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Background: There are limited data on the experiences of children being treated for drug-resistant tuberculosis (DR-TB), and most work in the area has been done with older children and adolescents. Comprehensive explorations of the caregiver experiences in this area are also lacking. Objective: To describe the experiences of being treated for drug-resistant tuberculosis of children and their caregivers. Methods: This was a qualitative study done using focus group discussions (FGDs) among three different groups of participants: 1) health care providers involved in the care of children being treated for DR-TB (including physicians, nurses, and pharmacists)—herein referred to as providers; 2) household caregivers of children being treated for DR-TB—herein referred to as caregivers; and 3) children who were being treated for DR-TB—herein referred to as children. The population was a convenience sample and included children hospitalized between January 1, 2018, and June 30, 2020, ages 0–14 years old, as well as their caregivers and providers. Focus group transcripts and notes were analysed using a thematic network analysis based in grounded theory The analysis was iterative and the coding system developed focused on "stressful experiences" as well as ways to address them along the diagnostic and treatment journey. This paper follows the COREQ guidelines. Results: 16 children between the ages 7 and 14 years participated in 5 FGDs, 30 caregivers participated in 7 FGDs, and 12 providers participated in 3 FDGs. Data from the children and the caregivers were the focus of this analysis, although some themes were informed by the discussions with the providers as well. In general, it was reported that for a child diagnosed with DR-TB, there is a lived experience of stress that impacts their physical, mental, and social well-being. These pediatric patients and their families therefore develop strategies for coping with these disruptions to their lives. In general, there were major disruptive experiences that resulted from the process around receiving a diagnosis of DR-TB and second distinct set of stressful experiences that occurred during the treatment of DR-TB once the diagnosis had been made. These stresses occur in the physical, mental, and social realms, and families develop multiple strategies to cope with them, demonstrating resilience in the face of this disease. Conclusion: Addressing the stresses experienced by children and their caregivers through child-friendly DR-TB testing, treatment, and counseling is not only essential for ending TB but also for enacting a human-rights based approach to child health in general. Children with DR-TB are a vulnerable population, and they have often been the last to benefit from advances in general pediatric care and in DR-TB care more specifically. [ABSTRACT FROM AUTHOR]

Background: A high prevalence of disrespectful and abusive behaviour by health workers towards women during labour and delivery has been widely described in health facilities, particularly in Africa, and is a worldwide public health concern. Such behaviours are barriers to care-seeking, and are associated with adverse outcomes for mothers and newborns. This paper reports experiences of disrespectful care among informal working women in three public health facilities in Durban, South Africa. Methods: A qualitative longitudinal study was conducted among a cohort of informal working women recruited during pregnancy in two clinics in Durban. The study comprised a series of in-depth interviews conducted at different time points from pregnancy until mothers had returned to work, followed by focus group discussions (FGDs) with cohort participants. We present data from participatory FGDs, known as 'Journey with my Baby', conducted at the end of the study, during which women's experiences from pregnancy until returning to work were reviewed and explored. Thematic analysis was used with NVIVO v12.4. Results: Three 'Journey with my Baby' FGDs were conducted with a total of 15 participants between March and October 2019. Many participants narrated experiences of disrespectful behavior from nurses during labour and childbirth, with several women becoming very distressed as a result. Women described experiencing rudeness and verbal abuse from nurses, lack of privacy and confidentiality, nurses refusing to provide care, being denied companionship and being left unattended for long periods during labour. Women described feeling anxious and unsafe while in the labour ward because of the behaviour they experienced directly and observed other patients experiencing. Such experiences created bad reputations for health facilities, so that women in the local community were reluctant to attend some facilities. Conclusion: Disrespect and abuse continues to be a serious concern in public health facilities in South Africa. We challenge the health system to effectively address the underlying causes of disrespectful behavior among health workers, initiate robust monitoring to identify abusive behavior when it occurs, and take appropriate actions to ensure accountability so that women receive the high-quality maternity care they deserve. [ABSTRACT FROM AUTHOR]

