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Introduction: Poverty, HIV and perinatal depression represent a triple threat to public health in sub-Saharan Africa because of their combined negative effects on parenting and child development. In the resource-constrained context of low-income and middle-income countries, a lay-counsellor-delivered intervention that combines a psychological and parenting intervention could offer the potential to mitigate the consequences of perinatal depression while also optimising scarce resources for healthcare.Measuring the cost-effectiveness of such a novel intervention will help decision-makers to better understand the relative costs and effects associated with replicating the intervention, thereby supporting evidence-based decision-making. This protocol sets out the methodological framework for analysing the cost-effectiveness of a cluster randomised controlled trial (RCT) that compares a combined intervention to enhanced standard of care when treating depressed, HIV-positive pregnant women and their infants in rural South Africa., Methods and Analysis: This cost-effectiveness analysis (CEA) protocol complies with the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. A societal perspective will be chosen.The proposed methods will determine the cost and efficiency of implementing the intervention as per the randomised control trial protocol, as well as the cost of replicating the intervention in a non-research setting. The costs will be calculated using an appropriately adjusted version of the Standardised Early Childhood Development Costing Tool.Primary health outcomes will be used in combination with costs to determine the cost per improvement in maternal perinatal depression at 12 months postnatal and the cost per improvement in child cognitive development at 24 months of age. To facilitate priority setting, the incremental cost-effectiveness ratios for improvements in child cognitive development will be ranked against six other child cognitive-development interventions according to Verguet et al 's methodology (2022).A combination of activity-based and ingredient-based costing approaches will be used to identify, measure and value activities and inputs for all alternatives. Outcomes data will be sourced from the RCT team., Ethics and Dissemination: The University of Oxford is the sponsor of the CEA. Ethics approval has been obtained from the Human Sciences Research Council (HSRC, #REC 5/23/08/17), South Africa and the Oxford Tropical Research Ethics Committee (OxTREC #31-17), UK.Consent for publication is not applicable since no participant data are used in this protocol.We plan to disseminate the CEA results to key policymakers and researchers in the form of a policy brief, meetings and academic papers., Trial Registration Details: ISRCTN registry #11 284 870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017)., Competing Interests: Competing interests: The authors, including the principal investigators, declare no financial or non-financial competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Programme Science (PS) and community-led monitoring (CLM) intersect in unexpected and promising ways. This commentary examines a CLM initiative in Malawi and South Africa to highlight the crucial role of CLM in bolstering the PS framework. By leveraging data sources often overlooked by conventional research and evaluation approaches, CLM emerges as a pivotal element in enhancing programme effectiveness. This paper delineates the fundamental principles of CLM, presents programme outcomes derived from CLM methodologies and contextualizes these findings within the broader framework of PS., Discussion: The Citizen Science Project implements CLM continuously at 33 health facilities: 14 in Malawi (eight in Kasungu District and six in Dedza District), and 19 in South Africa (all in the West Rand District), representing a total catchment area of 989,848 people. Monitoring indicators are developed in an iterative process with community groups. The indicators are unique to each country, but both focus on the uptake of health services (quantitative) and barriers to access (qualitative). Monthly clinic records surveys capture 34 indicators in Malawi and 20 in South Africa and are supplemented by qualitative interviews with care recipients and healthcare workers. Qualitative interviews provide additional granularity and help confirm and explain the more macro trends in service coverage as described in quantitative data. The resulting data analysis reveals key themes that help stakeholders and decision-makers to solve problems collaboratively. Noteworthy outcomes include a substantial increase in multi-month dispensing of antiretroviral therapy (ART) during COVID-19 (from 6% to 31%) with a subsequent recovery surpassing of HIV service benchmarks in Malawi post-pandemic., Conclusions: While quantifying direct impact remains challenging due to the project's design, CLM proves to be a robust methodology that generates credible data and produces impactful outcomes. Its potential extends beyond the health sector, empowering community leadership and fostering interventions aligned with community needs. As CLM continues to evolve, its integration into PS promises to improve relevance, quality and impact across diverse disciplines., (© 2024 The Author(s). Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Adolescents and men are two populations that perform poorly within the HIV cascade of care, having worse AIDS-related health outcomes, and experiencing higher levels of HIV-related stigma. This paper explores institutional health system discrimination as experienced by adolescent boys with perinatally-acquired HIV, situating them within the social and gendered contexts of the Eastern Cape Province, South Africa. Life history narratives ( n  = 36) and in-depth semi-structured interviews ( n  = 32) with adolescent boys living with HIV aged 13-22 were conducted in 2017-2018. In-depth semi-structured interviews with biomedical and traditional health practitioners ( n  = 14), analysis of health facility files ( n  = 41) and clinic observations were also conducted. Together, triangulated sources point to an incongruence between the complex needs of adoelscent boys and young men living with HIV and their experiences within the health system. Two institutional discrimination-related deterrents to retention in care were identified: (1) lack of confidentiality due to health facility layouts and practices that visibilised people living with HIV; and (2) mistreatment in the form of shouting. This article contributes to the limited literature on the experiences of young men within the HIV continuum of care, focusing on how stigma influences how young men experience and engage with the health sector.

