Search

Linkage to HIV care remains suboptimal among men. We investigated the effectiveness of a male-targeted HIV-specific decision support app, Empowering People through Informed Choices for HIV (EPIC-HIV), on increasing linkage to HIV care among men in rural South Africa. Home-Based Intervention to Test and Start (HITS) was a multi-component cluster-randomized controlled trial conducted among 45 communities in uMkhanyakude, KwaZulu-Natal. The development of EPIC-HIV was guided by self-determination theory and human-computer interaction design to increase intrinsic motivation to seek HIV testing and care among men. EPIC-HIV was offered in two stages: EPIC-HIV 1 at the time of home-based HIV counseling and testing (HBHCT), and EPIC-HIV 2 at 1 month after a positive HIV diagnosis if not linked to care. Sixteen communities were randomly assigned to the arms to receive EPIC-HIV, and 29 communities to the arms without EPIC-HIV. Among all eligible men, we compared linkage to care (initiation or resumption of antiretroviral therapy after > 3 months of care interruption) at local clinics within 1 year of a home visit, ascertained from individual clinical records. Intention-to-treat analysis was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., financial incentives) and clustering at the community level. We also conducted a satisfaction survey for EPIC-HIV 2. A total of 13,894 men were eligible (i.e., aged ≥ 15 years and resident in the 45 communities). The mean age was 34.6 (±16.8) years, and 65% were married or in an informal union. Overall, 20.7% received HBHCT, resulting in 122 HIV-positive and 6 discordant tests. Among these, 54 men linked to care within 1 year after HBHCT. Additionally, of the 13,765 eligible participants who did not receive HBHCT or received HIV-negative results, 301 men linked to care within 1 year. Overall, only 13 men received EPIC-HIV 2. The proportion of linkage to care did not differ between the arms randomized to EPIC-HIV and those without EPIC-HIV (adjusted risk ratio = 1.05; 95% CI:0.86-1.29). All 13 men who used EPIC-HIV 2 reported the app was acceptable, user-friendly, and useful for getting information on HIV testing and treatment. The reach was low, although the acceptability and usability of the app were very high among those who engaged with it. Enhanced digital support applications could form part of interventions to increase knowledge of HIV treatment among men. Clinical Trial Number: ClinicalTrials.gov # NCT03757104., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Given limited institutional resources, low-income populations often rely on social networks to improve their socioeconomic outcomes. However, it remains in question whether small-scale social interactions could affect large-scale economic inequalities in under-resourced contexts. Here, we leverage population-level data from one of the poorest South African settings to construct a large-scale, geographically defined, inter-household social network. Using a multilevel network model, we show that having social ties in close geographic proximity is associated with stable household asset conditions, while geographically distant ties correlate to changes in asset allocation. Notably, we find that localised network interactions are associated with an increase in wealth inequality at the regional level, demonstrating how macro-level inequality may arise from micro-level social processes. Our findings highlight the importance of understanding complex social connections underpinning inter-household resource dynamics, and raise the potential of large-scale social assistance programs to reduce disparities in resource-ownership by accounting for local social constraints., (© 2024. The Author(s).)

Men in sub-Saharan Africa are less likely to accept HIV testing and link to HIV care than women. We conducted a trial to investigate the impact of conditional financial incentives and a decision support application, called EPIC-HIV, on HIV testing and linkage to care. We report the findings of the trial process evaluation to explore whether the interventions were delivered as intended, identify mechanisms of impact and any contextual factors that may have impacted the trial outcomes. Between August 2018 and March 2019, we conducted in-depth interviews and focus group discussions with trial participants (n = 31) and staff (n = 14) to examine views on the implementation process, participant responses to the interventions and the external factors that may have impacted the implementation and outcomes of the study. Interviews were audio-recorded, transcribed, and translated where necessary, and thematically analyzed using ATLAS-ti and NVivo. Both interventions were perceived to be acceptable and useful by participants and implementers. EPIC-HIV proved challenging to implement as intended because it was difficult to ensure consistent use of earphones, and maintenance of privacy. Some participants struggled to navigate the EPIC-HIV app independently and select stories that appealed to them without support. Some participants stopped exploring the app before the end, resulting in an incomplete use of EPIC-HIV. While the financial incentive was implemented as intended, there were challenges with eligibility. The convenience and privacy of home testing influenced the uptake of HIV testing. Contextual barriers including fear of HIV stigma and disclosure if diagnosed with HIV, and expectations of poor treatment in clinics may have inhibited linkage to care. Financial incentives were relatively straightforward to implement and increased uptake of home-based rapid HIV testing but were not sufficient as a 'stand-alone' intervention. Barriers like fear of stigma should be addressed to facilitate linkage to care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Mathenjwa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: In South Africa, the HIV care cascade remains suboptimal. We investigated the impact of small conditional financial incentives (CFIs) and male-targeted HIV-specific decision-support application (EPIC-HIV) on the HIV care cascade., Methods: In 2018, in uMkhanyakude district, 45 communities were randomly assigned to one of four arms: (i) CFI for home-based HIV testing and linkage to care within 6 weeks (R50 [US$3] food voucher each); (ii) EPIC-HIV which are based on self-determination theory; (iii) both CFI and EPIC-HIV; and (iv) standard of care. EPIC-HIV consisted of two components: EPIC-HIV 1, provided to men through a tablet before home-based HIV testing, and EPIC-HIV 2, offered 1 month later to men who tested positive but had not yet linked to care. Linking HITS trial data to national antiretroviral treatment (ART) programme data and HIV surveillance programme data, we estimated HIV status awareness after the HITS trial implementation, ART status 3 month after the trial and viral load suppression 1 year later. Analysis included all known individuals living with HIV in the study area including those who did not participated in the HITS trial., Results: Among the 33,778 residents in the study area, 2763 men and 7266 women were identified as living with HIV by the end of the intervention period and included in the analysis. After the intervention, awareness of HIV-positive status was higher in the CFI arms compared to non-CFI arms (men: 793/908 [87.3%] vs. 1574/1855 [84.9%], RR = 1.03 [95% CI: 0.99-1.07]; women: 2259/2421 [93.3%] vs. 4439/4845 [91.6%], RR = 1.02 [95% CI: 1.00-1.04]). Three months after the intervention, no differences were found for linkage to ART between arms. One year after the intervention, only 1829 viral test results were retrieved. Viral suppression was higher but not significant in the EPIC-HIV intervention arms among men (65/99 [65.7%] vs. 182/308 [59.1%], RR = 1.11 [95% CI: 0.88-1.40])., Conclusions: Small CFIs can contribute to achieve the first step of the HIV care cascade. However, neither CFIs nor EPIC-HIV was sufficient to increase the number of people on ART. Additional evidence is needed to confirm the impact of EPIC-HIV on viral suppression., (© 2024 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Introduction: Understanding mortality variability by age and cause is critical to identifying intervention and prevention actions to support disadvantaged populations. We assessed mortality changes in two rural South African populations over 25 years covering pre-AIDS and peak AIDS epidemic and subsequent antiretroviral therapy (ART) availability., Methods: Using population surveillance data from the Agincourt Health and Socio-Demographic Surveillance System (AHDSS; 1994-2018) and Africa Health Research Institute (AHRI; 2000-2018) for 5-year periods, we calculated life expectancy from birth to age 85, mortality age distributions and variation, and life-years lost (LYL) decomposed into four cause-of-death groups., Results: The AIDS epidemic shifted the age-at-death distribution to younger ages and increased LYL. For AHDSS, between 1994-1998 and 1999-2003 LYL increased for females from 13.6 years (95% CI 12.7 to 14.4) to 22.1 (95% CI 21.2 to 23.0) and for males from 19.9 (95% CI 18.8 to 20.8) to 27.1 (95% CI 26.2 to 28.0). AHRI LYL in 2000-2003 was extremely high (females=40.7 years (95% CI 39.8 to 41.5), males=44.8 years (95% CI 44.1 to 45.5)). Subsequent widespread ART availability reduced LYL (2014-2018) for women (AHDSS=15.7 (95% CI 15.0 to 16.3); AHRI=22.4 (95% CI 21.7 to 23.1)) and men (AHDSS=21.2 (95% CI 20.5 to 22.0); AHRI=27.4 (95% CI 26.7 to 28.2)), primarily due to reduced HIV/AIDS/TB deaths in mid-life and other communicable disease deaths in children. External causes increased as a proportion of LYL for men (2014-2018: AHRI=25%, AHDSS=17%). The share of AHDSS LYL 2014-2018 due to non-communicable diseases exceeded pre-HIV levels: females=43%; males=40%., Conclusions: Our findings highlight shifting burdens in cause-specific LYL and persistent mortality differentials in two populations experiencing complex epidemiological transitions. Results show high contributions of child deaths to LYL at the height of the AIDS epidemic. Reductions in LYL were primarily driven by lowered HIV/AIDS/TB and other communicable disease mortality during the ART periods. LYL differentials persist despite widespread ART availability, highlighting the contributions of other communicable diseases in children, HIV/AIDS/TB and external causes in mid-life and non-communicable diseases in older ages., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Health-related quality of life (HRQoL) assesses the perceived impact of health status across life domains. Although research has explored the relationship between specific conditions, including HIV, and HRQoL in low-resource settings, less attention has been paid to the association between multimorbidity and HRQoL. In a secondary analysis of cross-sectional data from the Vukuzazi ("Wake up and know ourselves" in isiZulu) study, which identified the prevalence and overlap of non-communicable and infectious diseases in the uMkhanyakunde district of KwaZulu-Natal, we (1) evaluated the impact of multimorbidity on HRQoL; (2) determined the relative associations among infectious diseases, non-communicable diseases (NCDs), and HRQoL; and (3) examined the effects of controlled versus non-controlled disease on HRQoL. HRQoL was measured using the EQ-5D-3L, which assesses overall perceived health, five specific domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), and three levels of problems (no problems, some problems, and extreme problems). Six diseases and disease states were included in this analysis: HIV, diabetes, stroke, heart attack, high blood pressure, and TB. After examining the degree to which number of conditions affects HRQoL, we estimated the effect of joint associations among combinations of diseases, each HRQoL domain, and overall health. Then, in one set of ridge regression models, we assessed the relative impact of HIV, diabetes, stroke, heart attack, high blood pressure, and tuberculosis on the HRQoL domains; in a second set of models, the contribution of treatment (controlled vs. uncontrolled disease) was added. A total of 14,008 individuals were included in this analysis. Having more conditions adversely affected perceived health (r = -0.060, p<0.001, 95% CI: -0.073 to -0.046) and all HRQoL domains. Infectious conditions were related to better perceived health (r = 0.051, p<0.001, 95% CI: 0.037 to 0.064) and better HRQoL, whereas non-communicable diseases (NCDs) were associated with worse perceived health (r = -0.124, p<0.001, -95% CI: 0.137 to -0.110) and lower HRQoL. Particular combinations of NCDs were detrimental to perceived health, whereas HIV, which was characterized by access to care and suppressed viral load in the large majority of those affected, was counterintuitively associated with better perceived health. With respect to disease control, unique combinations of uncontrolled NCDs were significantly related to worse perceived health, and controlled HIV was associated with better perceived health. The presence of controlled and uncontrolled NCDs was associated with poor perceived health and worse HRQoL, whereas the presence of controlled HIV was associated with improved HRQoL. HIV disease control may be critical for HRQoL among people with HIV, and incorporating NCD prevention and attention to multimorbidity into healthcare strategies may improve HRQoL., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Stanton et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Tuberculosis (TB), a leading cause of infectious death, is curable when patients complete a course of multi-drug treatment. Because entry into the TB treatment cascade usually relies on symptomatic individuals seeking care, little is known about linkage to care and completion of treatment in people with subclinical TB identified through community-based screening., Methods: Participants of the Vukuzazi study, a community-based survey that provided TB screening in the rural uMkhanyakude district of KwaZulu-Natal from May 2018 - March 2020, who had a positive sputum (GeneXpert or Mtb culture, microbiologically-confirmed TB) or a chest x-ray consistent with active TB (radiologically-suggested TB) were referred to the public health system. Telephonic follow-up surveys were conducted from May 2021 - January 2023 to assess linkage to care and treatment status. Linked electronic TB register data was accessed. We analyzed the effect of baseline HIV and symptom status (by WHO 4-symptom screen) on the TB treatment cascade., Results: Seventy percent (122/174) of people with microbiologically-confirmed TB completed the telephonic survey. In this group, 84% (103/122) were asymptomatic and 46% (56/122) were people living with HIV (PLWH). By self-report, 98% (119/122) attended a healthcare facility after screening, 94% (115/122) started TB treatment and 93% (113/122) completed treatment. Analysis of electronic TB register data confirmed that 67% (116/174) of eligible individuals started TB treatment. Neither symptom status nor HIV status affected linkage to care. Among people with radiologically-suggested TB, 48% (153/318) completed the telephonic survey, of which 80% (122/153) were asymptomatic and 52% (79/153) were PLWH. By self-report, 75% (114/153) attended a healthcare facility after screening, 16% (24/153) started TB treatment and 14% (22/153) completed treatment. Nine percent (28/318) of eligible individuals had TB register data confirming that they started treatment., Conclusions: Despite high rates of subclinical TB, most people diagnosed with microbiologically-confirmed TB after community-based screening were willing to link to care and complete TB treatment. Lower rates of linkage to care in people with radiologically-suggested TB highlight the importance of streamlined care pathways for this group. Clearer guidelines for the management of people who screen positive during community-based TB screening are needed., Supplementary Information: The online version contains supplementary material available at 10.1186/s44263-024-00059-0., Competing Interests: Competing interestsThe authors declare no competing interests., (© The Author(s) 2024.)

