurses (10.8% [18/167] versus 7.5% [22/292], p = 0.236). Conclusion: This novel approach demonstrated the feasibility of using an existing registry of professionals to conduct surveys to estimate the prevalence of TB. Our findings showed a high TB prevalence; however the estimate might have been biased by the low response rate. Further research to optimise our approach could lead to a viable option in improving surveillance among health care professionals. [ABSTRACT FROM AUTHOR]

Background: Agreed international development standards underpin high quality de novo clinical practice guidelines (CPGs). There is however, no international consensus on how high quality CPGs should ‘look’; or on whether high quality CPGs from one country can be viably implemented elsewhere. Writing de novo CPGs is generally resource-intensive and expensive, making this challenging in resource-poor environments. This paper proposes an alternative, efficient method of producing high quality CPGs in such circumstances, using existing CPGs layered by local knowledge, contexts and products. Methods: We undertook a mixed methods case study in South African (SA) primary healthcare (PHC), building on findings from four independent studies. These comprised an overview of international CPG activities; a rapid literature review on international CPG development practices; critical appraisal of 16 purposively-sampled SA PHC CPGs; and additional interrogation of these CPGs regarding how, why and for whom, they had been produced, and how they ‘looked’. Results: Despite a common aim to improve SA PHC healthcare practices, the included CPGs had different, unclear and inconsistent production processes, terminology and evidence presentation styles. None aligned with international quality standards. However many included innovative succinct guidance for end-users (which we classified as evidence-based summary recommendations, patient management tools or protocols). We developed a three-tiered model, a checklist and a glossary of common terms, for more efficient future production of better quality, contextually-relevant, locally-implementable SA PHC CPGs. Tier 1 involves transparent synthesis of existing high quality CPG recommendations; Tier 2 reflects local expertise to layer Tier 1 evidence with local contexts; and Tier 3 comprises tailored locally-relevant end-user guidance. Conclusion: Our model could be relevant for any resource-poor environment. It should reduce effort and costs in finding and synthesising available research evidence, whilst efficiently focusing scant resources on contextually-relevant evidence-based guidance, and implementation. [ABSTRACT FROM AUTHOR]

Background: Operational research is required to design delivery of pre-exposure prophylaxis (PrEP) and early antiretroviral treatment (ART). This paper presents the primary analysis of programmatic data, as well as demographic, behavioural, and clinical data, from the TAPS Demonstration Project, which offered both interventions to female sex workers (FSWs) at 2 urban clinic sites in South Africa.Methods and Findings: The TAPS study was conducted between 30 March 2015 and 30 June 2017, with the enrolment period ending on 31 July 2016. TAPS was a prospective observational cohort study with 2 groups receiving interventions delivered in existing service settings: (1) PrEP as part of combination prevention for HIV-negative FSWs and (2) early ART for HIV-positive FSWs. The main outcome was programme retention at 12 months of follow-up. Of the 947 FSWs initially seen in clinic, 692 were HIV tested. HIV prevalence was 49%. Among those returning to clinic after HIV testing and clinical screening, 93% of the women who were HIV-negative were confirmed as clinically eligible for PrEP (n = 224/241), and 41% (n = 110/270) of the women who were HIV-positive had CD4 counts within National Department of Health ART initiation guidelines at assessment. Of the remaining women who were HIV-positive, 93% were eligible for early ART (n = 148/160). From those eligible, 98% (n = 219/224) and 94% (n = 139/148) took up PrEP and early ART, respectively. At baseline, a substantial fraction of women had a steady partner, worked in brothels, and were born in Zimbabwe. Of those enrolled, 22% on PrEP (n = 49/219) and 60% on early ART (n = 83/139) were seen at 12 months; we observed high rates of loss to follow-up: 71% (n = 156/219) and 30% (n = 42/139) in the PrEP and early ART groups, respectively. Little change over time was reported in consistent condom use or the number of sexual partners in the last 7 days, with high levels of consistent condom use with clients and low use with steady partners in both study groups. There were no seroconversions on PrEP and 7 virological failures on early ART among women remaining in the study. Reported adherence to PrEP varied over time between 70% and 85%, whereas over 90% of participants reported taking pills daily while on early ART. Data on provider-side costs were also collected and analysed. The total cost of service delivery was approximately US$126 for PrEP and US$406 for early ART per person-year. The main limitations of this study include the lack of a control group, which was not included due to ethical considerations; clinical study requirements imposed when PrEP was not approved through the regulatory system, which could have affected uptake; and the timing of the implementation of a national sex worker HIV programme, which could have also affected uptake and retention.Conclusions: PrEP and early ART services can be implemented within FSW routine services in high prevalence, urban settings. We observed good uptake for both PrEP and early ART; however, retention rates for PrEP were low. Retention rates for early ART were similar to retention rates for the current standard of care. While the cost of the interventions was higher than previously published, there is potential for cost reduction at scale. The TAPS Demonstration Project results provided the basis for the first government PrEP and early ART guidelines and the rollout of the national sex worker HIV programme in South Africa. [ABSTRACT FROM AUTHOR]

Background: Spatial analysis at different levels can help understand spatial variation of human immunodeficiency virus (HIV) infection, disease drivers, and targeted interventions. Combining spatial analysis and the evaluation of the determinants of the HIV burden in Southern African countries is essential for a better understanding of the disease dynamics in high-burden settings. Methods: The study countries were selected based on the availability of demographic and health surveys (DHS) and corresponding geographic coordinates. We used multivariable regression to evaluate the determinants of HIV burden and assessed the presence and nature of HIV spatial autocorrelation in six Southern African countries. Results: The overall prevalence of HIV for each country varied between 11.3% in Zambia and 22.4% in South Africa. The HIV prevalence rate was higher among female respondents in all six countries. There were reductions in prevalence estimates in most countries yearly from 2011 to 2020. The hotspot cluster findings show that the major cities in each country are the key sites of high HIV burden. Compared with female respondents, the odds of being HIV positive were lesser among the male respondents. The probability of HIV infection was higher among those who had sexually transmitted infections (STI) in the last 12 months, divorced and widowed individuals, and women aged 25 years and older. Conclusions: Our research findings show that analysis of survey data could provide reasonable estimates of the wide-ranging spatial structure of the HIV epidemic in Southern African countries. Key determinants such as individuals who are divorced, middle-aged women, and people who recently treated STIs, should be the focus of HIV prevention and control interventions. The spatial distribution of high-burden areas for HIV in the selected countries was more pronounced in the major cities. Interventions should also be focused on locations identified as hotspot clusters. [ABSTRACT FROM AUTHOR]