Southern African cities face several challenges including management of rapid urbanization, rising populations, expanding informal settlements; adequate water and other service provision, and a host of governance challenges. Climate change and variability add a compounding effect to this complex, multi stressor context. Addressing the complexity requires an understanding of urban ecosystems functioning and interactions amongst the built and natural environment (climate) and human systems. In this paper we argue that learning is essential for cities to be resilient to current and future challenges. We profile the Future Resilience for African CiTies And Lands (FRACTAL) project which contributed towards climate resilient development by providing relevant climate information for decision-making at the city regional scale in southern Africa. Following FRACTAL's city-to-city learning approach of sharing good practices, knowledge and experiences framed around transdisciplinary research, the study cities of Harare, Lusaka, Windhoek and Durban conducted city learning exchange visits between 2017 and 2018. We used a mixed methods approach to collect and analyze historical climate and hydrological data and current socio-economic and development data among the cities. A qualitative, in-depth, case study comparative analysis was used to identify similarities and differences as well as lessons drawn from the learning process during the city exchanges and these were complimented by desktop studies. Results showed water scarcity, large informal settlements, reliance on external water and energy sources, inadequate protection of ecologically sensitive resources and service provision as some of the common complications in the cities. Several lessons and transferable practices learnt from the cities included effective water conservation and waste management and the use of public-private partnerships in Windhoek, community engagements in Durban and Lusaka while lessons on decisive leadership in dealing with informal settlements emanated from Harare's limited informal settlements. Lastly, Durban's Adaptation Charter and integrated climate planning provided lessons for biodiversity protection and mainstreaming climate change at city governance level. While we recognize that cities are context-specific we consider these good practices as being broadly transferable to other southern African cities. We conclude that social, experiential and structured learning can be an innovative way of multi-stakeholder engagement and a useful approach to increase city resilience planning across southern Africa and cities that face similar developmental challenges. [ABSTRACT FROM AUTHOR]

The ongoing Covid-19 pandemic has generated an immense amount of potentially infectious waste, primarily face masks, which require rapid and sanitary disposal in order to mitigate the spread of the disease. Yet, within Africa, large segments of the population lack access to reliable municipal solid waste management (SWM) services, both complicating the disposal of hazardous waste, and public health efforts. Drawing on extensive qualitative fieldwork, including 96 semi-structured interviews, across four different low-income communities in Blantyre, Malawi and Durban, South Africa, the purpose of this article is to respond to a qualitative gap on mask disposal behaviours, particularly from within low-income and African contexts. Specifically, our purpose was to understand what behaviours have arisen over the past year, across the two disparate national contexts, and how they have been influenced by individual risk perceptions, established traditional practice, state communication, and other media sources. Findings suggest that the wearing of cloth masks simplifies disposal, as cloth masks can (with washing) be reused continuously. However, in communities where disposable masks are more prevalent, primarily within Blantyre, the pit latrine had been adopted as the most common space for 'safe' disposal for a used mask. We argue that this is not a new behaviour, however, and that the pit latrine was already an essential part of many low-income households SWM systems, and that within the Global South, the pit latrine fulfils a valuable and uncounted solid waste management function, in addition to its sanitation role. [ABSTRACT FROM AUTHOR]

Low adherence in vaginal microbicide clinical trials for HIV prevention has impeded interpretation of trial results and hindered evaluation of potentially efficacious HIV prevention gels. Understanding the underlying reasons why women join trials and their barriers to product use can support identification of ways to improve adherence and its reporting. Eight focus group discussion workshops were conducted with 46 former microbicide trial participants in Durban, South Africa and Mwanza, Tanzania. Participants provided feedback on why women join trials, the barriers to using study gel and reporting adherence accurately, and how clinical trial design can be improved to support better adherence and its reporting. Women join microbicide trials for a number of important reasons such as healthcare and financial reimbursement. Fear of adverse effects from the investigational product was the most important reason why participants reported not using the gel. The key reason for inaccurate reporting of gel use was fear of removal from the trial. Participants made concrete suggestions for improving microbicide trial design such as applicator use testing and real time feedback, improving education to participants about how trials answer their research questions, and improving transparency and clarity about study procedures. Participants also gave feedback on an innovative trial design with a non-randomised arm. Identifying HIV prevention products for women requires better understanding of the lives of women asked to join these trials, and application of that understanding to microbicide trial design. This study has demonstrated that participants and research teams can work collaboratively to design clinical trials that meet needs of both the research and of participants. [ABSTRACT FROM AUTHOR]