Background: The convergence of infectious diseases and non-communicable diseases in South Africa is challenging to health systems. In this analysis, we assessed the multimorbidity health needs of individuals and communities in rural KwaZulu-Natal and established a framework to quantify met and unmet health needs for individuals living with infectious and non-communicable diseases., Methods: We analysed data collected between May 25, 2018, and March 13, 2020, from participants of a large, community-based, cross-sectional multimorbidity survey (Vukuzazi) that offered community-based HIV, hypertension, and diabetes screening to all residents aged 15 years or older in a surveillance area in the uMkhanyakude district in KwaZulu-Natal, South Africa. Data from the Vukuzazi survey were linked with data from demographic and health surveillance surveys with a unique identifier common to both studies. Questionnaires were used to assess the diagnosed health conditions, treatment history, general health, and sociodemographic characteristics of an individual. For each condition (ie, HIV, hypertension, and diabetes), individuals were defined as having no health needs (absence of condition), met health needs (condition that is well controlled), or one or more unmet health needs (including diagnosis, engagement in care, or treatment optimisation). We analysed met and unmet health needs for individual and combined conditions and investigated their geospatial distribution., Findings: Of 18 041 participants who completed the survey (12 229 [67·8%] were female and 5812 [32·2%] were male), 9898 (54·9%) had at least one of the three chronic diseases measured. 4942 (49·9%) of these 9898 individuals had at least one unmet health need (1802 [18·2%] of 9898 needed treatment optimisation, 1282 [13·0%] needed engagement in care, and 1858 [18·8%] needed a diagnosis). Unmet health needs varied by disease; 1617 (93·1%) of 1737 people who screened positive for diabetes, 2681 (58·2%) of 4603 people who screened positive for hypertension, and 1321 (21·7%) of 6096 people who screened positive for HIV had unmet health needs. Geospatially, met health needs for HIV were widely distributed and unmet health needs for all three conditions had specific sites of concentration; all three conditions had an overlapping geographical pattern for the need for diagnosis., Interpretation: Although people living with HIV predominantly have a well controlled condition, there is a high burden of unmet health needs for people living with hypertension and diabetes. In South Africa, adapting current, widely available HIV care services to integrate non-communicable disease care is of high priority., Funding: Fogarty International Center and the National Institutes of Health, the Bill & Melinda Gates Foundation, the South African Department of Science and Innovation, the South African Medical Research Council, the South African Population Research Infrastructure Network, and the Wellcome Trust., Translation: For the isiZulu translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: HIV-negative men are over-represented in tuberculosis (TB) prevalence surveys including the first South African national TB prevalence survey in 2018. Traditionally, TB screening is focused in clinics. We aimed to determine the frequency of primary healthcare clinic (PHC) attendance among HIV-negative men in a TB-prevalent setting. Methods: Since January 2017, PHC attendees in a rural South African demographic surveillance area (DSA) were asked their reason for attendance. HIV status was defined as positive if tested positive in a DSA sero-survey or attended clinic for HIV care; negative if tested negative between January 2014-December 2017 and no HIV-related visits; and HIV-unknown otherwise. Results: Among 67124 DSA residents (≥15 years), 27038 (40.3%) were men; 14196 (21.2%) were classified HIV-positive, 18892 (28.1%) HIV-negative and 34036 (50.7%) HIV-unknown. Between April 2017 and March 2018, 24382/67124 (36.3%, 95% confidence interval [CI] 36.0-36.7) adults made ≥1 PHC visit, comprising 9805/40086 (24.5%, 95%CI 23.6-25.3) of HIV-negative or unknown women and 3440/27038 (12.7%, 95%CI 11.6-13.8) of HIV-negative or unknown men. Overall, HIV care accounted for 37556/88109 (42.6%) of adult PHC visits. Conclusion: In this rural population, HIV-negative and -unknown men rarely attend PHCs. Improving TB screening in clinics may not reach a key population with respect to undiagnosed TB. Additional strategies are needed to diagnose and treat TB earlier., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Randera-Rees S et al.)

