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Introduction: Human mobility is associated with an increased risk of HIV acquisition and disengagement from HIV care, leading to poorer health outcomes among highly mobile individuals compared to less mobile individuals. Mobile individuals, broadly defined as those who temporally, seasonally, or permanently move from one place to another for voluntary or involuntary reasons, face many challenges in accessing HIV care services. These challenges include logistical difficulties, interruptions in HIV care continuity, and limited access to services across different locations, which together hinder timely testing, treatment initiation, and viral suppression. Digital health interventions offer flexible approaches that can adjust to the mobile individual's location to improve HIV care engagement and health outcomes for this underserved and hard-to-reach population. However, evidence on the feasibility, acceptability, and efficacy of digital health interventions across the HIV care cascade among mobile populations has not yet been appraised., Objectives: We seek to synthesize empirical evidence on the feasibility, acceptability, and efficacy of digital health interventions targeting the HIV care cascade among mobile populations., Methods: We will conduct a mixed methods systematic review of peer reviewed studies published between 1 January 2010 and 31 July 2024 that evaluated digital health interventions targeting the HIV care cascade among mobile populations. We will search PubMed, Web of Science, and EBSCOhost (Academic Search Premier, Africa-Wide information, CINAHL, Health Source: Nursing/Academic Edition, APA PsycInfo, APA PsycArticles) electronic databases. Bibliographies of retrieved studies will also be reviewed for relevant citations. Only studies published in English language and involved a digital health intervention, report an outcome related to the HIV care cascade, and involve mobile populations either partially or completely will be included. Two reviewers will independently screen titles and abstracts against the inclusion criteria, followed by full text screening for eligible articles. In case of disagreements, consensus will be sought from a third reviewer. Data synthesis will follow the Joanne Briggs Institute's convergent segregated approach. If sufficient quantitative studies with comparable outcome measures are available, a meta-analysis will be performed., Discussion: This review will address a critical evidence gap by consolidating data on digital health interventions' feasibility, acceptability, and efficacy across the HIV care cascade among mobile populations. The results will inform the development of tailored digital health interventions to enhance HIV care delivery and health outcomes for this hard-to-reach population, supporting global HIV prevention and treatment goals., Systematic Review Registration: This protocol is registered on PROSPERO (CRD42024528122)., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests., (© 2025. The Author(s).)