Adolescents and young adults (AYA) are identified as a high-risk group for HIV acquisition. However, health services are generally not sensitive to the needs of this priority population. In addition, multimorbidity (having more than one disease in an individual) is not well studied among AYA, as it is typically associated with older individuals. This paper reports on commonly co-occurring disease conditions and disease patterns in AYA, aged 15-24 years, who took part in the 2016 South African Demographic and Health Survey. Chi-squared tests and logistic regression were used to examine the weighted prevalence of disease among those with/without HIV, and the risk factors associated with HIV. Latent class analysis (LCA) was conducted to identify common co-occurring diseases. Of the 1787 individuals included in our analysis, the weighted prevalence of HIV was 8.7%. Hypertension (30.5%), anaemia (35.8%) and diabetes (2.0%) were more prevalent among those with HIV. HIV and anaemia, hypertension and anaemia, and HIV and hypertension comprise the largest disease burden of co-occurring diseases. Co-morbidity was high among those with HIV, emphasizing the need for integrated care of HIV and non-communicable diseases.

Objectives: We sought to identify what proportion of each cardiovascular risk factor and Human Immunodeficiency Virus (HIV) was first diagnosed at the time of stroke, compared to those that were diagnosed prior to the event, and to explore if this had any impact on the severity of stroke., Methods: Adult patients presenting with a new stroke to a quaternary hospital in Johannesburg between 2014 and 2017 were prospectively recruited. Patients were investigated for undiagnosed traditional cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidaemia, atrial fibrillation, obesity and smoking), as well as HIV infection. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS)., Results: 346 patients were included. Stroke was the index presentation for at least one risk factor in 199 (57.5 %) patients. Dyslipidaemia was newly diagnosed in 76.0 % of all dyslipidaemics (95 out of 125). Newly-diagnosed dyslipidaemia was associated with a more severe neurological deficit (Median NIHSS of 12 (8-16) vs 7 (4-12), p=0.0007) and younger age on presentation (53 (44-63) years vs 62 (51-71) years, p=0.02) as compared to previously-diagnosed dyslipidaemia., Conclusions: More than half of patients had previously undiagnosed modifiable risk factors at the time of their stroke. Dyslipidaemia was undiagnosed in a very high proportion, and this was associated with a higher stroke severity and younger age of presentation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The ambitious goal to eliminate new pediatric HIV infections by 2030 requires accelerated prevention strategies in high-risk settings such as South Africa. One approach could be pre-exposure prophylaxis (PrEP) with broadly neutralizing anti-HIV-1 monoclonal antibodies (bNAbs). The aim of our study is to define the optimal dose(s), the ideal combination(s) of bNAbs in terms of potency and breadth, and timing of subcutaneous (SC) administration(s) to prevent breast milk transmission of HIV. Methods: Two bNAbs, CAP256V2LS and VRC07-523LS, will be assessed in a sequential and randomized phase I, single-site, single-blind, dose-finding trial. We aim to investigate the 28-day safety and pharmacokinetics (PK) profile of incrementally higher doses of these bNAbs in breastfeeding HIV-1 exposed born without HIV neonates alongside standard of care antiretroviral (ARV) medication to prevent (infants) or treat (mothers) HIV infection. The trial design includes 3 steps and 7 arms (1, 2, 3, 4, 5, 6 and 6b) with 8 infants in each arm. The first step will evaluate the safety and PK profile of the bNAbs when given alone as a single subcutaneous (SC) administration at increasing mg/kg body weight doses within 96 h of birth: arms 1, 2 and 3 at doses of 5, 10, and 20 mg/kg of CAP256V2LS, respectively; arms 4 and 5 at doses of 20 and 30 mg/kg of VRC07-523LS, respectively. Step two will evaluate the safety and PK profile of a combination of the two bNAbs administered SC at fixed doses within 96 h of birth. Step three will evaluate the safety and PK profile of the two bNAbs administered SC in combination at fixed doses, after 3 months. Arms 1 and 6 will follow sequential recruitment, whereas randomization will occur sequentially between arms (a) 2 & 4 and (b) 3 & 5. Before each randomization, a safety pause will allow review of safety