Introduction: Tuberculosis remains one of the top ten causes of mortality globally. Children accounted for 12% of all TB cases and 18% of all TB deaths in 2022. Paediatric TB is difficult to diagnose with conventional laboratory tests, and chest radiographs remain crucial. However, in low-and middle-income countries with high TB burden, the capacity for radiological diagnosis of paediatric TB is rarely documented and data on the associated radiation exposure limited. Methods: A multicentre, mixed-methods study is proposed in three countries, Mozambique, South Africa and Spain. At the national level, official registry databases will be utilised to retrospectively compile an inventory of licensed imaging resources (mainly X-ray and Computed Tomography (CT) scan equipment) for the year 2021. At the selected health facility level, three descriptive cross-sectional standardised surveys will be conducted to assess radiology capacity, radiological imaging diagnostic use for paediatric TB diagnosis, and radiation protection optimization: a site survey, a clinician-targeted survey, and a radiology staff-targeted survey, respectively. At the patient level, potential dose optimisation will be assessed for children under 16 years of age who were diagnosed and treated for TB in selected sites in each country. For this component, a retrospective analysis of dosimetry will be performed on TB and radiology data routinely collected at the respective sites. National inventory data will be presented as the number of units per million people by modality, region and country. Descriptive analyses will be conducted on survey data, including the demographic, clinical and programmatic characteristics of children treated for TB who had imaging examinations (chest X-ray (CXR) and/or CT scan). Dose exposure analysis will be performed by children's age, gender and disease spectrum. Discussion: As far as we know, this is the first multicentre and multi-national study to compare radiological capacity, radiation protection optimization and practices between high and low TB burden settings in the context of childhood TB management. The planned comparative analyses will inform policy-makers of existing radiological capacity and deficiencies, allowing better resource prioritisation. It will inform clinicians and radiologists on best practices and means to optimise the use of radiological technology in paediatric TB management. [ABSTRACT FROM AUTHOR]

Objective: Female Genital Schistosomiasis (FGS) causes intravaginal lesions and symptoms that could be mistaken for sexually transmitted diseases or cancer. In adults, FGS lesions [grainy sandy patches (GSP), homogenous yellow patches (HYP), abnormal blood vessels and rubbery papules] are refractory to treatment. The effect of treatment has never been explored in young women; it is unclear if gynaecological investigation will be possible in this young age group (16–23 years). We explored the predictors for accepting anti-schistosomal treatment and/or gynaecological reinvestigation in young women, and the effects of anti-schistosomal mass-treatment (praziquantel) on the clinical manifestations of FGS at an adolescent age. Method: The study was conducted between 2011 and 2013 in randomly selected, rural, high schools in Ilembe, uThungulu and Ugu Districts, KwaZulu-Natal Province, East Coast of South Africa. At baseline, gynaecological investigations were conducted in female learners in grades 8 to 12, aged 16–23 years (n = 2293). Mass-treatment was offered in the low-transmission season between May and August (a few in September, n = 48), in accordance with WHO recommendations. Reinvestigation was offered after a median of 9 months (range 5–14 months). Univariate, multivariable and logistic regression analysis were used to measure the association between variables. Results: Prevalence: Of the 2293 learners who came for baseline gynaecological investigations, 1045 (46%) had FGS lesions and/or schistosomiasis, 209/1045 (20%) had GSP; 208/1045 (20%) HYP; 772/1045 (74%) had abnormal blood vessels; and 404/1045 (39%) were urine positive. Overall participation rate for mass treatment and gynaecological investigation: Only 26% (587/2293) learners participated in the mass treatment and 17% (401/2293) participated in the follow up gynaecological reinvestigations. Loss to follow-up among those with FGS: More than 70% of learners with FGS lesions at baseline were lost to follow-up for gynaecological investigations: 156/209 (75%) GSP; 154/208 (74%) HYP; 539/722 (75%) abnormal blood vessels; 238/404 (59%) urine positive. The grade 12 pupil had left school and did not participate in the reinvestigations (n = 375; 16%). Follow-up findings: Amongst those with lesions who came for both treatment and reinvestigation, 12/19 still had GSP, 8/28 had HYP, and 54/90 had abnormal blood vessels. Only 3/55 remained positive for S. haematobium ova. Factors influencing treatment and follow-up gynaecological investigation: HIV, current water contact, water contact as a toddler and urinary schistosomiasis influenced participation in mass treatment. Grainy sandy patches, abnormal blood vessels, HYP, previous pregnancy, current water contact, water contact as a toddler and father present in the family were strongly associated with coming back for follow-up gynaecological investigation. Challenges in sample size for follow-up analysis of the effect of treatment: The low mass treatment uptake and loss to follow up among those who had baseline FGS reduced the chances of a larger sample size at follow up investigation. However, multivariable analysis showed that treatment had effect on the abnormal blood vessels (adjusted odds ratio = 2.1, 95% CI 1.1–3.9 and p 0.018). Conclusion: Compliance to treatment and gynaecological reinvestigation was very low. There is need to embark on large scale awareness and advocacy in schools and communities before implementing mass-treatment and investigation studies. Despite challenges in sample size and significant loss to follow-up, limiting the ability to fully understand the treatment's effect, multivariable analysis demonstrated a significant treatment effect on abnormal blood vessels. Author summary: Female genital schistosomiasis (FGS) is a neglected tropical disease and it affects many women and young girls in schistosomiasis endemic areas. A lot of research is still needed to understand the characteristics of FGS, its prevention, as well as the timing for treatment. As a result of the limited information, some women who suffer from FGS end up being misdiagnosed with diseases such as human papilloma virus or other sexually transmitted diseases. The study highlights issues that need to be taken into considerations when providing treatment or conducting mass treatment for schistosomiasis and FGS or planning gynaecological investigations to inform FGS control programmes. In this study of adolescent girls and young women of KwaZulu-Natal Province of South Africa, we sought to explore the factors that influence participation in mass treatment and gynaecological investigation, and investigating the effect of praziquantel treatment on FGS. Factors that influenced participation in mass treatment included HIV, current water contact, water contact as a toddler and urinary schistosomiasis. Factors that influenced participation in follow up gynaecological investigation included grainy sandy patches, abnormal blood vessels, homogenous yellow patches, previous pregnancy, current water contact, water contact as a toddler and father present in the family. There was low uptake and loss to follow up for mass treatment, and this contributed to small sample size for follow up gynaecological investigations to understand the effect of treatment. However, multivariable analysis showed that treatment had effect on the abnormal blood vessels and not on grainy sandy patches and homogenous yellow patches. [ABSTRACT FROM AUTHOR]