Suboptimal gestational weight gain (GWG) is associated with pregnancy complications and postpartum weight retention (PPWR). Little data exists about GWG and PPWR attitudes and beliefs in low-and-middle-income countries (LMICs) to inform interventions. We examined GWG and PPWR attitudes, beliefs, and intentions among pregnant people, with and without HIV, in Cape Town, South Africa. Pregnant persons were enrolled between 2019 and 2022 (N = 400). Study visits were conducted at 24-28 weeks' and 33-38 weeks' gestation. Rate of GWG (kg/week) between the second and third trimesters was estimated and reported as below, above, or within the 2009 Institute of Medicine guidelines. Multivariable-multinomial regression estimated predictors of GWG. In-depth interviews among pregnant participants, community leaders and healthcare providers informed GWG attitudes, beliefs, and perceptions. Over 90% of participants experienced suboptimal rates of GWG (35% below and 47% above guidelines) during pregnancy. Living with HIV [OR 0.50, 95% CI (0.26-0.95)] was protective against GWG rate above guidelines compared to those without HIV. Being 25-29 years old was associated with GWG rate below guidelines [OR 0.28 95% CI (0.08-0.95)]. Little concordance occurred between intended and true GWG. Despite GWG category, two-thirds of participants felt it was 'very important' to monitor GWG while 44% viewed losing weight gained during pregnancy as "not important". Barriers to meeting GWG goals included lack of access to healthy foods, exercise opportunities, and education. Given rising obesity in women of reproductive age in LMIC, locally-adapted interventions are needed during pregnancy and postpartum to aide in healthy GWG and improve maternal-child health outcomes., Competing Interests: Declarations. Ethics Approval and Consent to Participate: Ethics approval for the CAMP and HR-PAM studies was provided by the Brown University Institutional Review Board and the University of Cape Town’s Human Research Ethics Committee (protocols 486 and 505; protocol 225/2019;). Consent for Publication: Not applicable. Competing Interests: The authors declare that they have no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Oral pre-exposure prophylaxis (PrEP) is an effective and safe option to prevent HIV acquisition and vertical HIV transmission in pregnant and breastfeeding women. Understanding health system factors influencing the integration of PrEP into care for pregnant and breastfeeding women is key to increasing access. We explored managers' and health care workers' (HCWs) experiences with integrating PrEP into antenatal care and postnatal care services in primary health care clinics in Cape Town, South Africa., Methods: This exploratory qualitative study used codebook thematic analysis, where HCWs were purposively, heterogeneously sampled from an implementation science study. Semistructured individual interviews were conducted with 9 managerial-level staff, and 3 focus group discussions were conducted with HCWs (nurses, midwives, and HIV counselors) providing PrEP (6-7 HCWs per group) between November 2022 and January 2023 (N=28). Interview guides covered health system facilitators, barriers, and recommendations. The Health Systems Dynamics framework guided data analysis and presentation of results., Results: PrEP integration into antenatal care services was described as acceptable and feasible; however, changes to HIV testing policy and indicators in breastfeeding women are needed to integrate PrEP into postnatal clinics, together with identification of mother and baby as a dyad in visits. Results showed that supportive policies facilitated wider, simplified PrEP provision. The availability and accessibility of prescribing nurses and lay HIV counselors, PrEP (both within facilities and in communities), and information about PrEP for implementers and pregnant and breastfeeding women will be pivotal to facilitating integration., Conclusion: Facilitators for PrEP integration include task-shifting PrEP education and identification of women for PrEP initiation to HIV counselors, changes to national guidelines defining who can prescribe PrEP, revision and integration of PrEP training for HCWs, community-level interventions for PrEP demand creation and stigma reduction, and provision of differentiated PrEP delivery options., (© Court et al.)

Data to Care (D2C) strategies - using routine data to facilitate identification and linkage back to care of people living with HIV who are not in care - have shown promise in high-income settings but received little attention in lower resourced or vertical HIV transmission prevention (VTP) contexts. In this proof-of-concept study, we monitored existing linked electronic medical records in near real-time to identify key gaps in postpartum VTP steps among 336 mothers living with HIV and their infants in Cape Town, South Africa (recruited March 2021 - April 2022). We attempted to confirm observed gaps through source data systems and telephonic tracing, and facilitated re-engagement in care where needed. There were 302 gaps observed in the routine data; 123 (41%) were false gaps and 179 (59%) were considered probable gaps (133 mother-infant pairs). Overall, 54 mothers (16%) did not link to HIV care within 12 weeks of delivery, 43 mothers (13%) linked to care but had a gap in ART dispensing by nine months postpartum, 25 infants (10%) did not have an HIV test around 10 weeks and 57 (17%) had no HIV test around 6 months of age. Only 100 of the probable gaps (56%) could be confirmed through telephonic tracing and, of those, only 47 were successfully re-linked to care. Mobility and clinic transfer, fear of stigma and employment-related challenges were commonly reported reasons for gaps in VTP steps. This study highlights that linked routine data sources linking mother-infant pairs across health facilities has the potential to streamline tracing efforts; however, implementation is challenging and, even when gaps are identified, re-engagement in care may be difficult. Further research is needed to combine D2C strategies with interventions addressing broader social and structural determinants of health, and to tailor D2C strategies to fit available resources and data sources in low-resource settings.