data of the preceding arms. Discussion: The results of this trial will guide further studies on bNAbs to prevent breast milk transmission of HIV. Protocol version: Version 4.0 dated 15 March 2024. Trial registration: Pan African Clinical Trial Registry (PACTR): PACTR202205715278722, 21 April 2022; South African National Clinical Trial Registry (SANCTR): DOH-27–062022-6058. [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: Pre-exposure prophylaxis (PrEP) is an HIV prevention strategy that can reduce the risk of HIV acquisition by more than 90% if taken consistently. Although South Africa has been implementing PrEP since 2016, initially for selected population groups before expanding access to more people, there is a dearth of research focused on PrEP among adolescent boys and young men (ABYM), despite them experiencing high rates of HIV infection. To address this gap, we compared PrEP initiation rates by service delivery points (SDPs) among ABYM in KwaZulu-Natal, South Africa. Methods: We conducted a population-based prospective study in 22 SDPs from July 2021 to July 2022 in KwaZulu-Natal, South Africa. Sexually active ABYM aged 15–35 years who tested HIV negative were recruited at purposively selected PrEP SDPs (i.e., healthcare facilities, secondary schools and Technical Vocational Education and Training (TVET) colleges, and community-based youth zones). We collected baseline quantitative data from each participant using self-administered electronic questionnaires built into REDCap, including demographic information such as age, sex, employment status and level of education, as well as PrEP initiation outcomes. We extracted data from REDCap and exported it to Stata version 17.0 for analysis, and then eliminated discrepancies and removed duplicates. We described baseline characteristics using summary and descriptive statistics (median, interquartile range [IQR] and proportions) and reported PrEP initiation proportions overall and by SDPs. Results: The study included 1104 ABYM, with a median age of 24 years (interquartile range (IQR): 21–28)). Almost all participants were black African (n = 1090, 99%), with more than half aged 15–24 years (n = 603, 55%) and 45% (n = 501) aged 25–35 years. The majority (n = 963; 87%) had attained a secondary level of education. Overall PREP initiation rate among adolescent boys and young men was low: among 1078 participants who were eligible for PrEP, 13% (n = 141) were started on PrEP. Among the participants who were initiated on PrEP, over three quarters (78%, n = 58) were initiated from high schools, compared with community-based youth zones (40%, n = 37), TVET colleges (26%, n = 16) and healthcare facilities (4%, n = 30). Conclusions: This study provided evidence suggesting that expanding PrEP services to non-traditional settings, such as high schools, TVET colleges, and community-based organizations, may have a potential to increase PrEP access among ABYM in South Africa. [ABSTRACT FROM AUTHOR]

Aim: Human immunodeficiency virus (HIV) nursing has become more prominent with the increase in chronic HIV infections. This study examined articles related to HIV nursing to determine how the profession has developed and its future direction. Design: A bibliometric analysis was conducted. Methods: HIV nursing‐related articles published in the Web of Science core collection between 1999 and 2022 were searched. VOSviewer was used to identify the contributions of countries, institutions and authors in HIV‐related care. Collaborative maps, hot topics and keywords trends were analysed using VOSviewer and CiteSpace. Results: A total of 1513 publications were extracted. An increase in articles published between 1999 and 2012 was observed. After 2012, the increase in the number of publications was relatively stable. Since 2016, a downward trend in the number of publications has occurred. The USA, South Africa and the UK were the leading contributors to publications related to HIV nursing. The focus of the HIV nursing research has gradually shifted from "HIV infection", "risk factors", and "transmission routes" to "social support", "depression", and "public health". The result shows that increased collaboration among countries/regions can improve the development of HIV nursing and effectively reduce the global HIV infection rate. The mental health of patients has become a research centre in the field of HIV nursing. This study provides direction in clinical practice and future research areas in this field. [ABSTRACT FROM AUTHOR]