Background: Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted interventions. Our objective was to uncover distinct CD4-based trajectories and determine baseline demographic, clinical, and contextual factors associated with trajectory membership. Methods: We used data from the Sizanani trial (NCT01188941), in which adults were enrolled prior to HIV testing in Durban, South Africa from August 2010–January 2013. We ascertained CD4 counts from the National Health Laboratory Service over 5y follow-up. We used group-based statistical modeling to identify groups with similar CD4 count trajectories and Bayesian information criteria to determine distinct CD4 trajectories. We evaluated baseline factors that predict membership in specific trajectories using multinomial logistic regression. We examined calendar year of participant enrollment, age, gender, cohabitation, TB positivity, self-identified barriers to care, and ART initiation within 3 months of diagnosis. Results: 688 participants had longitudinal data available. Group-based trajectory modeling identified four distinct trajectories: one with consistently low CD4 counts (21%), one with low CD4 counts that increased over time (22%), one with moderate CD4 counts that remained stable (41%), and one with high CD4 counts that increased over time (16%). Those with higher CD4 counts at diagnosis were younger, less likely to have TB, and less likely to identify barriers to care. Those in the least favorable trajectory (consistently low CD4 count) were least likely to start ART within 3 months. Conclusions: One-fifth of people newly-diagnosed with HIV presented with low CD4 counts that failed to rise over time. Less than 40% were in a trajectory characterized by increasing CD4 counts. Patients in more favorable trajectories were younger, less likely to have TB, and less likely to report barriers to healthcare. Better understanding barriers to early care engagement and ART initiation will be necessary to improve long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Measures used to assess equitable relationship dynamics, including the sexual relationship power scale (SRPS) have previously been associated with lower HIV-risk among young women, and reduced perpetration of intimate partner violence among men. However, few studies describe how the SRPS has been adapted and validated for use within global youth sexual health studies. We examined gender-specific psychometric properties, reliability, and validity of a SRPS used within a South African youth-engaged cohort study. Methods: Young men and women (16–24 years) enrolled in community-based cohorts in Durban and Soweto (2014–2016) reporting a primary partner at 6-month follow-up completed a 13-item (strongly agree/agree/disagree/strongly disagree) South African adaptation of Pulerwitz’s SRPS (range 13–52, higher scores indicating greater sexual relationship power [SRP] equity). SRPS modifications were made using gender-specific exploratory factor analyses (EFAs), removing items with factor loadings <0.3. Cronbach alphas were conducted for full and modified scales by gender. Using modified scales, unadjusted and adjusted regression models examined associations between 1. relevant socio-demographic and relationship determinants and SRP equity, and 2. SRP equity and sexual relationship related outcomes. All models adjusted for education, age, site, and current employment. Results: 235 sexually-active youth (66% women, median age = 20) were included. Mean scores across all 13 scale items were 2.71 (SD 0.30) for women and 2.70 (SD 0.4) for men. Scale Cronbach’s alphas were 0.63 for women and 0.64 for men. EFAs resulted in two gender-specific single-factor SRPS. Modified SRPS Cronbach alphas increased to 0.67 for women (8-items) and 0.70 for men (9-items). After adjusting for age, site and current employment, higher education remained associated with SRP equity across genders. In adjusted models, correlates of SRP equity included primary partnerships that were age-similar (<5 years older) and <2 years in length for women and living in Soweto and younger age for men. Greater SRP equity among women was also independently associated with no recent partner violence. Conclusions: Results highlight important gender differences in SRP equity measures and associations, highlighting the critically need for future research to examine gendered constructions of SRP equity in order to accurately develop, validate and use appropriate measures within quantitative surveys. [ABSTRACT FROM AUTHOR]

We aimed to estimate the individual and joint impact of age, marital status and diagnosis with sexually transmitted infections (STIs) on HIV acquisition among young women at a population level in Durban, KwaZulu-Natal, South Africa. A total of 3,978 HIV seronegative women were recruited for four biomedical intervention trials from 2002–2009. Point and interval estimates of partial population attributable risk (PAR) were used to quantify the proportion of HIV seroconversions which can be prevented if a combination of risk factors is eliminated from a target population. More than 70% of the observed HIV acquisitions were collectively attributed to the three risk factors: younger age (<25 years old), unmarried and not cohabiting with a stable/regular partner and diagnosis with STIs. Addressing these risks requires targeted structural, behavioural, biomedical and cultural interventions in order to impact on unacceptably high HIV incidence rates among young women and the population as a whole. [ABSTRACT FROM AUTHOR]

Objective: Couples’ voluntary HIV counseling and testing (CVCT) significantly decreases HIV transmission within couples, the largest risk group in sub-Saharan Africa, but it is not currently offered in most HIV testing facilities. To roll out such an intervention, understanding locale-specific knowledge barriers is critical. In this study, we measured knowledge of HIV serodiscordance, transmission, and prevention before and after receipt of CVCT services in Durban. Design: Pre- and post-CVCT knowledge surveys were administered to a selection of individuals seeking CVCT services. Methods: Changes in knowledge scores were assessed with McNemar Chi-square tests for balanced data and generalized estimating equation methods for unbalanced data. Results: The survey included 317 heterosexual black couples (634 individuals) who were primarily Zulu (87%), unemployed (47%), and had at least a secondary level education (78%). 28% of couples proved to be discordant. Only 30% of individuals thought serodiscordance between couples was possible pre‐CVCT compared to 95% post-CVCT. One-third thought there was at least one benefit of CVCT pre‐CVCT, increasing to 96% post‐CVCT. Overall, there were positive changes in knowledge about HIV transmission and prevention. However, many respondents thought all HIV positive mothers give birth to babies with AIDS (64% pre-CVCT, 59% post-CVCT) and that male circumcision does not protect negative men against HIV (70% pre-CVCT, 67% post-CVCT). Conclusions: CVCT was well received and was followed by improvements in understanding of discordance, the benefits of joint testing, and HIV transmission. Country-level health messaging would benefit from targeting gaps in knowledge about serodiscordance, vertical transmission, and male circumcision. [ABSTRACT FROM AUTHOR]

