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Background: Medical xenophobia of migrant (either in-migrants or immigrants) youths is an ongoing problem in contemporary South African society. Medical mistreatment by healthcare workers and social phobia from migrant youths have been attributed to major obstacles to healthcare utilization as well as health services satisfaction. This study aimed to determine the prevalence and factors contributing to health services satisfaction and medical exclusion among migrant youths in Gauteng province in South Africa. Methods: The Round 5 Gauteng City-Region Observatory (GCRO) Quality of Life (QoL) survey was conducted in 2017‒2018, a nationally representative survey piloted every two years in South Africa, was utilized in this study. A 2-year cohort study of 24,889 respondents aged 18 to 29 and a baseline data consisted of 4,872 respondents, comprising non-migrants, in-migrants and immigrants, from where 2,162 in-migrants and immigrants were utilized as the sample size. The data was analysed using descriptive statistics, Chi-Square analysis and logistic regression. Results: A total of 2,162 migrants, comprising 35.4% in-migrants and 9.0% of immigrants, from the 4,872 respondents, were included in the analysis. The prevalence of medical exclusion of in-migrant and immigrant youths were 5.5% and 4.2%, and the majority of them reported the use of public health facilities (in-migrants ‒ 84.3% vs. immigrants ‒ 87.1%). At the bivariate level, demographic (age, sex, and population group), economic (employed and any income) and health-related (no medical aid and household member with mental health) factors were significantly associated with medical exclusion (ρ≤0.05). The adjusted odds ratio showed that only female gender (AOR: 1.07, 95% CI: 0.678, 1.705), no medical aid cover (AOR: 1.23, 95% CI: 0.450, 3.362), and neither (AOR: 1.59, 95% CI: 0.606, 4.174) or dissatisfied (AOR: 4.29, 95% CI: 2.528, 7.270) were independent predictors of medical exclusion. Conclusion: Having no medical aid cover, being a female and dissatisfied, or neither satisfied nor dissatisfied with health services significantly increased the odds of medical exclusion among migrant youths. To increase healthcare utilization and ensuring adequate medical care of migrant youths, opting for medical aid insurance without increasing costs should be guaranteed. Therefore, there should be no consequences for lack of residence status or correct documentation papers when accessing healthcare services among migrant youths in South Africa. [ABSTRACT FROM AUTHOR]

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities' misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19. [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]

Background: The proper management of isolation waste is of utmost importance in healthcare facilities to prevent the spread of infections and protect both healthcare workers and the general public. This study investigated waste handlers' knowledge of the management of isolation waste at Dr. George Mukhari Academic Hospital in Gauteng, South Africa. Methods: A survey was conducted to assess waste handlers' understanding of waste types, colour codes, safety precautions, and awareness of internal policies related to isolation waste management. Results: The study found that the majority of waste handlers demonstrated a good understanding of waste types generated in the isolation unit, including sharps waste, human tissue waste, infectious waste, and general waste. They also correctly identified examples of sharp waste, such as injections, blades, glass slides, and needles. Additionally, most respondents were aware of the colour code used for representing infectious waste as "yellow" and "red." The study revealed a statistically significant association between waste handlers' age and their knowledge of isolation waste, suggesting that age may influence their understanding of waste management practices. Furthermore, experience was found to be significantly associated with waste handlers' knowledge of the health-hazardous nature of isolation waste. While the majority of waste handlers recognized the importance of wearing protective clothing and correctly marking isolation waste, some respondents were not aware of the internal policy for waste handling such as guidelines and protocols specific to the segregation, packaging, labeling, and disposal of waste generated within the isolation units. Conclusion and contribution: These findings highlight the importance of continuous training, targeted education, and policy dissemination to ensure effective waste management and adherence to safety protocols among waste handlers. [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]