Background: Hypertension is the primary risk factor for stroke and heart disease, which are leading causes of death in South Africa. Despite the availability of treatments, there is an implementation gap in how best to deliver hypertension care in this resource-limited region., Methods: We describe a three-arm parallel group individually randomized control trial to evaluate the effectiveness and implementation of a technology-supported, community-based intervention to improve blood pressure control among people with hypertension in rural KwaZulu-Natal. The study will compare three strategies: 1) standard of care (SOC arm) clinic-based management, 2) home-based blood pressure management supported by community blood pressure monitors (CBPM arm) and a mobile health application to record blood pressure readings and enable clinic-based nurses to remotely manage care, and 3) an identical strategy to the CBPM arm, except that participants will use a cellular blood pressure cuff, which automatically transmits completed readings over cellular networks directly to clinic-based nurses (eCBPM+ arm). The primary effectiveness outcome is change in blood pressure from enrollment to 6 months. The secondary effectiveness outcome is the proportion of participants with blood pressure control at 6 months. Acceptability, fidelity, sustainability, and cost-effectiveness of the interventions will also be assessed., Conclusions: In this protocol, we report the development of interventions in partnership with the South Africa Department of Health, a description of the technology-enhanced interventions, and details of the study design so that our intervention and evaluation can inform similar efforts in rural, resource-limited settings., Protocol: Version 3 November 9th, 2022., Clinicaltrials: gov Trial Registration: NCT05492955 SAHPRA Trial Number: N20211201. SANCTR Number: DOH-27-112,022-4895., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

High COVID-19 vaccine hesitancy in South Africa limits protection against future epidemic waves. We evaluated how vaccine hesitancy and its correlates evolved April 2021-April 2022 in a well-characterized rural KwaZulu-Natal setting. All residents aged >15 in the Africa Health Research Institute's surveillance area were invited to complete a home-based, in-person interview. We described vaccine uptake and hesitancy trends, then evaluated associations with pre-existing personal factors, dynamic environmental context, and cues to action using ordinal logistic regression. Among 10,011 respondents, vaccine uptake rose as age-cohorts became vaccine-eligible before levelling off three months post-eligibility; younger age-groups had slower uptake and plateaued faster. Lifetime receipt of any COVID-19 vaccine rose from 3.0% in April-July 2021 to 32.9% in January-April 2022. Among 7,445 unvaccinated respondents, 47.7% said they would definitely take a free vaccine today in the first quarter of the study time period, falling to 32.0% in the last. By March/April 2022 only 48.0% of respondents were vaccinated or said they would definitely would take a vaccine. Predictors of lower vaccine hesitancy included being male (adjusted odds ratio [aOR]: 0.70, 95% confidence interval [CI]: 0.65-0.76), living with vaccinated household members (aOR:0.65, 95%CI: 0.59-0.71) and knowing someone who had had COVID-19 (aOR: 0.69, 95%CI: 0.59-0.80). Mistrust in government predicted greater hesitancy (aOR: 1.47, 95%CI: 1.42-1.53). Despite several COVID-19 waves, vaccine hesitancy was common in rural South Africa, rising over time and closely tied to mistrust in government. However, interpersonal experiences countered hesitancy and may be entry-points for interventions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Piltch-Loeb et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: The structure and composition of the household has important influences on child mortality. However, little is known about these factors in HIV-endemic areas and how associations may change with the introduction and widespread availability of antiretroviral treatment (ART). We use comparative, longitudinal data from two demographic surveillance sites in rural South Africa (2000-2015) on mortality of children younger than 5 years (n=101 105)., Design: We use multilevel discrete time event history analysis to estimate children's probability of dying by their matrilineal residential arrangements. We also test if associations have changed over time with ART availability., Setting: Rural South Africa., Participants: Children younger than 5 years (n=101 105)., Results: 3603 children died between 2000 and 2015. Mortality risks differed by co-residence patterns along with different types of kin present in the household. Children in nuclear households with both parents had the lowest risk of dying compared with all other household types. Associations with kin and child mortality were moderated by parental status. Having older siblings lowered the probability of dying only for children in a household with both parents (relative risk ratio (RRR)=0.736, 95% CI (0.633 to 0.855)). Only in the later ART period was there evidence that older adult kin lowered the probability of dying for children in single parent households (RRR=0.753, 95% CI (0.664 to 0.853))., Conclusions: Our findings provide comparative evidence of how differential household profiles may place children at higher mortality risk. Formative research is needed to understand the role of other household kin in promoting child well-being, particularly in one-parent households that are increasingly prevalent., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Non-communicable diseases (NCDs) account for half of all deaths in South Africa, partly reflecting unmet NCDs healthcare needs. Leveraging existing HIV infrastructure is touted as a strategy to alleviate this chronic care gap. We evaluated whether HIV care platforms are associated with improved NCDs care. We conducted a community-based screening of adults in rural KwaZulu-Natal, collecting BP, HbA1c, and health services utilization data. Care cascade indicators for hypertension and diabetes mellitus were defined as: 1) aware, if previously diagnosed, 2) in care, if seeing a provider within last 6 months; 3) treated, if reporting medication use within preceding 2 weeks; and 4) controlled, if BP<140/90mmHg or HbA1c<6.5%. We fit multivariable adjusted logistic regression models to compare successful completion of each step of the care cascade for hypertension and diabetes between people with virally suppressed HIV and HIV-negative comparators. Inverse probability sampling weights were applied to derive population-level estimates. The analytic sample included 4,933 individuals [mean age 58.4 years; 77% female]. Compared to being HIV-negative, having suppressed HIV was associated with lower adjusted prevalence of being aware (-6.0% [95% CI: -11.0, -1.1%]), in care (-5.7% [-10.6, -0.8%]), and in treatment (-4.8% [-9.7, 0.1%]) for diabetes; but higher adjusted prevalence of controlled diabetes (3.2% [0.2-6.2%]). In contrast, having suppressed HIV was associated with higher adjusted prevalence of being aware (7.4% [5.3-9.6%]), in care (8.0% [5.9-10.2%]), in treatment (8.4% [6.1-10.6%]) and controlled (9.0% [6.2-11.8%]), for hypertension. Overall, disease control was achieved for 40.0% (38.6-40.8%) and 6.8% (5.9-7.8%) of individuals with hypertension and diabetes, respectively. Engagement in HIV care in rural KwaZulu-Natal was generally associated with worse diabetes care and improved hypertension care. While further work should explore how success of HIV programs can be translated to NCD care, strengthening of primary healthcare will also be needed to respond to the growing NCDs epidemic., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Magodoro et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Data on social contact patterns are widely used to parameterize age-mixing matrices in mathematical models of infectious diseases. Most studies focus on close contacts only (i.e., persons spoken with face-to-face). This focus may be appropriate for studies of droplet and short-range aerosol transmission but neglects casual or shared air contacts, who may be at risk from airborne transmission. Using data from 2 provinces in South Africa, we estimated age mixing patterns relevant for droplet transmission, nonsaturating airborne transmission, and Mycobacterium tuberculosis transmission, an airborne infection where saturation of household contacts occurs. Estimated contact patterns by age did not vary greatly between the infection types, indicating that widespread use of close contact data may not be resulting in major inaccuracies. However, contact in persons >50 years of age was lower when we considered casual contacts, and therefore the contribution of older age groups to airborne transmission may be overestimated.