Background: Routine screening for HIV infection leads to early detection and treatment. We examined patient characteristics associated with repeated screening in a high prevalence country. Methods: We analyzed data from a cohort of 5,229 adults presenting for rapid HIV testing in the outpatient departments of 2 South African hospitals from November 2006 to August 2010. Patients were eligible if they were ≥18 years, reported no previous diagnosis with HIV infection, and not pregnant. Before testing, participants completed a questionnaire including gender, age, HIV testing history, health status, and knowledge about HIV and acquaintances with HIV. Enrollment HIV test results and CD4 counts were abstracted from the medical record. We present prevalence of HIV infection and median CD4 counts by HIV testing history (first-time vs. repeat). We estimated adjusted relative risks (ARR’s) for repeat testing by demographics, health status, and knowledge of HIV and others with HIV in a generalized linear model. Results: Of 4,877 participants with HIV test results available, 26% (N = 1258) were repeat testers. Repeat testers were less likely than first-time testers to be HIV-infected (34% vs. 54%, p<0.001). Median CD4 count was higher among repeat than first-time testers (201/uL vs. 147/uL, p<0.001). Among those HIV negative at enrollment (N = 2,499), repeat testing was more common among those with family or friends living with HIV (ARR 1.50, 95% CI: 1.33–1.68), women (ARR: 1.24, 95% CI: 1.11–1.40), and those self-reporting very good health (ARR: 1.28, 95% CI: 1.12–1.45). Conclusions: In this high prevalence setting, repeat testing was common among those undergoing HIV screening, and was associated with female sex, lower prevalence of HIV infection, and higher CD4 counts at diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: Although youth (12-24 years) in Sub-Saharan Africa have a high HIV risk, many have poor access to HIV testing services and are unaware of their status. Our objective was to evaluate the proportion of adolescents (12-17 years) and young adults (18-24 years) who underwent HIV testing and the prevalence among those tested in an urban adult outpatient clinic with a routine HIV testing program in Durban, South Africa. Design: We conducted a retrospective cross-sectional analysis of adolescent and young adult outpatient records between February 2008 and December 2009. Methods: We determined the number of unique outpatient visitors, HIV tests, and positive rapid tests among those tested. Results: During the study period, 956 adolescents registered in the outpatient clinic, of which 527 (55%) were female. Among adolescents, 260/527 (49%, 95% CI 45-54%) females underwent HIV testing compared to 129/429 (30%, 95% CI 26-35%) males (p<0.01). The HIV prevalence among the 389 (41%, 95% CI 38-44%) adolescents who underwent testing was 16% (95% CI 13-20%) and did not vary by gender (p = 0.99). During this period, there were 2,351 young adult registrations, and of these 1,492 (63%) were female. The proportion consenting for HIV testing was similar among females 980/1,492 (66%, 95% CI 63-68%) and males 543/859 (63%, 95% CI 60-66%, p = 0.25). Among the 1,523 (65%, 95% CI 63-67%) young adults who underwent testing, the HIV prevalence was 22% (95% CI 19-24%) in females versus 14% in males (95% CI 11-17%, p<0.01). Conclusions: Although the HIV prevalence is high among youth participating in an adult outpatient clinic routine HIV program, the uptake of testing is low, especially among 12-17 year old males. There is an urgent need to offer targeted, age-appropriate routine HIV testing to youth presenting to outpatient clinics in epidemic settings. [ABSTRACT FROM AUTHOR]

Background: Although loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. Our objective was to determine PTLC in newly identified HIV-infected individuals in South Africa. Methodology/Principal Findings: We assembled the South African Test, Identify and Link (STIAL) Cohort of persons presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. We defined PTLC as failure to have a CD4 count within 8 weeks of HIV diagnosis. We performed multivariate analysis to identify factors associated with PTLC. From November 2006 to May 2007, of 712 persons who underwent HIV testing and received their test result, 454 (64%) were HIV-positive. Of those, 206 (45%) had PTLC. Infected patients were significantly more likely to have PTLC if they lived ≥10 kilometers from the testing center (RR = 1.37; 95% CI: 1.11-1.71), had a history of tuberculosis treatment (RR = 1.26; 95% CI: 1.00-1.58), or were referred for testing by a health care provider rather than self-referred (RR = 1.61; 95% CI: 1.22-2.13). Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors. Conclusions/Significance: Nearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test. [ABSTRACT FROM AUTHOR]