Introduction: Voluntary medical male circumcision (VMMC) remains an effective biomedical intervention for HIV prevention in high HIV prevalence countries. In South Africa, United States Agency for International Development VMMC partners provide technical assistance to the Department of Health, at national and provincial levels in support of the establishment of VMMC sites as well as in providing direct VMMC services at site level since April 2012. We describe the outcomes of the Right to Care (RTC) VMMC program implemented in South Africa from 2012 to 2017. Methods: This retrospective study was undertaken at RTC supported facilities across six provinces. Young males aged ≥10 years who presented at these facilities from 1 July 2012 to 31 September 2017 were included. Outcomes were VMMC uptake, HIV testing uptake and rate of adverse events (AEs). Using a de-identified observational database of these clients, summary statistics of the demographic characteristics and outcomes were calculated. Results: There were a total 1,001,226 attendees of which 998,213 (99.7%) were offered VMMC and had a median age of 15 years (IQR = 12–23 years). Of those offered VMMC, 99.6% (994,293) consented, 96.7% (965,370) were circumcised and the majority (46.3%) were from Gauteng province. HIV testing uptake was 71% with a refusal rate of 15%. Of the newly diagnosed HIV positives, 64% (6,371 / 9,972) referrals were made. The rate of AEs, defined as bleeding, infection, and insufficient skin removal) declined from 3.26% in 2012 to 1.17% in 2017. There was a reduction in infection-related AEs from 2,448 of the 2,602 adverse events (94.08%) in 2012 to 129 of the 2,069 adverse events (6.23%) in 2017. Conclusion: There was a high VMMC uptake with a decline in AEs over time. Adolescent men contributed the most to the circumcised population, an indication that the young population accesses medical circumcision more. VMMC programs need to implement innovative demand creation strategies to encourage older males (20–34 years) at higher risk of HIV acquisition to get circumcised for immediate impact in reduction of HIV incidence. HIV prevalence in the total population increased with increasing age, notably in clients above 25 years. [ABSTRACT FROM AUTHOR]

Multiple factors make adherence to antiretroviral therapy (ART) a complex process. This study aims to describe the barriers and facilitators to adherence for patients receiving first-line and second-line ART, identify different adherence strategies utilized and make recommendations for an improved adherence strategy. This mixed method parallel convergent study will be conducted in seven high volume public health facilities in Gauteng and one in Limpopo province in South Africa. The study consists of four phases; a retrospective secondary data analysis of a large cohort of patients on ART (using TIER.Net, an ART patient and data management system for recording and monitoring patients on ART and tuberculosis (TB)) from seven Johannesburg inner-city public health facilities (Gauteng province); a secondary data analysis of the Intensified Treatment Monitoring Accumulation (ITREMA) trial (a randomized control trial which ran from June 2015 to January 2019) conducted at the Ndlovu Medical Center (Limpopo province); in-depth interviews with people living with Human Immunodeficiency Virus (PLHIV) who are taking ART (in both urban and rural settings); and a systematic review of the impact of treatment adherence interventions for chronic conditions in sub-Saharan Africa. Data will be collected on demographics, socio-economic status, treatment support, retention in care status, disclosure, stigma, clinical markers (CD4 count and viral load (VL)), self-reported adherence information, intrapersonal, and interpersonal factors, community networks, and policy level factors. The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting and Population, Interventions, Comparisons and Outcomes (PICO) criteria. Analyses will involve tests of association (Chi-square and t-test), thematic analysis (deductive and inductive approaches) and network meta-analysis. Using an integrated multilevel socio-ecological framework this study will describe the factors associated with adherence for PLHIV who are taking first-line or second-line ART. Implementing evidence-based adherence approaches, when taken up, will improve patient's overall health outcomes. Our study results will provide guidance regarding context-specific intervention strategies to improve ART adherence. [ABSTRACT FROM AUTHOR]