Background: Accurate human immunodeficiency virus (HIV) risk assessment can guide optimal HIV prevention. We evaluated the performance of risk prediction models incorporating geospatial measures., Methods: We developed and validated HIV risk prediction models in a population-based cohort in South Africa. Individual-level covariates included demographic and sexual behavior measures, and geospatial covariates included community HIV prevalence and viral load estimates. We trained models on 2012-2015 data using LASSO Cox models and validated predictions in 2016-2019 data. We compared full models to simpler models restricted to only individual-level covariates or only age and geospatial covariates. We compared the spatial distribution of predicted risk to that of high incidence areas (≥ 3/100 person-years)., Results: Our analysis included 19 556 individuals contributing 44 871 person-years and 1308 seroconversions. Incidence among the highest predicted risk quintile using the full model was 6.6/100 person-years (women) and 2.8/100 person-years (men). Models using only age group and geospatial covariates had similar performance (women: AUROC = 0.65, men: AUROC = 0.71) to the full models (women: AUROC = 0.68, men: AUROC = 0.72). Geospatial models more accurately identified high incidence regions than individual-level models; 20% of the study area with the highest predicted risk accounted for 60% of the high incidence areas when using geospatial models but only 13% using models with only individual-level covariates., Conclusions: Geospatial models with no individual measures other than age group predicted HIV risk nearly as well as models that included detailed behavioral data. Geospatial models may help guide HIV prevention efforts to individuals and geographic areas at highest risk., Competing Interests: Potential conflicts of interest. R. V. B. reports grants from the Bill & Melinda Gates Foundation (BMGF) and the NIH; participation on a Data Safety Monitoring Board or Advisory Board for HIV Vaccine Trials Network (HVTN), University of California, San Francisco (USCF), and London School of Hygiene & Tropical Medicine (LSHTM); and Regeneron Pharmaceuticals for conference abstract and manuscript writing support, outside the submitted work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Tuberculosis (TB) case finding efforts typically target symptomatic people attending health facilities. We compared the prevalence of Mycobacterium tuberculosis (Mtb) sputum culture-positivity among adult clinic attendees in rural South Africa with a concurrent, community-based estimate from the surrounding demographic surveillance area (DSA)., Methods: Clinic: Randomly selected adults (≥18 years) attending 2 primary healthcare clinics were interviewed and requested to give sputum for mycobacterial culture. Human immunodeficiency virus (HIV) and antiretroviral therapy (ART) status were based on self-report and record review. Community: All adult (≥15 years) DSA residents were invited to a mobile clinic for health screening, including serological HIV testing; those with ≥1 TB symptom (cough, weight loss, night sweats, fever) or abnormal chest radiograph were asked for sputum., Results: Clinic: 2055 patients were enrolled (76.9% female; median age, 36 years); 1479 (72.0%) were classified HIV-positive (98.9% on ART) and 131 (6.4%) reported ≥1 TB symptom. Of 20/2055 (1.0% [95% CI, .6-1.5]) with Mtb culture-positive sputum, 14 (70%) reported no symptoms. Community: 10 320 residents were enrolled (68.3% female; median age, 38 years); 3105 (30.3%) tested HIV-positive (87.4% on ART) and 1091 (10.6%) reported ≥1 TB symptom. Of 58/10 320 (0.6% [95% CI, .4-.7]) with Mtb culture-positive sputum, 45 (77.6%) reported no symptoms. In both surveys, sputum culture positivity was associated with male sex and reporting >1 TB symptom., Conclusions: In both clinic and community settings, most participants with Mtb culture-positive sputum were asymptomatic. TB screening based only on symptoms will miss many people with active disease in both settings., Competing Interests: Potential conflicts of interest. I. G. reports salary support from the UK Economic and Social Research Council (grant awarded to the London School of Hygiene and Tropical Medicine [LSHTM]). A. S. K. reports support from The Bloomsbury SET (Research England) (grant awarded to their institution, London School of Hygiene & Tropical Medicine), the National Institute for Health Research (UK), Colt Foundation (UK), ViiV Healthcare (USA), Queen Margaret University (UK), World Health Organization, Medical Research Council (UK), London School of Hygiene and Tropical Medicine (UK), and grants awarded to their employer/institution; reports consulting fees from the University of Cape Town (South Africa), South African National TB Think Tank (funded by the Bill and Melinda Gates Foundation, USA), Center for Health Policy and Studies (Republic of Moldova), Vital Strategies (Singapore; funded by Bloomberg Philanthropies, USA), The Aurum Institute (South Africa), and Edanz Group (Japan); reports travel and accommodation costs from Africa Health Research Institute (South Africa), Kyoto University (Japan), University College London (UK), Vital Strategies (Singapore), and Open Access publishing costs from the Bill and Melinda Gates Foundation (USA). K. K. reports salary support and travel expenses and support towards article-processing charges received for a role on the Umoya Omuhle project (from which the paper draws its data) from the UK Economic and Social Research Council (payments made to Queen Margaret University), grant received from the Joint Health Systems Research Initiative (Medical Research Council/Economic and Social Research Council/Department for International Development/Wellcome Trust) and a grant received from the National Institute for Health Research (NIHR; payments made to Queen Margaret University). O. K. reports salary support through grant to the institutions (Africa Health Research Institute [AHRI] and LSHTM) from Wellcome Trust (core grant 082384/Z/07/Z) and the Bill and Melinda Gates Foundation (OPP1175182). T. N. reports support from Wellcome Trust African Academy of Sciences and the South African National Research Foundation, the Bill and Melinda Gates Foundation and Max Planck Society and reports serving as member of the External Advisory Committee for HIV Vaccine Trials Network. E. B. W. reports support from Massachusetts General Hospital, the Africa Health Research Institute, University of Alabama at Birmingham, Bill and Melinda Gates Foundation, Wellcome Trust and National Institutes of Health. A. G. reports funding for other projects paid to their institution by the National Institutes of Allergy and Infectious Diseases, Bill and Melinda Gates Foundation, Research England, Wellcome Trust, and Medical Research Council and reports travel support paid to their institution by Wellcome Trust and Economic and Social Research Council. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Limited research has been conducted on explanations and understandings of biobanking for future genomic research in African contexts with low literacy and limited healthcare access. We report on the findings of a sub-study on participant understanding embedded in a multi-disease community health screening and biobank platform study known as 'Vukuzazi' in rural KwaZulu-Natal, South Africa., Methods: Semi-structured interviews were conducted with research participants who had been invited to take part in the Vukuzazi study, including both participants and non-participants, and research staff that worked on the study. The interviews were transcribed, and themes were identified from the interview transcripts, manually coded, and thematically analysed., Results: Thirty-nine individuals were interviewed. We found that the research team explained biobanking and future genomic research by describing how hereditary characteristics create similarities among individuals. However, recollection and understanding of this explanation seven months after participation was variable. The large volume of information about the Vukuzazi study objectives and procedures presented a challenge to participant recall. By the time of interviews, some participants recalled rudimentary facts about the genetic aspects of the study, but many expressed little to no interest in genetics and biobanking., Conclusion: Participant's understanding of information related to genetics and biobanking provided during the consent process is affected by the volume of information as well as participant's interest (or lack thereof) in the subject matter being discussed. We recommend that future studies undertaking biobanking and genomic research treat explanations of this kind of research to participants as an on-going process of communication between researchers, participants and the community and that explanatory imagery and video graphic storytelling should be incorporated into theses explanations as these have previously been found to facilitate understanding among those with low literacy levels. Studies should also avoid having broader research objectives as this can divert participant's interest and therefore understanding of why their samples are being collected., (© 2022. The Author(s).)

Background: There is poor viral load monitoring (VLM) and inadequate management of virological failure in HIV-positive individuals on antiretroviral therapy in rural KwaZulu-Natal, South Africa. This could be contributing to increasing HIV drug resistance in the setting. This study aims to investigate the clinical and process impediments in VLM within the health system and to evaluate a quality improvement package (QIP) to address the identified gaps. The QIP comprises (i) a designated viral load champion responsible for administrative management and triaging of viral load results (ii) technological enhancement of the routine clinic-based Three Interlinked Electronic Register (TIER.Net) to facilitate daily automatic import of viral load results from the National Health Service Laboratory to TIER.Net (iii) development of a dashboard system to support VLM., Methods/design: The study will evaluate the effectiveness of the QIP compared to current care for improving VLM and virological suppression using an effectiveness implementation hybrid type 3 design. This will use a cluster-randomised design with the primary healthcare clinics as the unit of randomisation with ten clinics randomised in a 1:1 ratio to either the intervention or control arm. We will enrol 150 HIV-positive individuals who had been on ART for ≥ 12 months from each of the ten clinics (750 in 5 intervention clinics vs. 750 in 5 control clinics) and follow them up for a period of 12 months. The primary outcome is the proportion of all patients who have a viral load (VL) measurement and are virally suppressed (composite outcome) after 12 months of follow up. Secondary outcomes during follow up include proportion of all patients with at least one documented VL in TIER.Net, proportion with VL ≥ 50 copies/mL, proportion with VL ≥ 1000 copies/mL (virological failure) and subsequent switch to second-line ART., Discussion: We aim to provide evidence that a staff-centred quality improvement package, designated viral load monitoring champion, and augmentation of TIER.Net with a dashboard system will improve viral load monitoring and lead to improved virological suppression., Trial Registration: This trial is registered on ClinicalTrials.gov on 8 Oct 2021. Identifier: NCT05071573; https://clinicaltrials.gov/ct2/show/NCT05071573?term=NCT05071573&draw=2&rank=1., (© 2021. The Author(s).)