Background: Stillbirths are a global public health challenge, predominantly affecting low- and middle-income countries. The causes of most stillbirths are preventable. Objectives: this study reviewed perinatal clinical audit data from Kgapane Hospital over a 4-year period with a special focus on the factors associated with stillbirths. Methods: File audits were done for all stillbirths occurring at Kgapane Hospital and its catchment area from 2018 to 2021. The data from these audits were analysed to identify factors associated with stillbirths. Results: A total of 392 stillbirths occurred during the study period at Kgapane Hospital and its surrounding clinics, resulting in a stillborn rate of 19.06/1000 births. Of the 392 stillbirths recorded, audits were conducted on 354 of the maternal case records. The five most common causes of stillbirths identified were: hypertensive disorders in pregnancy (HDP) (29.7%), intrauterine growth restriction without HDP (11.6%), birth asphyxia (7.1%), premature labour (< 1000 g) (6.5%) and maternal infections (5.9%) including HIV with unsuppressed VL, intrauterine infection, coronavirus disease (COVID) and syphilis. Modifiable factors that can form the basis of improvement strategies should include training, timeous referral, plus improved resources and staffing. Conclusion: Understanding the causes of stillbirths can guide improvement strategies to reduce this heart-breaking complication of pregnancy. Contribution: Family physicians working in rural hospitals are also responsible for perinatal care. Understanding the factors associated with stillbirths will guide them to develop improvement strategies to reduce these preventable deaths. [ABSTRACT FROM AUTHOR]

Adolescents living with HIV (ALHIVs) are considered a priority population in the fight against HIV, requiring dedicated services. The COVID-19 pandemic and subsequent disruptions deprived ALHIVs on antiretroviral therapy (ART) of the care and social support essential for treatment adherence and positive treatment outcomes. This study describes health managers' and healthcare workers' responses to the impact of COVID-19 on service delivery to ALHIVs in HIV treatment in the Cape Town Metropole. A descriptive qualitative design was employed, where semi-structured individual interviews (n = 13) were conducted with senior and programme managers as well as healthcare workers between April and October 2023. Inductive thematic analysis was performed using Atlas.ti version 23. Two main themes emerged from these interviews: "HIV service delivery to adolescents during the COVID-19 pandemic" and "Lessons learnt—the way forward". The de-escalation of health services at primary health facilities and the disruption of HIV services resulted in disengagement from care by ALHIVs, increasing mental health and treatment challenges. This warrants the restoration of psychosocial support services and the re-engagement of ALHIVs. The findings from this study can function as a guide for health systems and healthcare providers to navigate future pandemics to ensure that vulnerable populations such as ALHIVs continue to receive care and treatment. [ABSTRACT FROM AUTHOR]

Background: HIV partner disclosure rates remain low among pregnant women living with HIV in many African countries despite potential benefits for women and their families. Partner disclosure can trigger negative responses like blame, violence, and separation. Women diagnosed with HIV late in pregnancy have limited time to prepare for partner disclosure. We sought to understand challenges around partner disclosure and non-disclosure faced by women diagnosed with HIV late in pregnancy in South Africa and Uganda and to explore pathways to safe partner disclosure. Methods: We conducted in-depth interviews and focus group discussions with pregnant women and lactating mothers living with HIV (n = 109), disaggregated by antenatal care (ANC) initiation before and after 20 weeks of gestation, male partners (n = 87), and health workers (n = 53). All participants were recruited from DolPHIN2 trial sites in Kampala (Uganda) and Gugulethu (South Africa). Topic guides explored barriers to partner disclosure, effects of non-disclosure, strategies for safe disclosure. Using the framework analysis approach, we coded and summarised data based on a socio-ecological model, topic guides, and emerging issues from the data. Data was analysed in NVivo software. Results: Our findings illustrate pregnant women who initiate ANC late experience many difficulties which are compounded by the late HIV diagnosis. Various individual, interpersonal, community, and health system factors complicate partner disclosure among these women. They postpone or decide against partner disclosure mainly for own and baby's safety. Women experience stress and poor mental health because of non-disclosure while demonstrating agency and resilience. We found many similarities and some differences around preferred approaches to safe partner disclosure among female and male participants across countries. Women and male partners preferred healthcare workers to assist with disclosure by identifying the 'right' time to disclose, mentoring women to enhance their confidence and communication skills, and providing professional mediation for partner disclosure and couple testing. Increasing the number of counsellors and training them on safe partner disclosure was deemed necessary for strengthening local health services to improve safe partner disclosure. Conclusion: HIV diagnosis late in pregnancy amplifies existing difficulties among pregnant women. Late ANC initiation is an indicator for the likelihood that a pregnant woman is highly vulnerable and needs safeguarding. Respective health programmes should be prepared to offer women initiating ANC late in pregnancy additional support and referral to complementary programmes to achieve safe partner disclosure and good health. [ABSTRACT FROM AUTHOR]