There has been an increase in female incarcerated offenders nationally and internationally. Despite this trend, literature and research on female offenders remain limited compared to their male counterparts. Evidence of the relationship between certain personality disorders and offending behaviour has led numerous countries to prioritise identifying and assessing personality disorders among the offender population. Psychopathic personality traits may contribute to women's risk factors for expressing antisocial behaviours, resulting in their potential future incarceration. Thus, a need exists to understand possible factors that may predict the expression of psychopathic traits in females, which may have notable utility among female offenders. This study aimed to investigate possible predictor variables of psychopathy amongst incarcerated female offenders in South Africa. A quantitative research approach, non-experimental research type, and correlational research design were employed. A convenience sampling technique was used. The sample consisted of 139 (N = 139) female offenders housed in two correctional centres in South Africa who voluntarily participated in this study. Correlation analyses and hierarchical regression analysis procedures were conducted to analyse the results. Results indicated (i) a certain combination of predictor variables that statistically and practically significantly explained both primary and secondary psychopathy and (ii) individual predictor variables (e.g., Impulsivity, Simple Tasks, Risk-Seeking, and Self-Centredness) that explained both primary and secondary psychopathy statistically and practically significantly. This study provides valuable information about the possible predictor variables of psychopathy amongst female offenders within the context of South Africa. However, further research must be conducted to validate these findings and advance our knowledge on this topic. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare workers globally have experienced increased social and occupational stressors in their working environments and communities because of COVID-19 which has increased the risk of mental health concerns. This study aimed to explore the prevalence and correlates of depression and anxiety amongst healthcare workers during the COVID-19 pandemic in the Western Cape, South Africa. In addition, role-related stressors and coping strategies were explored. Material and methods: We conducted a cross-sectional survey of doctors and nurses working in public healthcare facilities across the Western Cape, South Africa. Participants completed the Generalized Anxiety Disorder-7 (GAD-7), the Center for Epidemiologic Studies Depression (CES-D), the Professional Quality of Life (PROQL-R-IV), and the Brief Coping Orientation to Problems Experienced (COPE-R) scales. Data were analysed using multivariable logistic regression analysis. Results: The sample comprised 416 health workers (303 nurses, 113 doctors). Almost 40% of the sample (n = 161) had CES-D scores suggestive of probable depression, and 45.9% (n = 186) had GAD-7 scores suggestive of anxiety. In the logistic regression model, the odds of probable depression were higher for female participants compared to men (OR = 2.26, 95% CI 1.00–5.10) and for participants who used behavioural disengagement as a coping strategy (OR = 1.50, 95% CI 1.14–1.97). More time spent working with COVID patients was associated with increased odds of having high levels of anxiety [OR = 1.13, 95% CI (1.02–1.25). Substance use (OR = 1.39, 95% CI 1.08–1.81), venting (OR = 1.31, 95% CI 1.01–1.70), and self-blame (OR = 1.42, 95% CI 1.08–1.87) were some of the coping strategies used by healthcare workers. High levels of secondary traumatic stress and burnout were found to increase the odds of both depression and anxiety. Conclusion: Findings of this study suggest that there is a high prevalence of mental health issues among healthcare workers, and a critical need to focus on workplace mental health interventions to support these frontline workers. [ABSTRACT FROM AUTHOR]

Background: Cash transfers are a promising but understudied intervention that may protect cognitive function in adults. Although South Africa has a rapidly ageing population, little is known about the nature of association between cash transfers and cognitive function in this setting. Objectives: We leveraged age-eligibility expansions to South Africa's Child Support Grant (CSG) to investigate the association between duration of CSG eligibility and cognitive function of biological mothers of child beneficiaries in South Africa. Methods: We analysed 2014/2015 baseline data from 944 women, aged 40–59 years with at least one CSG-eligible child, enrolled in the population-representative HAALSI cohort in Agincourt, South Africa. Duration of CSG eligibility for each mother was calculated based on the birth dates of all their children and the CSG age-eligibility expansion years (2003–2012). Cognitive function was measured using a cognitive battery administered at the HAALSI baseline interview. Linear regression was used to estimate the association between duration of CSG eligibility, dichotomized as low (≤10 years) and high (>10 years) eligibility, and cognitive function z-scores of the mothers. Results: High vs. low duration of CSG eligibility, was associated with higher cognitive function z-scores in the full sample [β: 0.15 SD units; 95% CI: 0.04, 0.26; p-value = 0.01]. In mothers with one to four lifetime children, but not five or more, high vs. low duration of CSG eligibility, was associated with higher cognitive function z-scores [β: 0.19 SD units; 95% CI: 0.05, 0.34, p-value = 0.02]. Conclusion: Government cash transfers given to support raising children may confer substantial protective effects on the subsequent cognitive function of mothers. Further studies are needed to understand how parity may influence this relationship. Our findings bring evidence to policymakers for designing income supplementation programmes to promote healthy cognitive ageing in low-income settings. [ABSTRACT FROM AUTHOR]

Background: Covid-19 epidemics raged around the world in years 2020–2022. The dynamics of the epidemics and their mortality varied by country depending on prevention, treatments, vaccination and health status of the population. Objective: The study compares Covid-19 morbidity and mortality in South-Africa and in France, two countries with similar population size and with reliable reporting systems, in order to better understand the dynamics and impacts of the epidemics and the effects of health policies and programs. Data and methods: Data on cases, deaths, hospitalizations, vaccinations were drawn from national statistics. Published data on cases and deaths were corrected for undercount. Results: Results show a different epidemiology in the two countries in the first three years of the epidemic (2020–2022). Incidence was higher in South Africa, and some 44% more people were infected by December 2022 than in France. Mortality and case-fatality were also higher in South Africa despite a favourable age structure. The age pattern of mortality showed higher values in South Africa among the young adults. Young women appeared somewhat disadvantaged in South Africa. Lastly, vaccination appeared to have had no effect on incidence, but a large effect on case-fatality in France. Conclusions: Despite about the same population size and the same crude death rate at baseline, South Africa exhibited more cases and more deaths from Covid-19 over the 2020–2022 period. Prevention strategies (lockdown and vaccination) appear to have had large impacts on morbidity and mortality. [ABSTRACT FROM AUTHOR]

Most studies rely on cross-sectional retrospective reports from adult samples to collect information about adverse childhood experiences (ACEs) to examine relationships with adult outcomes. The problems associated with these reports have long been debated, with only a few studies determining their reliability and validity and fewer still reaching consensus on the matter. This paper uses repeat prospective and retrospective reports of adverse childhood experiences from two respondent sources in the South African Birth to Twenty Plus (Bt20+) cohort to explore agreement and concordance in the prospective reporting of ACEs by caregivers and respective children as adolescents and then as young adults. The findings demonstrate little overall agreement between prospective and retrospective accounts of childhood experiences, with 80% of kappa values below the moderate agreement cutoff (k = .41). The highest levels of agreement were found between prospective and retrospective reporting on parental and household death (kappas ranging from .519 to .944). Comparisons between prospective caregiver reports and retrospective young adult reports yielded high concordance rates on sexual and physical abuse and exposure to intimate partner violence (91.0%, 87.7% and 80.2%, respectively). The prevalence of reported ACEs varied with the age of the respondent, with adolescents reporting much higher rates of exposure to violence, physical and sexual abuse than are reported retrospectively or by caregivers. This variation may partly reflect actual changes in circumstances with maturation, but may be influenced by developmental stage and issues of memory, cognition and emotional state more than has been considered in previous analyses. More research, across disciplines, is needed to understand these processes and their effect on recall. Long-term prospective studies are critical for this purpose. In conclusion, methodological research that uses a range of information sources to establish the reliability and validity of both retrospective and prospective reports ‒ recognizing that the two approaches may fundamentally answer different questions ‒ should be encouraged. [ABSTRACT FROM AUTHOR]

: This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. John E. Ataguba and colleagues illustrate progress towards UHC and its monitoring and evaluation in South Africa. Please see later in the article for the Editors' Summary [ABSTRACT FROM AUTHOR]