Background: Cross-sectional screening programs are used to detect and refer individuals with non-communicable diseases to healthcare services. We evaluated the positive predictive value of cross-sectional measurements for Diabetes Mellitus (DM) and hypertension (HTN) as part of a community-based disease screening study, 'Vukuzazi' in rural South Africa., Methods: We conducted community-based screening for HTN and DM using the World Health Organization STEPS protocol and glycated haemoglobin A1c (HbA1c) testing, respectively. Nurses conducted follow-up home visits for confirmatory diagnostic testing among individuals with a screening BP above 140/90 mmHg and/or HbA1c above 6.5% at the initial screen, and without a prior diagnosis. We assessed the positive predictive value of the initial screening, compared to the follow up measure. We also sought to identify a screening threshold for HTN and DM with greater than 90% positive predictive value., Results: Of 18,027 participants enrolled, 10.2% (1,831) had a screening BP over 140/90 mmHg. Of those without a prior diagnosis, 871 (47.6%) received follow-up measurements. Only 51.2% (451) of those with completed follow-up measurements had a repeat BP>140/90 mmHg at the home visit and were referred to care. To achieve a 90% correct referral rate, a systolic BP threshold of 192 was needed at first screening. For DM screening, 1,615 (9.0%) individuals had an HbA1c > 6.5%, and of those without a prior diagnosis, 1,151 (71.2%) received a follow-up blood glucose. Of these, only 34.1% (395) met criteria for referral for DM. To ensure a 90% positive predictive value i.e. a screening HbA1c of >16.6% was needed., Conclusions: A second home-based screening visit to confirm a diagnosis of DM and HTN reduced health system referrals by 48% and 66%, respectively. Two-day screening programmes for DM and HTN screening might save individual and healthcare resources and should be evaluated carefully in future cost effectiveness evaluations., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: Early infant HIV diagnosis (EID) is critical to ensuring timely diagnosis of HIV-exposed infants, and treatment in those found to be infected. However estimates of coverage vary considerably, depending on data sources used. We used 4 methods to estimate coverage among a historical cohort of HIV-exposed infants in rural South Africa, between 2010-2016., Methods: We estimated the proportion of infants ever tested (methods 1-3) and tested by 7 weeks of age (1-4) as follows: (1) infants born to women identified as HIV-positive in demographic surveillance were linked to those with ≥1 EID result in routine laboratory surveillance; (2) the number of infants with ≥1 EID result in laboratory surveillance divided by the estimated number of HIV-exposed infants, calculated as total live births multiplied by antenatal HIV seroprevalence; (3) the number of infants with ≥1 EID result in routine laboratory surveillance, divided by the number of HIV-exposed infants as estimated by the district health service; (4) from documentation in infants' Road-to-Health-booklets., Results: The proportion ever tested was 43%, 88% and 138% for methods 1-3, and by 7 weeks of age was 25%, 49%, 86% and 46% for methods 1-4 respectively., Conclusions: The four methods, applied to a range of routine data sources, resulted in estimates varying considerably, and the true coverage of EID remains unclear. Our findings highlight the importance of developing unique patient identifiers, improving training of healthcare providers using reporting systems, and ensuring the accuracy of healthcare records, to ensure the best possible health outcomes for HIV-exposed infants., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: EC has indirectly received funding from ViiV Healthcare supporting their employment at UCL, through a grant made from ViiV Healthcare directly to the Penta Foundation. AJ and IJC have indirectly received funding supporting their employment at UCL from Abbvie, Bristol Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals and ViiV Healthcare through grants from these companies to the Penta Foundation. They have also received direct support for their employment through grants from the Collaborative Initiative for Paediatric HIV Education and Research, Gilead Sciences, NHS England, Medical Research Council and Penta Foundation to UCL, outside the submitted work. CT has indirectly received funding from ViiV Healthcare and AbbVie (via direct grants to the Penta Foundation) plus other non-commercial funders; CT has directly received support from ViiV Healthcare to contribute to a thinktank on Women and HIV. For all authors, all monies were paid to their institution, and related to employment only; no money was for consultancy, patents, products in development or marketed products. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Recent declines in adult HIV-1 incidence have followed the large-scale expansion of antiretroviral therapy and primary HIV prevention across high-burden communities of sub-Saharan Africa. Mathematical modeling suggests that HIV risk will decline disproportionately in younger adult age-groups as interventions scale, concentrating new HIV infections in those >age 25 over time. Yet, no empirical data exist to support these projections. We conducted a population-based cohort study over a 16-y period (2004 to 2019), spanning the early scale-up of antiretroviral therapy and voluntary medical male circumcision, to estimate changes in the age distribution of HIV incidence in a hyperepidemic region of KwaZulu-Natal, South Africa, where adult HIV incidence has recently declined. Median age of HIV seroconversion increased by 5.5 y in men and 3.0 y in women, and the age of peak HIV incidence increased by 5.0 y in men and 2.0 y in women. Incidence declined disproportionately among young men (64% in men 15 to 19, 68% in men 20 to 24, and 46% in men 25 to 29) and young women (44% in women 15 to 19, 24% in women 20 to 24) comparing periods pre- versus post-universal test and treat. Incidence was stable (<20% change) in women aged 30 to 39 and men aged 30 to 34. Age shifts in incidence occurred after 2012 and were observed earlier in men than in women. These results provide direct epidemiological evidence of the changing demographics of HIV risk in sub-Saharan Africa in the era of large-scale treatment and prevention. More attention is needed to address lagging incidence decline among older individuals., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Computer-aided digital chest radiograph interpretation (CAD) can facilitate high-throughput screening for tuberculosis (TB), but its use in population-based active case-finding programs has been limited. In an HIV-endemic area in rural South Africa, we used a CAD algorithm (CAD4TBv5) to interpret digital chest x-rays (CXR) as part of a mobile health screening effort. Participants with TB symptoms or CAD4TBv5 score above the triaging threshold were referred for microbiological sputum assessment. During an initial pilot phase, a low CAD4TBv5 triaging threshold of 25 was selected to maximize TB case finding. We report the performance of CAD4TBv5 in screening 9,914 participants, 99 (1.0%) of whom were found to have microbiologically proven TB. CAD4TBv5 was able to identify TB cases at the same sensitivity but lower specificity as a blinded radiologist, whereas the next generation of the algorithm (CAD4TBv6) achieved comparable sensitivity and specificity to the radiologist. The CXRs of people with microbiologically confirmed TB spanned a range of lung field abnormality, including 19 (19.2%) cases deemed normal by the radiologist. HIV serostatus did not impact CAD4TB's performance. Notably, 78.8% of the TB cases identified during this population-based survey were asymptomatic and therefore triaged for sputum collection on the basis of CAD4TBv5 score alone. While CAD4TBv6 has the potential to replace radiologists for triaging CXRs in TB prevalence surveys, population-specific piloting is necessary to set the appropriate triaging thresholds. Further work on image analysis strategies is needed to identify radiologically subtle active TB.

Background: There has been remarkable progress in the treatment of HIV throughout sub-Saharan Africa, but there are few data on the prevalence and overlap of other significant causes of disease in HIV endemic populations. Our aim was to identify the prevalence and overlap of infectious and non-communicable diseases in such a population in rural South Africa., Methods: We did a cross-sectional study of eligible adolescents and adults from the Africa Health Research Institute demographic surveillance area in the uMkhanyakude district of KwaZulu-Natal, South Africa. The participants, who were 15 years or older, were invited to participate at a mobile health camp. Medical history for HIV, tuberculosis, hypertension, and diabetes was established through a questionnaire. Blood pressure measurements, chest x-rays, and tests of blood and sputum were taken to estimate the population prevalence and geospatial distribution of HIV, active and lifetime tuberculosis, elevated blood glucose, elevated blood pressure, and combinations of these., Findings: 17 118 adolescents and adults were recruited from May 25, 2018, to Nov 28, 2019, and assessed. Overall, 52·1% (95% CI 51·3-52·9) had at least one active disease. 34·2% (33·5-34·9) had HIV, 1·4% (1·2-1·6) had active tuberculosis, 21·8% (21·2-22·4) had lifetime tuberculosis, 8·5% (8·1-8·9) had elevated blood glucose, and 23·0% (22·4-23·6) had elevated blood pressure. Appropriate treatment and optimal disease control was highest for HIV (78·1%), and lower for elevated blood pressure (42·5%), active tuberculosis (29·6%), and elevated blood glucose (7·1%). Disease prevalence differed notably by sex, across age groups, and geospatially: men had a higher prevalence of active and lifetime tuberculosis, whereas women had a substantially high prevalence of HIV at 30-49 years and an increasing prevalence of multiple and poorly controlled non-communicable diseases when older than 50 years., Interpretation: We found a convergence of infectious and non-communicable disease epidemics in a rural South African population, with HIV well treated relative to all other diseases, but tuberculosis, elevated blood glucose, and elevated blood pressure poorly diagnosed and treated. A public health response that expands the successes of the HIV testing and treatment programme to provide multidisease care targeted to specific populations is required to optimise health in such settings in sub-Saharan Africa., Funding: Wellcome Trust, Bill & Melinda Gates Foundation, the South African Department of Science and Innovation, South African Medical Research Council, and South African Population Research Infrastructure Network., Translation: For the isiZulu translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests TN reports grants from the Wellcome Trust, the African Academy of Sciences, and the South African National Research Foundation, during the conduct of the study. ADG reports grants from the Wellcome Trust, during the conduct of the study. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: In March 2020, South Africa implemented strict nonpharmaceutical interventions (NPIs) to contain the spread of COVID-19. Over the subsequent 5 months, NPI policies were eased in stages according to a national strategy. COVID-19 spread throughout the country heterogeneously; the disease reached rural areas by July and case numbers peaked from July to August. A second COVID-19 wave began in late 2020. Data on the impact of NPI policies on social and economic well-being and access to health care are limited., Objective: We aimed to determine how rural residents in three South African provinces changed their behaviors during the first COVID-19 epidemic wave., Methods: The South African Population Research Infrastructure Network nodes in the Mpumalanga (Agincourt), KwaZulu-Natal, (Africa Health Research Institute) and Limpopo (Dikgale-Mamabolo-Mothiba) provinces conducted up to 14 rounds of longitudinal telephone surveys among randomly sampled households from rural and periurban surveillance populations every 2-3 weeks. Interviews included questions on the following topics: COVID-19-related knowledge and behaviors, the health and economic impacts of NPIs, and mental health. We analyzed how responses varied based on NPI stringency and household sociodemographics., Results: In total, 5120 households completed 23,095 interviews between April and December 2020. Respondents' self-reported satisfaction with their COVID-19-related knowledge and face mask use rapidly rose to 85% and 95%, respectively, by August. As selected NPIs were eased, the amount of travel increased, economic losses were reduced, and the prevalence of anxiety and depression symptoms fell. When the number of COVID-19 cases spiked at one node in July, the amount of travel dropped rapidly and the rate of missed daily medications doubled. Households where more adults received government-funded old-age pensions reported concerns about economic matters and medication access less often., Conclusions: South Africans complied with stringent, COVID-19-related NPIs despite the threat of substantial social, economic, and health repercussions. Government-supported social welfare programs appeared to buffer interruptions in income and health care access during local outbreaks. Epidemic control policies must be balanced against the broader well-being of people in resource-limited settings and designed with parallel support systems when such policies threaten peoples' income and access to basic services., (©Guy Harling, Francesc Xavier Gómez-Olivé, Joseph Tlouyamma, Tinofa Mutevedzi, Chodziwadziwa Whiteson Kabudula, Ruth Mahlako, Urisha Singh, Daniel Ohene-Kwofie, Rose Buckland, Pedzisai Ndagurwa, Dickman Gareta, Resign Gunda, Thobeka Mngomezulu, Siyabonga Nxumalo, Emily B Wong, Kathleen Kahn, Mark J Siedner, Eric Maimela, Stephen Tollman, Mark Collinson, Kobus Herbst. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 13.05.2021.)