Background: Gauteng province, with 26.3% of South Africa's population, is the commercial and industrial powerhouse of the country. During the first epidemic wave in 2020, Gauteng accounted for 32.0% of South Africa's reported COVID-19 cases. Aim: The aim of this study was to describe the health system response to the COVID-19 pandemic during the first epidemic wave in Gauteng province and to explore the perspectives of key informants on the provincial response. Material and methods: Using an adapted Pandemic Emergency Response Conceptual Framework, this was a qualitative case study design consisting of 36 key informant interviews and a document analysis. We used thematic analysis to identify themes and sub-themes from the qualitative data. Results: Our case study found that Gauteng developed an innovative, multi-sectoral and comprehensive provincial COVID-19 response that aimed to address the dual challenge of saving lives and the economy. However, the interviews revealed multiple perspectives, experiences, contestations and contradictions in the pandemic response. The COVID-19 pandemic exposed and amplified the fragilities of existing systems, reflected in the corruption on personal protective equipment, poor data quality and inappropriate decisions on self-standing field hospitals. Rooted in a chronic under-investment and insufficient focus on the health workforce, the response failed to take into account or deal with their fears, and to incorporate strategies for psychosocial support, and safe working environments. The single-minded focus on COVID-19 exacerbated these fragilities, resulting in a de facto health system lockdown and reported collateral damage. The key informants identified missed opportunities to invest in primary health care, partner with communities and to include the private health sector in the pandemic response. Conclusion: Gauteng province should build on the innovations of the multi-sectoral response to the COVID-19 pandemic, while addressing the contested areas and health system fragilities. [ABSTRACT FROM AUTHOR]

Background: Universal health coverage (UHC) for all people, regardless of citizenship, is a global priority. Health care providers are central to the achievement of UHC, and their attitudes and behaviour could either advance or impede UHC for migrants. Using a social exclusion conceptual framework, this study examined the perspectives of health care providers on delivering health services to migrants in public health facilities in Gauteng Province, South Africa. Methods: We used stratified, random sampling to select 13 public health facilities. All health care providers working in ambulatory care were invited to complete a self-administered questionnaire. In addition to socio-demographic information, the questionnaire asked health care providers if they had witnessed discrimination against migrants at work, and measured their perspectives on social exclusionary views and practices. Multiple regression analysis was used to identify predictors of more exclusionary perspectives for each item. Results: 277 of 308 health care providers participated in the study–a response rate of 90%. The participants were predominantly female (77.6%) and nurses (51.9%), and had worked for an average of 6.8 years in their facilities. 19.2% of health care providers reported that they had witnessed discrimination against migrants, while 20.0% reported differential treatment of migrant patients. Exclusionary perspectives varied across the different items, and for different provider groups. Enrolled nurses and nursing assistants were significantly more exclusionary on a number of items, while the opposite was found for providers born outside South Africa. For some questions, female providers held more exclusionary perspectives and this was also the case for providers from higher levels of care. Conclusion: Health care providers are critical to inclusive UHC. Social exclusionary views or practices must be addressed through enabling health policies; training in culture-sensitivity, ethics and human rights; and advocacy to ensure that health care providers uphold their professional obligations to all patients. [ABSTRACT FROM AUTHOR]