Unhealthy food choices and consumption, coupled with sedentary lifestyles among consumers, intensify public health concerns regarding the quadruple disease burden, despite Primary Health Care (PHC) policy. However, the current relationship between consumer knowledge about healthy foods and following a healthy lifestyle needs to be explored. Our study, therefore, aimed to determine the association between consumers' subjective and objective knowledge about healthy foods and various healthy lifestyle choices. A cross-sectional survey was conducted among employed consumers (N = 157) from South African corporate settings. We used structural equation modelling (SEM) to determine associations between subjective and objective knowledge about healthy foods and healthy lifestyle choices. Our findings showed that most participants scored high on making healthy lifestyle choices relating to avoiding smoking (69.5%) and limiting drinking alcohol (68.7%) but less so for food and sleep (44.4%) while neglecting exercise, relaxation (13.7%), and choices that require dedicated effort (25.2%). On average, participants had high levels of subjective (mean = 3.59; 5-point Likert scale) knowledge and objective knowledge about healthy foods (88.4−95.9% correct responses). However, their objective knowledge about weight and cholesterol had severe deficiencies (36.7%). SEM confirmed an association between subjective knowledge and most healthy lifestyle choice categories, while income contributed to dedicated effort lifestyle choices. By contrast, objective knowledge did not associate with such choices. Our structural model suggests that subjective knowledge about healthy foods contributes to healthy lifestyle choices. Therefore, subjective knowledge and the objective knowledge deficiencies we identified among corporate consumers can serve as a valuable starting point for informed education to promote PHC policy and healthy lifestyle choices. [ABSTRACT FROM AUTHOR]

Background: In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs). Methods and findings: We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data. Conclusions: In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems. Using data from three national surveys, Naeemah Abrahams and colleagues compare rates of femicide, intimate partner femicide and non-intimate partner femicide in South Africa between 1999 and 2017. Author summary: Why was the study done?: Femicide, the most severe form of gender-based violence, is not well described in middle- and low-income countries. Reliable routine data from police, justice and statistical departments are not available, and dedicated studies are needed to understand the scope of femicide in the country. What did the researchers do and find?: South Africa has a methodogy to collect national data from forensic and police services to estimate femicide and repeated surveys on 3 occasions (1999, 2009, and 2017) allowed for the assessement of change over 18 years. We found that an estimated 3,793 women 14 years and older were victims of femicide in 1999, and this decreased to an estimated 2,407 femicide victims in 2017. We further found a decrease in intimate partner femicide with the age-standardised rates decreasing from 9.5/100,000 population in 1999 to 4.9/100,000 population in 2017. What do the findings mean?: The 3 surveys over 18 years shows that femicide is preventable but that South Africa remains a country with the highest globally recorded rate of femicide. The reduction in femicide rates may be partially due to the contribution of activism of women and community-based organisations in bringing about change in Government's gender-based violence policy and programme. A concern is the increase in missing data from police sources over the years, which points to the urgent need to improve information systems and integration of data across departments. [ABSTRACT FROM AUTHOR]

Objective: To determine trends in incidence, etiology and antimicrobial susceptibility of blood and cerebrospinal fluid (CSF) culture confirmed infections in hospitalized infants in a large tertiary neonatal unit in South Africa. Methods: Single-center, retrospective review of laboratory records of bacteria and fungi, and their susceptibility profiles, isolated from blood and CSF of infants hospitalized in the neonatal unit at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from 1st January 2010 to 31st December 2019. Laboratory data on isolates and their antimicrobial susceptibilities were collected. Coagulase-negative Staphylococcus, Corynebacteria and Bacillus spp. were excluded. Patient-level clinical and laboratory data were not available. Results: There were 8,319 significant isolates, giving an infection rate of 14.3/1000 patient-days. Infection rates increased from 12.0 to 15.7/1000 patient-days (estimated average yearly change 0.6[95%CI, 0.5–0.7];p = <0.001). Gram-negative infection rates increased from 4.3 to 10.8/1000 patient-days (estimated average yearly change 0.7[95%CI,0.6–0.8];p = <0.001). The 2 most commonly isolated Gram-negative organisms were Acinetobacter baumannii (44%) and Klebsiella pneumoniae (39%). Carbapenem resistance was seen in 31% of all Gram-negatives and increased over time (estimated average yearly change 4.8%[95%CI,4.2%-5.3%];p<0.001). Gram-positive infection rates decreased (estimated average yearly change -0.1[95%CI,-0.2– -0.05];p = <0.001). Staphylococcus aureus was the most common Gram-positive isolated. Rates of methicillin-resistant Staphylococcus aureus decreased from 91% to 55%(estimated average yearly change -2.8%[95%CI,-3.5%–2%],p< 0.001). Rates of fungal isolates decreased (estimated average yearly change -0.06[95%CI,-0.1 –-0.02]);p = 0.007). Candida parapsilosis (52%) and Candida albicans (35%) were the most common fungi isolated. Conclusions: There has been a marked overall increase in rates of blood and/or CSF infections, with an absolute increase in Gram-negative infections observed, replacing Gram-positive and fungal pathogens. Extended spectrum beta-lactamase Gram-negative isolates are being replaced by carbapenem resistance, with around one third of all significant Gram-negative isolates now carbapenem resistant. Research into hospital based novel treatment and prevention interventions for neonatal sepsis should be urgently prioritized. [ABSTRACT FROM AUTHOR]

Emergomyces africanus is a recently identified thermally-dimorphic fungal pathogen that causes disseminated infection in people living with advanced HIV disease. Known as emergomycosis, this disseminated disease is associated with very high case fatality rates. Over the last decade, improved diagnostics and fungal identification in South Africa resulted in a dramatic increase in the number of reported cases. Although the true burden of disease is still unknown, emergomycosis is among the most frequently diagnosed dimorphic fungal infections in Southern Africa; and additional species in the genus have been identified on four continents. Little is known about the pathogenesis and the host's immune response to this emerging pathogen. Therefore, we established a murine model of pulmonary infection using a clinical isolate, E. africanus (CBS 136260). Both conidia and yeast forms caused pulmonary and disseminated infection in mice with organisms isolated in culture from lung, spleen, liver, and kidney. Wild-type C57BL/6 mice demonstrated a drop in body weight at two weeks post-infection, corresponding to a peak in fungal burden in the lung, spleen, liver, and kidney. An increase in pro-inflammatory cytokine production was detected in homogenized lung supernatants including IFN-γ, IL-1β, IL-6, IL12-p40 and IL-17 at three- and four-weeks post-infection. No significant differences in TNF, IL-12p70 and IL-10 were observed in wild-type mice between one and four-weeks post-infection. Rag-1-deficient mice, lacking mature T-and B-cells, had an increased fungal burden associated with reduced IFN-γ production. Together our data support a protective T-helper type-1 immune response to E. africanus infection. This may provide a possible explanation for the susceptibility of only a subset of people living with advanced HIV disease despite hypothesized widespread environmental exposure. In summary, we have established a novel murine model of E. africanus disease providing critical insights into the host immune components required for eliminating the infection. Author summary: Emergomyces africanus is a thermally-dimorphic fungus that was recently described as the cause of disseminated infections in persons living with advanced HIV disease in South Africa, where emergomycosis is among the most frequently diagnosed dimorphic fungal diseases. Four additional Emergomyces species have been described causing serious infections around the world, and the infection has a high case fatality rate. Despite the seriousness of this infection, the pathophysiology, immunology, diagnosis, and optimal management of emergomycosis remain largely unknown, hampered by the absence of an animal model. Here, we established a mouse model of pulmonary and disseminated emergomycosis using a clinical isolate of E. africanus with the aim of investigating the host immune response. We found that infection spread from the lungs to other organs within two weeks. We describe the effector immune responses in immune-competent mice aiding in controlled infection. We also highlight the immune-modulating components lacking in immunocompromised mice that promote susceptibilty to infection. Our study provides new insights into the components of the host immune response required for controlling Emergomyces spp. infection. [ABSTRACT FROM AUTHOR]