Objective: To assess the effect of lockdown during the 2020 COVID-19 pandemic on daily all-cause admissions, and by age and diagnosis subgroups, and the odds of all-cause mortality in a hospital in rural KwaZulu-Natal (KZN)., Design: Observational cohort., Setting: Referral hospital for 17 primary care clinics in uMkhanyakude District., Participants: Data collected by the Africa Health Research Institute on all admissions from 1 January to 20 October: 5848 patients contributed to 6173 admissions., Exposure: Five levels of national lockdown in South Africa from 27 March 2020, with restrictions decreasing from levels 5 to 1, respectively., Outcome Measures: Changes and trends in daily all-cause admissions and risk of in-hospital mortality before and at each stage of lockdown, estimated by Poisson and logistic interrupted time series regression, with stratification for age, sex and diagnosis., Results: Daily admissions decreased during level 5 lockdown for infants (incidence rate ratio (IRR) compared with prelockdown 0.63, 95% CI 0.44 to 0.90), children aged 1-5 years old (IRR 0.43, 95% CI 028 to 0.65) and respiratory diagnoses (IRR 0.57, 95% CI 0.36 to 0.90). From level 4 to level 3, total admissions increased (IRR 1.17, 95% CI 1.06 to 1.28), as well as for men >19 years (IRR 1.50, 95% CI 1.17 to 1.92) and respiratory diagnoses (IRR 4.26, 95% CI 2.36 to 7.70). Among patients admitted to hospital, the odds of death decreased during level 5 compared with prelockdown (adjusted OR 0.48, 95% CI 0.28 to 0.83) and then increased in later stages., Conclusions: Level 5 lockdown is likely to have prevented the most vulnerable population, children under 5 years and those more severely ill from accessing hospital care in rural KZN, as reflected by the drop in admissions and odds of mortality. Subsequent increases in admissions and in odds of death in the hospital could be due to improved and delayed access to hospital as restrictions were eased., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: The effect of the period before a mother's death on child survival has been assessed in only a few studies. We conducted a comparative investigation of the effect of the timing of a mother's death on child survival up to age five years in rural South Africa., Methods: We used discrete time survival analysis on data from two HIV-endemic population surveillance sites (2000-2015) to estimate a child's risk of dying before and after their mother's death. We tested if this relationship varied between sites and by availability of antiretroviral therapy (ART). We assessed if related adults in the household altered the effect of a mother's death on child survival., Findings: 3,618 children died from 2000-2015. The probability of a child dying began to increase in the 7-11 months prior to the mother's death and increased markedly in the 3 months before (2000-2003 relative risk = 22.2, 95% CI = 14.2-34.6) and 3 months following her death (2000-2003 RR = 20.1; CI = 10.3-39.4). This increased risk pattern was evident at both sites. The pattern attenuated with ART availability but remained even with availability at both sites. The father and maternal grandmother in the household lowered children's mortality risk independent of the association between timing of mother and child mortality., Conclusions: The persistence of elevated mortality risk both before and after the mother's death for children of different ages suggests that absence of maternal care and abrupt breastfeeding cessation might be crucial risk factors. Formative research is needed to understand the circumstances for children when a mother is very ill or dies, and behavioral and other risk factors that increase both the mother and child's risk of dying. Identifying families when a mother is very ill and implementing training and support strategies for other members of the household are urgently needed to reduce preventable child mortality., Competing Interests: The authors have declared that no competing interests exist.

Background: In low- and middle-income settings, obtaining informed consent for biobanking may be complicated by socio-economic vulnerability and context-specific power dynamics. We explored participants experiences and perceptions of the research objectives in a community-based multidisease screening and biospecimen collection platform in rural KwaZulu-Natal, South Africa., Methods: We undertook semi-structured in-depth interviews to assess participant understanding of the informed consent, research objectives and motivation for participation., Results: Thirty-nine people participated (individuals who participated in screening/biospecimen collection and those who did not and members of the research team). Some participants said they understood the information shared with them. Some said they participated due to the perceived benefits of the reimbursement and convenience of free healthcare. Most who did not participate said it was due to logistical rather than ethical concerns. None of the participants recalled aspects of biobanking and genetics from the consent process., Conclusions: Although most people understood the study objectives, we observed challenges to identifying language appropriate to explain biobanking and genetic testing to our target population. Engagement with communities to adopt contextually relevant terminologies that participants can understand is crucial. Researchers need to be mindful of the impact of communities' socio-economic status and how compensation can be potentially coercive., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Evidence for the effectiveness of continuous quality improvement (CQI) in resource-poor settings is very limited. We aimed to establish the effects of CQI on quality of antenatal HIV care in primary care clinics in rural South Africa., Methods and Findings: We conducted a stepped-wedge cluster-randomised controlled trial (RCT) comparing CQI to usual standard of antenatal care (ANC) in 7 nurse-led, public-sector primary care clinics-combined into 6 clusters-over 8 steps and 19 months. Clusters randomly switched from comparator to intervention on pre-specified dates until all had rolled over to the CQI intervention. Investigators and clusters were blinded to randomisation until 2 weeks prior to each step. The intervention was delivered by trained CQI mentors and included standard CQI tools (process maps, fishbone diagrams, run charts, Plan-Do-Study-Act [PDSA] cycles, and action learning sessions). CQI mentors worked with health workers, including nurses and HIV lay counsellors. The mentors used the standard CQI tools flexibly, tailored to local clinic needs. Health workers were the direct recipients of the intervention, whereas the ultimate beneficiaries were pregnant women attending ANC. Our 2 registered primary endpoints were viral load (VL) monitoring (which is critical for elimination of mother-to-child transmission of HIV [eMTCT] and the health of pregnant women living with HIV) and repeat HIV testing (which is necessary to identify and treat women who seroconvert during pregnancy). All pregnant women who attended their first antenatal visit at one of the 7 study clinics and were ≥18 years old at delivery were eligible for endpoint assessment. We performed intention-to-treat (ITT) analyses using modified Poisson generalised linear mixed effects models. We estimated effect sizes with time-step fixed effects and clinic random effects (Model 1). In separate models, we added a nested random clinic-time step interaction term (Model 2) or individual random effects (Model 3). Between 15 July 2015 and 30 January 2017, 2,160 participants with 13,212 ANC visits (intervention n = 6,877, control n = 6,335) were eligible for ITT analysis. No adverse events were reported. Median age at first booking was 25 years (interquartile range [IQR] 21 to 30), and median parity was 1 (IQR 0 to 2). HIV prevalence was 47% (95% CI 42% to 53%). In Model 1, CQI significantly increased VL monitoring (relative risk [RR] 1.38, 95% CI 1.21 to 1.57, p < 0.001) but did not improve repeat HIV testing (RR 1.00, 95% CI 0.88 to 1.13, p = 0.958). These results remained essentially the same in both Model 2 and Model 3. Limitations of our study include that we did not establish impact beyond the duration of the relatively short study period of 19 months, and that transition steps may have been too short to achieve the full potential impact of the CQI intervention., Conclusions: We found that CQI can be effective at increasing quality of primary care in rural Africa. Policy makers should consider CQI as a routine intervention to boost quality of primary care in rural African communities. Implementation research should accompany future CQI use to elucidate mechanisms of action and to identify factors supporting long-term success., Trial Registration: This trial is registered at ClinicalTrials.gov under registration number NCT02626351., Competing Interests: The authors have declared that no competing interests exist.