Background: Fluconazole is used in combination with amphotericin B for induction treatment of cryptococcal meningitis and as monotherapy for consolidation and maintenance treatment. More than 90% of isolates from first episodes of cryptococcal disease had a fluconazole minimum inhibitory concentration (MIC) ≤4 μg/ml in a Gauteng population-based surveillance study of Cryptococcus neoformans in 2007–2008. We assessed whether fluconazole resistance had emerged in clinical cryptococcal isolates over a decade. Methodology and principal findings: We prospectively collected C. neoformans isolates from 1 January through 31 March 2017 from persons with a first episode of culture-confirmed cryptococcal disease at 37 South African hospitals. Isolates were phenotypically confirmed to C. neoformans species-complex level. We determined fluconazole MICs (range: 0.125 μg/ml to 64 μg/ml) of 229 C. neoformans isolates using custom-made broth microdilution panels prepared, inoculated and read according to Clinical and Laboratory Standards Institute M27-A3 and M60 recommendations. These MIC values were compared to MICs of 249 isolates from earlier surveillance (2007–2008). Clinical data were collected from patients during both surveillance periods. There were more males (61% vs 39%) and more participants on combination induction antifungal treatment (92% vs 32%) in 2017 compared to 2007–2008. The fluconazole MIC50, MIC90 and geometric mean MIC was 4 μg/ml, 8 μg/ml and 4.11 μg/ml in 2017 (n = 229) compared to 1 μg/ml, 2 μg/ml and 2.08 μg/ml in 2007–2008 (n = 249) respectively. Voriconazole, itraconazole and posaconazole Etests were performed on 16 of 229 (7%) C. neoformans isolates with a fluconazole MIC value of ≥16 μg/ml; only one had MIC values of >32 μg/ml for these three antifungal agents. Conclusions and significance: Fluconazole MIC50 and MIC90 values were two-fold higher in 2017 compared to 2007–2008. Although there are no breakpoints, higher fluconazole doses may be required to maintain efficacy of standard treatment regimens for cryptococcal meningitis. Author summary: Cryptococcus neoformans, a pathogenic fungal species-complex with an environmental niche, is the most common cause of meningitis among HIV-seropositive adults in sub-Saharan Africa. Fluconazole is recommended in combination with amphotericin B for induction treatment of cryptococcal meningitis and as monotherapy for consolidation and maintenance treatment. Fluconazole is also commonly prescribed to HIV-seropositive individuals for other indications; fluconazole exposure may result in secondary resistance if patients have concurrent active cryptococcal disease. Azole fungicides used in agriculture may potentially drive primary cryptococcal resistance when the fungus is exposed to these fungicides in the environment. We aimed to determine fluconazole MICs in 2017 and compare these values to those obtained in a 2007–2008 South African survey to assess whether fluconazole resistance had emerged in C. neoformans over a decade. We found that the proportion of isolates with an MIC of ≥16 μg/ml increased from 0% in 2007–2008 to 7% in 2017. MIC50 and MIC90 values were also two-fold higher in 2017 compared to 2007–2008. These study findings provided evidence for higher fluconazole dose recommendations (in combination with amphotericin B for the induction phase and as monotherapy for consolidation and maintenance phases) in the 2019 Southern African guideline for HIV-associated cryptococcosis. [ABSTRACT FROM AUTHOR]

Background: Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD4<500 cells/μl antiretroviral therapy (ART) eligibility threshold and universal test and treat (UTT) policies in the Gauteng province of South Africa. Method: We conducted a retrospective cohort study of 692 HIV positive adult (>18 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3–9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression. Results: Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4–2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4–3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1–1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001). Conclusion: These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring. [ABSTRACT FROM AUTHOR]

Organisational readiness is an implementation pre-requisite to gain its members' appropriate and committed use of the intervention. Implementation climate and organisational readiness for implementing change were evaluated conjointly to assess organisational readiness for an obesity and HIV health intervention that imparts health information directly to Grade 6 learners, and indirectly to their parents/caregivers in their home environment. The study objectives were to assess the level of organisational readiness at schools and to identify organisational factors (facilitators, barriers and contextual factors). A mixed-methods approach collected data from five public schools in Gauteng, South Africa. Forty-six educators and school management answered a self-administered questionnaire and contributed to a focus group discussion at each school. Mean scores with standard deviations, or median scores with interquartile ranges, were calculated to determine levels of organisational readiness. Qualitative data were transcribed and analysed thematically. The overall implementation climate and organisational readiness for implementing change median scores were acceptable, at 3.6 (IQR 3.2–4.1) and 4.3 (IQR 3.8–4.9), respectively. Results indicated that educators collectively valued the change highly enough to commit to its implementation, and that the motivation for the intervention, associated goals and objectives, the realisation for change, and the benefits thereof were well-comprehended by educators. Thirteen barriers and 13 facilitators were identified. The perceived degree of fit between the significance and values attached to the intervention by educators, and how these would be received by the target group (parents and learners) was also beneficial. Key barriers and facilitators indicated that the intervention needed to be a fit with existing workflows and educational systems. Contextual factors such as intervention appropriateness and acceptability as well as sensitivity to HIV were identified. These findings suggested proactive improvements to further improve the intervention and its implementation strategy. [ABSTRACT FROM AUTHOR]