Introduction: Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method; however, males over 15 years face challenges with its effective use. Long-acting prevention products could address barriers to effective PrEP use. This study aimed to estimate the potential uptake of a mono-PrEP implant and the factors influencing uptake among males in South Africa. The study also examined messaging and demand creation tactics that males perceive will improve HIV prevention uptake. Methods: We conducted a mixed methods study comprising participatory workshops and a self-administered survey among 142 PrEP-eligible males (18–40 years) in three provinces (Gauteng, Eastern Cape, and Kwa-Zulu Natal) in South Africa from July to November 2022. Logistic regression was used to assess the relationship between the potential uptake of a hypothetical, non-biodegradable mono-PrEP implant and socioeconomic and behavioural factors. Workshop data were analysed using content analysis. Results: The top three HIV prevention products that males would consider using were the monthly pill (74.6%), the mono-PrEP implant (62.7%), and event-driven oral PrEP (59.2%). If one prevention option was available, 31.7% of participants stated that they would use the monthly oral pill, 28.2% would use the six-monthly injection, and 19.7% the mono-PrEP implant. Four key themes were noted as influential to potential mono-PrEP uptake: "Health Over Everything", "Mono-PrEP Implant Concerns", "Potential Disclosure of Mono-PrEP Use", and "Information Distribution Channels". Participants preferred social and mainstream media as information distribution channels to receive information on HIV prevention services, including the mono-PrEP implant. Conclusion: In this study among predominantly heterosexual men in South Africa, there was interest in long-acting HIV prevention methods but concerns about the mono-PrEP implant. A comprehensive and participatory introduction will be needed for the implant, to improve acceptability and address potential concerns. Demand-creation strategies utilising social media and health campaigns should be considered to engage and reach males. [ABSTRACT FROM AUTHOR]

During TB-case finding, we assessed the feasibility of implementing the advanced HIV disease (AHD) care package, including VISITECT CD4 Advanced Disease (VISITECT), a semiquantitative test to identify a CD4≤200cells/μl. Adult participants with tuberculosis symptoms, recruited near-facility in Lesotho and South-Africa between 2021–2022, were offered HIV testing (capillary blood), Xpert MTB/RIF and Ultra, and MGIT culture (sputum). People living with HIV (PLHIV) were offered VISITECT (venous blood) and Alere tuberculosis-lipoarabinomannan (AlereLAM, urine) testing. AHD was defined as a CD4≤200cells/μl on VISITECT or a positive tuberculosis test. A CD4≤200cells/μl on VISITECT triggered Immy cryptococcal antigen (Immy CrAg, plasma) testing. Participants were referred with test results. To evaluate feasibility, we assessed i) acceptability and ii) intervention delivery of point-of-care diagnostics among study staff using questionnaires and group discussions, iii) process compliance, and iv) early effectiveness (12-week survival and treatment status) in PLHIV. Predictors for 12-week survival were assessed with logistic regression. Thematic content analysis and triangulation were performed. Among PLHIV (N = 676, 48.6% of 1392 participants), 7.8% were newly diagnosed, 81.8% on ART, and 10.4% knew their HIV status but were not on ART. Among 676 PLHIV, 41.7% had AHD, 29.9% a CD4≤200cells/μl and 20.6% a tuberculosis diagnosis. Among 200 PLHIV tested with Immy CrAg, 4.0% were positive. The procedures were acceptable for study staff, despite intervention delivery challenges related to supply and the long procedural duration (median: 73 minutes). At 12 weeks, among 276 PLHIV with AHD and 328 without, 3.3% and 0.9% had died, 84.8% and 92.1% were alive and 12.0% and 7.0% had an unknown status, respectively. Neither AHD nor tuberculosis status were associated with survival. Implementing AHD care package diagnostics was feasible during tuberculosis-case finding. AHD was prevalent, and not associated with survival, which is likely explained by the low specificity of VISITECT. Challenges with CD4 testing and preventive treatment uptake require addressing. [ABSTRACT FROM AUTHOR]

Objectives: Every child around the globe should get routine childhood vaccination, which is mostly affected by the country's economic capacity besides the socioeconomic differences. However, how well countries with different economic capacities address equitable child vaccination remains unanswered. Methods: Cross-sectional data from the latest Demographic and Health Survey (DHS) database of Mali, Bangladesh, and South Africa was used for this study. The dependent variable was full child vaccination, and wealth-based inequality was assessed using rate-ratio, concentration curve, and concentration index. A multilevel Poisson regression analysis was used to determine the predictors of inequalities. A risk ratio (RR) with a p-value of 0.05 was used to declare statistical significance. All analysis was weighted. Results: Full child vaccination status was 30.15%, 62.18%, and 46.94% in Mali, Bangladesh, and South Africa respectively. Even if the disparity is higher in Mali, the full vaccination favors the better-off family both in Mali, and Bangladesh respectively [CInd: 0.05, 95% CI: 0.01, 0.09], [CInd: 0.02, 95% CI: 0.001, 0.03], wealth status did not have an effect in South Africa. The multilevel poison regression indicated maternal age, occupation, wealth of household, and frequency of watching television to positively affect full vaccination, whereas the number of children in the house negatively affected full vaccination. Conclusion: Wealth-based inequality in child vaccination was higher in Mali followed by Bangladesh. There was no observable significant equity gap in South Africa. Wealth status, maternal occupation, maternal age, frequency of watching television, and number of children were predictors of full child vaccination. [ABSTRACT FROM AUTHOR]