Objectives: We evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN)., Design: Observational cohort SETTING: Data were analysed from 11 primary healthcare clinics in northern KZN., Participants: A total of 46 523 individuals made 89 476 clinic visits during the observation period., Exposure of Interest: We conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods., Outcome Measures: Daily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata., Results: We found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI -16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (-7.1 visits/clinic/day, 95% CI -8.9 to 5.3), both for children aged <1 year and 1-5 years, with a gradual return to prelockdown within 3 months after the first lockdown measure. In contrast, we found no drop in clinic visitation in adults at the start of the level 5 lockdown, or related to HIV care (from 37.5 to 45.6, 8.0 visits/clinic/day, 95% CI 2.1 to 13.8)., Conclusions: In rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective : We compared the prevalence of frailty by HIV serostatus and related biomarkers to the modified frailty phenotype among older individuals in a rural population in South Africa. Methods : Questionnaire data were from a cohort of people living with HIV (PWH) on antiretroviral therapy (ART) and HIV-uninfected people aged 50 years and older sampled from the Africa Health Research Institute Demographic Health and Surveillance area in northern KwaZulu-Natal. The prevalence of frailty was compared using five categories: (1) physical activity; (2) mobility; (3) fatigue; (4) gait speed; and (5) grip strength, and assessed for demographic, clinical, and inflammatory correlates of frailty. Results : Among 614 individuals in the study, 384 (62.5%) were women. The median age at study enrolment was 64 years [Interquartile range (IQR) (58.6-72.0)]. 292 (47.6%) were PWH. 499 (81%) were classified as either pre-frail or frail. 43 (7%) were frail and HIV positive, 185 (30%) were pre-frail and HIV positive, 57 were frail and HIV negative and 214 (35%) were pre-frail and HIV negative. Frailty was similar for HIV negative and PWH (17.7% vs 14.7%, p = 0.72). Women were more likely to be frail (18.3% vs 13.04%, p = 0.16). The prevalence of frailty increased with age for both HIV groups. In the multivariable analysis, the odds of being frail were higher in those aged 70 years and above than those aged between 50 and 59 years ( p < 0.001). Females were less likely to be pre-frail than males ( p < 0.001). There was no association between any of the inflammatory biomarkers and frailty and pre-frailty. Conclusion : In this population, the prevalence of frailty is similar for PWH and people without HIV, but higher for women than men. These data suggest that the odds of developing frailty is similar for PWH over the age of 50 years, who survive into older age, as for people without HIV.

A coordinated system of disease surveillance will be critical to effectively control the coronavirus disease 2019 (Covid-19) pandemic. Such systems enable rapid detection and mapping of epidemics and inform allocation of scarce prevention and intervention resources. Although many lower- and middle-income settings lack infrastructure for optimal disease surveillance, health and demographic surveillance systems (HDSS) provide a unique opportunity for epidemic monitoring. This protocol describes a surveillance program at the Africa Health Research Institute's Population Intervention Platform site in northern KwaZulu-Natal. The program leverages a longstanding HDSS in a rural, resource-limited setting with very high prevalence of HIV and tuberculosis to perform Covid-19 surveillance. Our primary aims include: describing the epidemiology of the Covid-19 epidemic in rural KwaZulu-Natal; determining the impact of the Covid-19 outbreak and non-pharmaceutical control interventions (NPI) on behaviour and wellbeing; determining the impact of HIV and tuberculosis on Covid-19 susceptibility; and using collected data to support the local public-sector health response. The program involves telephone-based interviews with over 20,000 households every four months, plus a sub-study calling 750 households every two weeks. Each call asks a household representative how the epidemic and NPI are affecting the household and conducts a Covid-19 risk screen for all resident members. Any individuals screening positive are invited to a clinical screen, potential test and referral to necessary care - conducted in-person near their home following careful risk minimization procedures. In this protocol we report the details of our cohort design, questionnaires, data and reporting structures, and standard operating procedures in hopes that our project can inform similar efforts elsewhere., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Siedner MJ et al.)

A coordinated system of disease surveillance will be critical to effectively control the coronavirus disease 2019 (Covid-19) pandemic. Such systems enable rapid detection and mapping of epidemics and inform allocation of scarce prevention and intervention resources. Although many lower- and middle-income settings lack infrastructure for optimal disease surveillance, health and demographic surveillance systems (HDSS) provide a unique opportunity for epidemic monitoring. This protocol describes a surveillance program at the Africa Health Research Institute's Population Intervention Platform site in northern KwaZulu-Natal. The program leverages a longstanding HDSS in a rural, resource-limited setting with very high prevalence of HIV and tuberculosis to perform Covid-19 surveillance. Our primary aims include: describing the epidemiology of the Covid-19 epidemic in rural KwaZulu-Natal; determining the impact of the Covid-19 outbreak and non-pharmaceutical control interventions (NPI) on behaviour and wellbeing; determining the impact of HIV and tuberculosis on Covid-19 susceptibility; and using collected data to support the local public-sector health response. The program involves telephone-based interviews with over 20,000 households every four months, plus a sub-study calling 750 households every two weeks. Each call asks a household representative how the epidemic and NPI are affecting the household and conducts a Covid-19 risk screen for all resident members. Any individuals screening positive are invited to a clinical screen, potential test and referral to necessary care - conducted in-person near their home following careful risk minimization procedures. In this protocol we report the details of our cohort design, questionnaires, data and reporting structures, and standard operating procedures in hopes that our project can inform similar efforts elsewhere., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Siedner MJ et al.)

Objectives: The aim of the study was to estimate rates of linkage to HIV care and antiretroviral treatment (ART) initiation after the introduction of home-based HIV counselling and testing (HBHCT) and telephone-facilitated support for linkage in rural South Africa., Methods: A population-based prospective cohort study was carried out in KwaZulu Natal, South Africa. All residents aged ≥ 15 years were eligible for HBHCT. Those who tested positive and were not in care were referred for ART at one of 11 public-sector clinics. Individuals who did not attend the clinic within 2 weeks were sent a short message service (SMS) reminder; those who had not attended after a further 2 weeks were telephoned by a nurse counsellor, to discuss concerns and encourage linkage. Kaplan-Meier methods were used to estimate the proportion of newly diagnosed individuals linking to care and initiating ART., Results: Among 38 827 individuals visited, 26% accepted HBHCT. Uptake was higher in women than in men (30% versus 20%, respectively), but similar in people aged < 30 years and ≥ 30 years (28% versus 26%, respectively). A total of 784 (8%) tested HIV positive, of whom 427 (54%) were newly diagnosed. Within 6 months, 31% of women and 18% of men < 30 years old had linked to care, and 29% and 16%, respectively, had started ART. Among those ≥ 30 years, 41% of women and 38% of men had linked to care within 6 months, and 41% and 35%, respectively, had started ART., Conclusions: Despite facilitated linkage, rates of timely linkage to care and ART initiation after HBHCT were very low, particularly among young men. Innovations are needed to provide effective HIV care and prevention interventions to young people, and thus maximize the benefits of universal test and treat., (© 2019 British HIV Association.)