Background: Bovine Taenia saginata cysticercus infections (also called bovine cysticercosis or beef measles) is usually diagnosed in cattle only during post-mortem meat inspection. The aim of this study was to investigate the identification rates of these infections in and to identify predictors/determinants of variations in the identification rates in abattoirs in Gauteng province, South Africa. Methods: Retrospective data for over 1.4 million cattle carcasses inspected in 26 abattoirs between January 2010 and December 2013 were used for the study. The identification rates (proportion of bovine Taenia saginata cysticercus positive carcasses) were computed and generalized estimating equations used to identify predictors/determinants of identification rates. Results: The overall identification rate was 0.70% (95% CI: 0.45, 0.95). Significantly (p< 0.05) lower rates were reported during summer (0.55%) than other seasons. Some geographic areas reported significantly (p<0.05) higher rates than others. The identification rates in high throughput abattoirs was significantly (p<0.05) higher (RR: 9.4; 95% CI: 4.7–19.1) than in low throughput abattoirs. Similarly, the identification rates among animals from feedlots were significantly (p<0.05) higher (RR: 1.6; 95% CI: 1.7–3.5) than those from non-feedlot sources. No significant (p>0.05) association was identified between identification rates and either the number of meat inspectors per abattoir or the provider of inspection services. Conclusion: Although no significant association was found between identification rates and provider of inspection services, follow-up studies will need to be done to specifically investigate the potential conflict of interest arising from the fact that abattoir owners hire meat inspection services directly. Capture of abattoir surveillance data needs to include farm address and for each case to be reported separately. Finally, information on the type of identified cysts (alive or calcified) need to be collected to help better estimate risk to consumers. This study provides useful baseline data to guide future studies, surveillance and control efforts. [ABSTRACT FROM AUTHOR]

Background: Though South Africa has high contraceptive use, unintended pregnancies are still widespread. The SILCS diaphragm could reduce the number of women with unmet need by introducing a discreet, woman-initiated, non-hormonal barrier method to the contraceptive method mix. Methods: A decision model was built to estimate the impact and cost-effectiveness of the introduction of the SILCS diaphragm in Gauteng among women with unmet need for contraception in terms of unintended and mistimed pregnancies averted, assuming that the available contraceptives on the market were not a satisfying option for those women. Full costs were estimated both from a provider’s and user’s perspective, which also accounts for women’s travel and opportunity cost of time, assuming a 5% uptake among women with unmet contraceptive need. The incremental cost-effectiveness ratio is computed at five and 10 years after introduction to allow for a distribution of fixed costs over time. A probabilistic sensitivity analysis was conducted to incorporate decision uncertainty. Results: The introduction of the SILCS diaphragm in Gauteng could prevent an estimated 8,365 unintended pregnancies and 2,117 abortions over five years, at an annual estimated cost of US$55 per woman. This comes to a cost per pregnancy averted of US$153 and US$171 from a user’s and provider’s perspectives, respectively, with slightly lower unit costs at 10 years. Major cost drivers will be the price of the SILCS diaphragm and the contraceptive gel, given their large contribution to total costs (around 60%). Conclusions: The introduction of the SILCS diaphragm in the public sector is likely to provide protection for some women for whom current contraceptive technologies are not an option. However to realize its potential, targeting will be needed to reach women with unmet need and those with likely high adherence. Further analyses are needed among potential users to optimize the introduction strategy. [ABSTRACT FROM AUTHOR]

Background Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa. Methods and Findings Cost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189–428) infections over 20 years. The cost is $181 (80% CI $117–$306) per HIA, and net savings are $2.4 million (80% CI $1.3 million to $3.6 million). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is $551 (80% CI $344–$1,071) and net savings are $753,000 (80% CI $0.3 million to $1.2 million). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage. Conclusions In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs. [ABSTRACT FROM AUTHOR]