Background: Registered nurses working in the mobile health clinics (MHCs) play an important role in enabling HIV care access to populations in remote areas through Nurse Initiated Antiretroviral Therapy program (NIMART). Aim: To explore and describe the nurses' experiences regarding operational factors influencing the implementation of HIV care services in the mobile health clinics (MHCs) of eThekwini Municipality in KwaZulu Natal. Methods: Qualitative Exploratory Descriptive (QED) method was used after permission was granted from North-West University Human Research Ethics Committee provincial and local health authorities. Data saturation informed sample size of thirteen MHCs nurses were purposefully sampled to participate. Audio-recorded, semi-structured, online, one-on-one interviews guided by open-ended questions were done for data collection, and including demographic profile. The interview transcripts were analysed using Atlas-TI and SPSS descriptive statistics was used for demographics. Results: Eleven subthemes emerged under patient-related, nurse-related, and organisational-related themes which influence the operational factors in the MHCs, namely: patient defaulting treatment, lack of privacy, unavailability of phones, stressful and demotivating MHCs, nurses feel unsafe, lack of support from management, lack of budget, unavailability of computers, shortage of medical equipment, shortage of nursing staff and absence of data capturers. Conclusion: Structured contextual coaching and support program for nurses is imperative to ensure effective and strengthened operations in MHCs, further supported by improvement in human resource for health allocation for MHCs in light of expanding health care programs Contributions: Evaluation of health care programmes, and human resource for health quality improvement needs in the clinical practice of HIV care of MHCs nurses which advocate for specific policy formulations. [ABSTRACT FROM AUTHOR]

Sexually transmitted infections in South Africa are increasing at alarming rates. This study's setting is no. 5, with the highest STI, pregnancy, and HIV statistics in Limpopo province among 13- to 19-year-old teenagers. This study explored preventative measures against STIs practiced by teenagers in rural areas of Limpopo province, South Africa. This study was conducted at a selected rural-based clinic using an exploratory descriptive qualitative research approach. Unstructured in-depth face-to-face interviews were used to collect data from sixteen conveniently sampled teenagers aged 13–19, consisting of 13 females and 3 males, who came to Manavhela Clinic for youth-friendly services in August/September 2022. Open-coding analysis was used to identify themes and sub-themes. Measures to ensure trustworthiness were ensured. Ethical clearance (FSH/21/PH/22/2211) was obtained, and ethics principles were observed throughout this study. Two themes emerged from data analysis: STI preventive measures practiced by teenagers and factors influencing the choice of STI preventive measures practiced by teenagers. Only a few participants aged 13 and 14 years of age practiced abstinence and condom use. Most participants were sexually active and used mythical mixtures made from boiling aloe or morula tree (which they drank before and after sex), applied plain yogurt on the vagina once a week, or practiced vaginal steaming. Participants cited patriarchy, lack of sex education in rural schools, long distances to clinics, and desire to taste sex as reasons for adopting the practiced preventive measures. Risky sexual behavior among 13- to 19-year-old teenagers is still rife in rural areas. Rural clinics in Limpopo province should intensify STI school health education and youth-friendly services programs to raise awareness and improve accessibility to condoms. [ABSTRACT FROM AUTHOR]

The disclosure of HIV status among adolescents living with perinatally acquired HIV (APHIV) has become one of the core challenges in the management of APHIV. Disclosure is a challenge that undermines positive advances and achievements in HIV management. There is limited literature on the voices of APHIV on disclosure of their status. This study aims to explore the current disclosure process and how it affects APHIV. A qualitative exploratory design was employed to conduct one-on-one in-depth interviews using a semi-structured interview guide. Purposive sampling was used to sample 21 APHIV in 16 selected health facilities in the Vhembe district of Limpopo Province, South Africa. Data were analyzed using Tesch's qualitative data method. The findings of this study reflect the gaps in the current disclosure process and guidelines while acknowledging the importance of disclosure to APHIV. A notable finding in this study is that most APHIV, especially those in early adolescence, did not want to know their HIV status due to the stigma attached to an HIV-positive diagnosis. This study suggests that proper training and support of parents and/or guardians in the disclosure process are needed, as they are the primary caregivers of APHIV. The disclosure of HIV status must be a comprehensive part of the management and care of HIV for APHIV. Furthermore, dedicated support programs should be developed and implemented to improve their lives post-disclosure. [ABSTRACT FROM AUTHOR]