Background: Young men are less likely than young women to engage with HIV prevention and care, and their HIV-related mortality is higher. We describe HIV incidence and uptake of HIV services in men 20-29 years(y) in rural KwaZulu-Natal, South Africa, before the roll-out of DREAMS., Methods: We used data from a population-based demographic and HIV surveillance cohort. HIV incidence was estimated from anonymised testing in an annual serosurvey. Service uptake was assessed in 2011 and 2015, through two self-reported outcomes: 1) HIV testing in the past 12 months(m); 2) voluntary medical male circumcision(VMMC). Logistic regression was used to estimate odds ratios(OR) and 95% confidence intervals(CI) for factors associated with each outcome., Results: HIV incidence in 2011-2015 was 2.6/100 person-years (95%CI = 2.0-3.4) and 4.2 (95%CI = 3.1-5.6) among men 20-24y and 25-29y, respectively, with no significant change from 2006-2010. N = 1311 and N = 1221 young men participated in the 2011 and 2015 surveys, respectively. In both years, <50% reported testing for HIV in the past 12m. In 2011, only 5% reported VMMC, but coverage in 2015 increased to 40% and 20% in men 20-24y and 25-29y, respectively. HIV testing was positively associated with higher education and mobility. Testing uptake was higher in men reporting >1 partner in the past 12m, or condom use at last sex, but lower in those reporting a casual partner (adjusted (a)OR = 0.53, 95%CI = 0.37-0.75). VMMC uptake was associated with survey year and higher education. Men aged 25-29y and those who were employed (aOR = 0.66; 95%CI = 0.49-0.89) were less likely to report VMMC., Conclusions: HIV incidence in men 20-29y was very high, and pre-exposure prophylaxis (PrEP) should be considered in this population. Uptake of services was low. VMMC coverage increased dramatically from 2011 to 2015, especially among younger men, suggesting a demand for this service. Interventions designed with and for young men are urgently needed., Competing Interests: The authors have declared that no competing interests exist.

Background: Optimism regarding prospects for eliminating HIV by expanding antiretroviral treatment has been emboldened in part by projections from several mathematical modeling studies. Drawing from a detailed empirical assessment of rates of progression through the entire HIV care cascade, we quantify for the first time the extent to which models may overestimate health benefits from policy changes when they fail to incorporate a realistic understanding of the cascade., Setting: Rural KwaZulu-Natal, South Africa., Methods: We estimated rates of progression through stages of the HIV treatment cascade using data from a longitudinal population-based HIV surveillance system in rural KwaZulu-Natal. Incorporating empirical estimates in a mathematical model of HIV progression, infection transmission, and care, we estimated life expectancy and secondary infections averted under a range of treatment scale-up scenarios reflecting expanding treatment eligibility thresholds. We compared the results with those implied by the conventional assumptions that have been commonly adopted by existing models., Results: Survival gains from expanding the treatment eligibility threshold from CD4 350-500 cells/μL and from 500 cells/μL to treating everyone irrespective of their CD4 count may be overestimated by 3.60 and 3.79 times in models that fail to capture realities of the care cascade. HIV infections averted from raising the threshold from CD4 200 to 350, 350 to 500, and 500 cells/μL to treating everyone may be overestimated by 1.10, 2.65, and 1.18 times, respectively., Conclusions: Models using conventional assumptions about cascade progression may substantially overestimate health benefits. As implementation of treatment scale-up proceeds, it is important to assess the effects of required scale-up efforts in a way that incorporates empirical realities of how people move through the HIV cascade.

Background: Adolescent girls and young women (AGYW) bear the brunt of the HIV epidemic in South Africa. 'DREAMS' aims to reduce HIV incidence through multi-level combination prevention. We describe HIV incidence and uptake of HIV and sexual reproductive health (SRH) by AGYW in KwaZulu-Natal (KZN), prior to DREAMS., Methods: Longitudinal and cross-sectional analysis of women (15-24 year old) in a population-based HIV incidence cohort within a demographic surveillance site in KZN. Observation time for HIV incidence was person-years at risk while resident. "Current use of contraceptives" and "having an HIV test in the past 12 months" was compared between 2011 and 2015., Results: In 2015, HIV prevalence was 11.0% and 34.1% and HIV incidence (2011-2015) was 4.54% (95%CI:3.89-5.30) and 7.45% (95%CI:6.51-8.51) per year in 15-19 and 20-24 year olds respectively, with no significant decline compared to 2006-2010. In 2015, 90.7% of 20-24-year-olds were unemployed, 36.4% and 51.7% of 15-19 and 20-24 year olds reported recent migration; 20.9% and 72.6% of 15-19 and 20-24 year olds had ever been pregnant. In 2015, less than 50% reported condom-use at last sex, 15.0% of 15-19 year olds and 48.9% of 20-24 year olds were currently using contraception and 32.0% and 66.7% of 15-19 and 20-24 year olds had tested for HIV in the past 12 months. There had been no improvement compared to 2011. Factors associated with AGYW testing for HIV in the past 12 months were, survey year-2011 more likely than 2015 (aOR = 0.50), number of partners (aOR = 3.25), ever been pregnant (aOR = 2.47) and knowing where to find ART (aOR = 1.54). Factors associated with contraception use were being older (aOR = 4.83); ever been pregnant (aOR = 12.62); knowing where to get ART (aOR = 1.79) and having had an HIV test in past 12 months (aOR = 1.74)., Conclusion: Prior to DREAMS, HIV incidence in AGYW was high. HIV and SRH service uptake did not improve and was suboptimal. Findings highlight the need for combination HIV prevention programmes for AGYW in this economically vulnerable area., Competing Interests: The authors have declared that no competing interests exist.

Background: List randomization (LR), a survey method intended to mitigate biases related to sensitive true/false questions, has received recent attention from researchers. However, tests of its validity are limited, with no study comparing LR-elicited results with individually known truths. We conducted a test of LR for HIV-related responses in a high HIV prevalence setting in KwaZulu-Natal. By using researcher-known HIV serostatus and HIV test refusal data, we were able to assess how LR and direct questionnaires perform against individual known truth., Methods: Participants were recruited from the participation list from the 2016 round of the Africa Health Research Institute demographic surveillance system, oversampling individuals who were HIV positive. Participants were randomized to two study arms. In Arm A, participants were presented five true/false statements, one of which was the sensitive item, the others non-sensitive. Participants were then asked how many of the five statements they believed were true. In Arm B, participants were asked about each statement individually. LR estimates used data from both arms, while direct estimates were generated from Arm B alone. We compared elicited responses to HIV testing and serostatus data collected through the demographic surveillance system., Results: We enrolled 483 participants, 262 (54%) were randomly assigned to Arm A, and 221 (46%) to Arm B. LR estimated 56% (95% CI: 40 to 72%) of the population to be HIV-negative, compared to 47% (95% CI: 39 to 54%) using direct estimates; the population-estimate of the true value was 32% (95% CI: 28 to 36%). LR estimates yielded HIV test refusal percentages of 55% (95% CI: 37 to 73%) compared to 13% (95% CI: 8 to 17%) by direct estimation, and 15% (95% CI: 12 to 18%) based on observed past behavior., Conclusions: In this context, LR performed poorly when compared to known truth, and did not improve estimates over direct questioning methods when comparing with known truth. These results may reflect difficulties in implementation or comprehension of the LR approach, which is inherently complex. Adjustments to delivery procedures may improve LR's usefulness. Further investigation of the cognitive processes of participants in answering LR surveys is warranted.

Background: Sexually transmitted infections (STIs) and bacterial vaginosis (BV) are associated with increased transmission of HIV, and poor reproductive and sexual health. The burden of STIs/BV among young people is unknown in many high HIV prevalence settings. We conducted an acceptability, feasibility, and prevalence study of home-based sampling for STIs/BV among young men and women aged 15-24 years old in a health and demographic surveillance site (HDSS) in rural KwaZulu-Natal, South Africa., Methods and Findings: A total of 1,342 young people, stratified by age (15-19 and 20-24 years) and sex were selected from the HDSS sampling frame; 1,171/1,342 (87%) individuals had ≥1 attempted home visit between 4 October 2016 and 31 January 2017, of whom 790 (67%) were successfully contacted. Among the 645 who were contacted and eligible, 447 (69%) enrolled. Consenting/assenting participants were interviewed, and blood, self-collected urine (men), and vaginal swabs (women) were tested for herpes simplex virus type 2 (HSV-2), chlamydia, gonorrhoea, syphilis, trichomoniasis, and BV. Both men and women reported that sample collection was easy. Participants disagreed that sampling was painful; more than half of the participants disagreed that they felt anxious or embarrassed. The weighted prevalence of STIs/BV among men and women, respectively, was 5.3% and 11.2% for chlamydia, 1.5% and 1.8% for gonorrhoea, 0% and 0.4% for active syphilis, 0.6% and 4.6% for trichomoniasis, 16.8% and 28.7% for HSV-2, and 42.1% for BV (women only). Of the women with ≥1 curable STI, 75% reported no symptoms. Factors associated with STIs/BV included having older age, being female, and not being in school or working. Among those who participated in the 2016 HIV serosurvey, the prevalence of HIV was 5.6% among men and 19% among women. Feasibility was impacted by the short study duration and the difficulty finding men at home., Conclusions: A high prevalence of STIs/BV was found in this rural setting with high HIV prevalence in South Africa. Most STIs and HIV infections were asymptomatic and would not have been identified or treated under national syndromic management guidelines. A nested STI/BV survey within a HDSS proved acceptable and feasible. This is a proof of concept for population-based STI surveillance in low- and middle-income countries that could be utilised in the evaluation of STI/HIV prevention and control programmes.