Schistosomiasis is a vector-borne disease transmitted by freshwater snails and is prevalent in rural areas with poor sanitation and no access to tap water. Three snail species are known to transmit schistosomiasis in South Africa (SA), namely Biomphalaria pfeifferi, Bulinus globosus and Bulinus africanus. In 2003, a predicted prevalence of 70% was reported in tropical climates in SA. Temperature and rainfall variability can alter schistosomiasis-transmitting snails' development by increasing or decreasing their abundance and geographical distribution. This study aimed to map the historical distribution of schistosomiasis from 1950 to 2006 in SA. The snail sampling data were obtained from the historical National Snail Freshwater Collection (NFSC). Bioclimatic variables were extracted using ERA 5 reanalysis data provided by the Copernicus Climate Change Service. In this study, we used 19 bioclimatic and four soil variables. The temporal aggregation was the mean climatological period pre-calculated over the 40-year reference period with a spatial resolution of 0.5° x 0.5°. Multicollinearity was reduced by calculating the Variance Inflation Factor Core (VIF), and highly correlated variables (> 0.85) were excluded. To obtain an "ensemble" and avoid the integration of weak models, we averaged predictions using the True Skill Statistical (TSS) method. Results showed that the ensemble model achieved the highest Area Under the Curve (AUC) scores (0.99). For B. africanus, precipitation-related variables contributed to determining the suitability for schistosomiasis. Temperature and precipitation-related variables influenced the distribution of B. globosus in all three models. Biomphalaria pfeifferi showed that Temperature Seasonality (bio4) contributed the most (47%) in all three models. According to the models, suitable areas for transmitting schistosomiasis were in the eastern regions of South Africa. Temperature and rainfall can impact the transmission and distribution of schistosomiasis in SA. The results will enable us to develop future projections for Schistosoma in SA based on climate scenarios. [ABSTRACT FROM AUTHOR]

Background: Innovative approaches are needed to increase lay health workers in HIV programs. The Youth Health Africa (YHA) program is a novel approach that places young adults seeking work experience in one-year internships in health facilities to support HIV-related programming (e.g., HIV testing) or administration (e.g., filing). Methods: We implemented a pragmatic, randomized trial among 20 facilities in Ngaka Modiri Molema district in North West province from October 2020-August 2021 to assess impact of YHA interns on HIV testing, treatment initiation, and retention in care. The primary outcome was proportion of patients tested for HIV. Secondary outcomes assessed HIV positivity, initiation in care, retention in care, and HIV testing among males and adolescents/young adults. We conducted an intention-to-treat analysis accounting for variations in baseline outcomes between control and intervention facilities using difference-in-difference and controlled time series approaches. We repeated this using as-treated groupings for sensitivity analyses. Results: Fifty interns were placed in 20 facilities; thirty-four interns remained at 18 facilities through August 2021. Compared to control facilities, intervention facilities had a greater improvement in HIV testing (ΔΔ+5.7%, 95% Confidence Interval (CI): -3.7%-15.1%) and treatment initiation (ΔΔ+10.3%, 95% CI: -27.8–48.5%), but these differences were not statistically significant. There was an immediate increase in HIV testing in intervention facilities after program interns were placed, which was not observed in control facilities; this difference was significant (ΔΔ+8.4%, 95% CI: 0.5–16.4%, p = 0.036). There were no other differences in outcomes observed between intervention and control facilities. Conclusion: This was largely a null trial, but there were signals that program interns may have positive impact on HIV testing and treatment initiation. As implemented in this study, addition of YHA program interns had little impact on facility-based HIV service delivery. A higher number of interns placed per facility may be necessary to affect HIV services. Trial registration: Registration: This trial was registered with the ISRCTN (Registration number: ISRCTN67031403) in October 2022. [ABSTRACT FROM AUTHOR]

This study examines the dynamic short- and long-run causal relationship between South African real house prices and key macroeconomic fundamentals (gross domestic product(GDP), mortgage rate, exchange rate-USDZAR, affordability, household debt to disposable income, unemployment rate, share prices (JSE ALL share index), foreign direct investment, and producer price index) over the period 2000Q1-2019Q4. The study uses a vector error correction model (VECM) to estimate the relationships while accounting for endogeneity and reverse causality. Although, there seems to be a significant association(both short and long-run) between house prices and all macroeconomic fundamental variables, GDP and producer price index appear to have the greatest impact. Further, our results suggest that any short-term disequilibrium in house prices always self-corrects in the long-run. [ABSTRACT FROM AUTHOR]

Rodentia is the most species-rich order among mammals. The Republic of South Africa harbours a high rodent diversity whose taxonomy and phylogeny have been extensively studied using genetic tools. Such advances have led to the establishment of new faunal lists for the country. Because rodents are frequently recovered from archaeological cave site material and owl pellets, and constitute prime material for studying both past and present environmental conditions, it is necessary to characterize their osteological remains. The skull and teeth are the most useful diagnostic skeletal elements preserved in modern and fossil accumulations. This key provides updated craniodental criteria for identifying rodent genera found in Quaternary deposits, and modern material from the Republic of South Africa, thus facilitating research on past and present rodent diversity. [ABSTRACT FROM AUTHOR]

Introduction: Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings. Methods: Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings. Results: VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively. Conclusion: Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality. [ABSTRACT FROM AUTHOR]

The healthcare sector in South Africa has seen a rise in medical errors and negligence adversely affecting healthcare delivery. This study aimed to determine the nature and magnitude of Patient Safety Incidents at a tertiary hospital between April 2018 to March 2021 (the COVID-19 era). A retrospective review of Patient Safety Incidents forms and clinical records of inpatients above 12 years with a reported incident were included. The overall incidence of patient safety incidents was 4.40 PSIs per 10 000 patient-days. The majority of PSIs were harmful incidents (An incident that results in harm to a patient that is related to medical management, in contrast to disease complications or underlying disease) at 72.50% [145/200], followed by no harm incidents at 18.00% [36/200] and 9.50% [19/200] near-miss incidents. The five highest incident types were clinical process/procedure [83/200; 41.50%], behaviour [49/200; 24.50%], falls [28/200; 14%], complications [20/200; 10%], and pressure sores [11/200; 5.50%]. Incidents occurred more frequently within the week (83.50%) and during day shift (67.50%). Overall, the study showed low PSI reporting rates which is an inherent challenge with voluntary reporting. Notably, there has been an increasing trend in reporting. The results reflect a reporting culture more inclined to bring awareness to incidents that have negative outcomes. [ABSTRACT FROM AUTHOR]

Background: Despite the overall reduction in the HIV mother-to-child transmission (MTCT) rate in South Africa, poor adherence and retention in care during breastfeeding contribute to this period being a major driver of MTCT in South Africa. To improve this retention, postnatal clubs were created as an integrated, differentiated model of care providing psychosocial support and comprehensive care for the mother-infant pairs (MIP), including HIV and under-5-child services. We describe the implementation of these facility-based clubs and examine its health outcomes in a peri-urban primary health care setting in Cape Town, South Africa. Methods: In this prospective cohort study, conducted between June 2016 and December 2019, MIPs were recruited into postnatal clubs between 6 weeks and 6 months of age and followed-up until 18 months of age. Outcomes including maternal Viral Load (VL), and children's HIV testing were compared to a historical control group. Children's immunizations and maternal sexual and reproductive health outcomes are also described. Results: During the implementation of the postnatal club study period, 484 MIP were recruited with 84% overall attendance, 95% overall viral load suppression, and 98% overall uptake of HIV infant testing. Compared to historical controls, the club infant rapid test uptake was 1.6 times higher (95% CI: 1.4–1.9) at 9 months and 2.0 times higher at 18 months (95% CI: 1.6–2.6). Through 12 months and between 12–18 months, maternal VL monitoring was higher in the club group compared to the historical control by 1.5 times (95% CI: 1.3–1.6) and 2.6 times (95% CI: 2.1–3.2), respectively, with similar maternal VL suppression. Of 105 infants attending the 12 months visit, 99% were fully vaccinated by one year. Conclusion: MIP in the postnatal clubs showed better PMTCT outcomes than historical controls with high levels of retention in care. Other outcomes such as immunisation results suggest that integration of services, such as in the postnatal club, is feasible and beneficial for MIPs. [ABSTRACT FROM AUTHOR]

Background: Interventions to prevent rape perpetration must be designed to address its drivers. This paper seeks to extend understanding of drivers of single and multiple perpetrator rape (referred to here as SPR and MPR respectively) and the relationships between socio-economic status, childhood trauma, peer pressure, other masculine behaviours and rape. Method: 1370 young men aged 15 to 26 were interviewed as part of the randomised controlled trial evaluation of Stepping Stones in the rural Eastern Cape. We used multinomial to compare the characteristics of men who reported rape perpetration at baseline. We used structural equation modelling (SEM) to examine pathways to rape perpetration. Results: 76.1% of young men had never raped, 10.0% had perpetrated SPR and 13.9% MPR. The factors associated with both MPR and SPR (compared to never having raped) were indicators of socio-economic status (SES), childhood trauma, sexual coercion by a woman, drug and alcohol use, peer pressure susceptibility, having had transactional sex, multiple sexual partners and being physically violent towards a partner. The SEM showed the relationship between SES and rape perpetration to be mediated by gender inequitable masculinity. It was complex as there was a direct path indicating that SES correlated with the masculinity variable directly such that men of higher SES had more gender inequitable masculinities, and indirect path mediated by peer pressure resistance indicated that the former pertained so long as men lacked peer pressure resistance. Having a higher SES conveyed greater resistance for some men. There was also a path mediated through childhood trauma, such that men of lower SES were more likely to have a higher childhood trauma exposure and this correlated with a higher likelihood of having the gender inequitable masculinity (with or without the mediating effect of peer pressure resistance). Discussion: Both higher and lower socio-economic status were associated with raping. Prevention of rape perpetration must focus on changing men’s gender ideals, entitlements and inequitable practices. Reducing poverty and adverse childhood experiences should also be of benefit. [ABSTRACT FROM AUTHOR]

Background: Empirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach-analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC's cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period.Methods/findings: The model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold-the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government.Conclusions: VMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age. [ABSTRACT FROM AUTHOR]

In 1994, South Africa approved a constitution providing freedom from discrimination based on sexual orientation. Other Southern African countries, including Botswana, Malawi, and Namibia, criminalize same-sex behavior. Men who have sex with men (MSM) have been shown to experience high levels of stigma and discrimination, increasing their vulnerability to negative health and other outcomes. This paper examines the relationship between criminalization of same-sex behavior and experiences of human rights abuses by MSM. It compares the extent to which MSM in peri-urban Cape Town experience human rights abuses with that of MSM in Gaborone, Botswana; Blantyre and Lilongwe, Malawi; and Windhoek, Namibia. In 2008, 737 MSM participated in a cross-sectional study using a structured survey collecting data regarding demographics, human rights, HIV status, and risk behavior. Participants accrued in each site were compared using bivariate and multivariate logistic regression. Encouragingly, the results indicate MSM in Cape Town were more likely to disclose their sexual orientation to family or healthcare workers and less likely to be blackmailed or feel afraid in their communities than MSM in Botswana, Malawi, or Namibia. However, South African MSM were not statistically significantly less likely experience a human rights abuse than their peers in cities in other study countries, showing that while legal protections may reduce experiences of certain abuses, legislative changes alone are insufficient for protecting MSM. A comprehensive approach with interventions at multiple levels in multiple sectors is needed to create the legal and social change necessary to address attitudes, discrimination, and violence affecting MSM. [ABSTRACT FROM AUTHOR]

Background: Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa. Methods: A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16–55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex. Results: About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1–4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5–6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex. Conclusion: Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex. [ABSTRACT FROM AUTHOR]

Amidst the rapid global spread of Covid-19, many governments enforced country-wide lockdowns, with likely severe well-being consequences. In this regard, South Africa is an extreme case suffering from low levels of well-being, but at the same time enforcing very strict lockdown regulations. In this study, we analyse the causal effect of a lockdown and consequently, the determinants of happiness during the aforementioned. A difference-in-difference approach is used to make causal inferences on the lockdown effect on happiness, and an OLS estimation investigates the determinants of happiness after lockdown. The results show that the lockdown had a significant and negative impact on happiness. In analysing the determinants of happiness after lockdown, we found that stay-at-home orders have positively impacted happiness during this period. On the other hand, other lockdown regulations such as a ban on alcohol sales, a fear of becoming unemployed and a greater reliance on social media have negative effects, culminating in a net loss in happiness. Interestingly, Covid-19, proxied by new deaths per day, had an inverted U-shape relationship with happiness. Seemingly people were, at the onset of Covid-19 positive and optimistic about the low fatality rates and the high recovery rates. However, as the pandemic progressed, they became more concerned, and this relationship changed and became negative, with peoples' happiness decreasing as the number of new deaths increased. [ABSTRACT FROM AUTHOR]

Introduction: Family planning contributes significantly to the prevention of maternal and child mortality. However, many women still do not use modern contraception and the numbers of unintended pregnancies, abortions and subsequent deaths are high. In this paper, we estimate the service delivery costs of scaling up modern contraception, and the potential impact on maternal, newborn and child survival in South Africa. Methods: The Family Planning model in Spectrum was used to project the impact of modern contraception on pregnancies, abortions and births in South Africa (2015-2030). The contraceptive prevalence rate (CPR) was increased annually by 0.68 percentage points. The Lives Saved Tool was used to estimate maternal and child deaths, with coverage of essential maternal and child health interventions increasing by 5% annually. A scenario analysis was done to test impacts when: the change in CPR was 0.1% annually; and intervention coverage increased linearly to 99% in 2030. Results: If CPR increased by 0.68% annually, the number of pregnancies would reduce from 1.3 million in 2014 to one million in 2030. Unintended pregnancies, abortions and births decrease by approximately 20%. Family planning can avert approximately 7,000 newborn and child and 600 maternal deaths. The total annual costs of providing modern contraception in 2030 are estimated to be US$33 million and the cost per user of modern contraception is US$7 per year. The incremental cost per life year gained is US$40 for children and US$1,000 for mothers. Conclusion: Maternal and child mortality remain high in South Africa, and scaling up family planning together with optimal maternal, newborn and child care is crucial. A huge impact can be made on maternal and child mortality, with a minimal investment per user of modern contraception. [ABSTRACT FROM AUTHOR]

Large carnivores face numerous threats, including habitat loss and fragmentation, direct killing, and prey depletion, leading to significant global range and population declines. Despite such threats, leopards (Panthera pardus) persist outside protected areas throughout most of their range, occupying diverse habitat types and land uses, including peri-urban and rural areas. Understanding of leopard population dynamics in mixed-use landscapes is limited, especially in South Africa, where the majority of leopard research has focused on protected areas. We use spatially explicit capture-recapture models to estimate leopard density across a mixed-use landscape of protected areas, farmland, and urban areas in the Overberg region of the Western Cape, South Africa. Data from 86 paired camera stations provided 221 independent captures of 25 leopards at 50 camera trap stations with a population density estimate of 0.64 leopards per 100 km2 (95% CI: 0.55–0.73). Elevation, terrain ruggedness, and vegetation productivity were important drivers of leopard density in the landscape, being highest on elevated remnants of natural land outside of protected areas. These results are similar to previous research findings in other parts of the Western Cape, where high-lying natural vegetation was shown to serve as both a refuge and a corridor for leopard movement in otherwise transformed landscapes. Given the low leopard density and the prevalence of transformed land intermixed with patches of more suitable leopard habitat, prioritising and preserving connectivity for leopards is vital in this shared landscape. Ecological corridors should be developed in partnership with private landowners through an inclusive and multifaceted conservation strategy which also incorporates monitoring of and rapid mitigation of emerging threats to leopards. [ABSTRACT FROM AUTHOR]

Background: Dental therapy is a category of mid-level oral health professional that was introduced to address inequities in oral health service provision in South Africa within a constrained human resource for health context. However, low numbers of registered dental therapists and attrition threaten this strategy. Aim: This study explored reasons for this attrition, building on the Hertzberg Two-Factor Theory. Methods: Through a qualitative exploratory study design, in-depth interviews were conducted with former dental therapists to explore their reasons for leaving the profession. They were recruited using snowball sampling. All interviews were audio recorded, transcribed verbatim, and coded in NVIVO12. A team of researchers applied thematic analysis to agree on themes and sub-themes, guided by Hertzberg's ideas of intrinsic and extrinsic factors. Findings: All 14 former dental therapists interviewed expressed their passion for the profession, even though their motivations to join the profession varied. Many of their reasons for leaving aligned with extrinsic and intrinsic factors defined in Hertzberg's Two-Factor Theory. However, they also spoke about a desire for a professional identity that was recognized and respected within the oral health profession, health system, and communities. This is a novel study contribution. Conclusion: Dental therapist attrition in South Africa is mainly caused by job dissatisfaction and motivation issues resulting from health system level factors. While the Hertzberg Two-Factor Theory helped identify extrinsic and intrinsic factors at an individual level, we used the Human Resources for Health System Development Analytical Framework to identify solutions for dental therapist production, deployment, and retention. Addressing these issues will enhance retention and accessibility to oral health services in the country. [ABSTRACT FROM AUTHOR]

For the first time, ophiuroids have been found in South African strata predating the lowermost Bokkeveld Group. These comprise natural moulds and casts from two localities in the 'upper unit' of the Baviaanskloof Formation (Table Mountain Group). As a Pragian to earliest Emsian age has been inferred for this member, the new taxa comprise the earliest high-palaeolatitude ophiuroid records from southern Gondwana. Morphological analysis of the specimens revealed the presence of two distinct taxa. One is here described as Krommaster spinosus gen. et sp. nov., a new encrinasterid characterised by very large spines on the dorsal side of the disc, the ventral interradial marginal plates and the arm midlines. The second taxon is a poorly preserved specimen of Hexuraster weitzi, a cheiropterasterid previously described from the slightly younger Bokkeveld Group. [ABSTRACT FROM AUTHOR]

Background: The study aimed to estimate the burden of ticks and tick-borne diseases (TBDs) among rural cattle-keeping households of the Eastern Cape province of South Africa using Productivity Adjusted Life Years (PALYs). We modified Disability Adjusted Life Year (DALY) equations for humans to PALYs to estimate the societal burden of tick-borne animal diseases. Whilst the World Health Organization has indicated the adaptability of DALYs to assess burden of animal diseases, nothing has been done in this regard. This could be due to several reasons including that the assessment of animal disease burden is often less of a priority compared to human diseases, particularly in low- and middle-income countries where resources may be limited. As a result, less funding and attention may be given to developing and implementing PALYs for animal diseases. Furthermore, technical and conceptual challenges may be associated with applying DALYs equations to animal diseases, such as determining appropriate measures of productivity loss for different types and categories of animals and diseases. This motivated our study, which is focused on modelling the burden of ticks and TBDs in cattle (cows, oxen and bulls) reared in resource-poor settings. Method: We formulated a PALYs approach for cattle populations by adapting the DALYs approach to assess the burden of ticks and TBDs for cattle populations in 20 villages in the Eastern Cape province of South Africa. PALYs is a measurement used to assess the burden of disease in cattle populations, quantifying the years of life lost due to premature mortality and disability. It encompasses years of life lost due to premature mortality (YLL) and years lost due to disability (YLD) caused by health conditions. PALYs provide a comprehensive perspective on the effective number of years lost due to disability and premature death in cattle populations. The PALYs model involves several parameters that are examined to understand their impact on the model's behavior. To illustrate this, we used a structured questionnaire to collect data on parameters that feed into PALY equations. We coded and entered data from questionnaires directly into Statistical Package of Social Sciences (IBM SPSS Version 20) and entered the estimated values of PALY parameters to calculate PALYs equations, which were to estimate the societal disease burden of ticks and TBDs in cattle. PALYs calculations were done in three categories; PALYs without discounting and age weighting, PALYs with only discounting, and PALYs with discounting and age weighting in a practical example to study how these parameters influence the outcomes of the PALYs model. Results: Our results revealed that the years of productivity lost by a cow, bull, and ox that suffered from ticks and TBDs could be estimated at various disability weights. Approximately 26%, 23% and 35% of the productivity years of a cow, ox and bull, respectively, reared by resource-poor livestock owners are lost due to the burden of ticks and TBDs in the Eastern Cape province of South Africa. However, introducing tick control measures reduces the loss to approximately 3%, 2% and 3% of their lifespan productivity, an indication that tick control will save approximately 23%, 21% and 32% of years of the productive life of cows, oxen and bulls, respectively. Therefore, it is evident that using ticks and TBD prevention measures at an early age of cattle will improve cattle productivity and hence the socioeconomic welfare of resource-poor rural farming communities in the Eastern Cape province of South Africa. Conclusion: The findings generated from the PALYs approach are helpful in projections for the future burden of any livestock disease. They may be used as a basis in policy formulation and decision-making by various stakeholders, and hence a priority in animal health economics. We recommend that a classification of livestock diseases of national economic importance should consider both the societal burden (non-monetary) and economic impact instead of the common practice of only considering the economic (monetary) impact. Adding a societal burden measure to existing economic measures provides a holistic understanding of the impact of a disease on society especially in resource-limited settings where the livestock value goes beyond monetary value. [ABSTRACT FROM AUTHOR]