In recent years, significant progress has been made in treatment access for women living with HIV (WLHIV). For example, option B+, which requires that all pregnant persons who test positive for HIV start on antiretroviral treatment, has been instrumental in reducing the risk of vertical transmission. For birthing individuals who have a low HIV viral load, there is a minimized risk of vertical transmission during breastfeeding. However, an alarming rate of WLHIV in South Africa disengage from care during postpartum. Given that work is intricately linked to individuals' socioeconomic status, and thus health outcomes, and their health-seeking ability, it is important to explore the role of work in decisions that impact HIV-related care for the dyad postpartum. Semi-structured interviews were conducted with 26 women living with HIV at 6-8 weeks postpartum in Cape Town, South Africa. A secondary qualitative data analysis was conducted following thematic content analysis. Three themes were identified, spanning participants' financial considerations, navigating childcare needs, and considerations for exclusive breastfeeding. For many participants, there was often a conflict between returning to work, childcare, and the decision whether or not to breastfeed-in addition to their HIV care. This conflict between participants' commitments suggests an increased pressure that WLHIV may face postpartum, which could impact their ability to remain engaged in their healthcare and adherent to medication. Although exclusive breastfeeding is an important recommendation for the baby's health outcomes; there is a need for structural support for WLHIV as they navigate work re-entry during postpartum., Competing Interests: Declarations. Competing Interests: The authors have no competing interests to declare., (© 2024. The Author(s).)

Background: Full coverage of childhood vaccines is a persistent challenge in low- and middle-income countries, suggesting the presence of specific contextual barriers. The emergence of the COVID-19 pandemic further worsened the situation. The complementary use of community-based participatory research (CBPR) and human-centered design (HCD) approaches has the potential to effectively create tailored interventions for improving public health outcomes. This protocol provides examples of methods to evaluate the use of these novel approaches in low- and middle-income countries. The 'Let's talk about vaccines' project is a multisite community-based participatory project by VillageReach that uses the CBPR and HCD approaches to identify the barriers and co-create interventions/solutions to address under two routine immunization access and uptake in Malawi and Mozambique., Methods: Guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, this evaluation prospectively evaluates the effectiveness (on under-two immunization coverage and related outcomes) of VillageReach's co-created interventions and processes of implementation (reach, adoption, implementation and maintenance) in two districts in Mozambique and two in Malawi. This paper will also describe the theory of change for VillageReach's project. Thematic analysis will be used to analyze the qualitative data, and interrupted time series analysis used to analyze the co-created interventions' effectiveness on specific under two immunization outcomes. The analysis will integrate complex systems thinking and constructs inherent in health systems strengthening., Discussion: This evaluation is an opportunity to share the use of novel and best practices, opportunities and challenges for improved community-responsive programming in routine immunization. It will be fundamental in providing evidence on the impact of interventions, evidence on mechanisms behind improvements in under- two immunization outcomes due to codesigned community-driven solutions and informing their scalability in similar contexts. Findings will inform the development of a comprehensive framework to guide the scalability of community-based approaches on childhood immunization uptake and access into similar contexts., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2024 Shuro 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.)

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z =  - 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z =  - 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z =  - 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z =  - 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z =  - 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019., (© 2024. The Author(s).)

Perinatal mental health disorders place a particularly high public health burden on South Africa (SA) via negative health outcomes for the birthing parent and adverse health outcomes for infants (e.g., low birth weight, preterm deliveries, malnourishment) as well as emotional and behavioral problems in children. Depression, posttraumatic stress disorder (PTSD), and other mental health disorders may also compromise engagement in HIV prevention behaviors during the perinatal period, when HIV acquisition risk increases. This is particularly important in SA, where almost a quarter of women between ages 15 to 49 have HIV. There is little research exploring the anticipated impacts mental health symptoms have on one's ability to emotionally connect or caregive after delivery; this critical information will enable providers to support women and their mental health during the transition from pregnancy to postpartum. HIV-negative pregnant persons were recruited from an antenatal clinic in Cape Town as a part of a larger study investigating mental health barriers to pre-exposure prophylaxis (PrEP) uptake during pregnancy. Participants qualified for an in-depth interview based on elevated symptoms of depression and/or PTSD. The interviews explored the likely impact of their mental health symptoms on their baby's wellbeing, their ability to bond with their baby, and their ability to meet their baby's needs. Following the principles of thematic analysis, we identified three main themes that described these relationships: (1) a strong perceived connection between maternal mental health and baby's wellbeing; (2) perceived strains on bonding with the baby; and (3) negative impact of mental health on likelihood of completing parenting tasks. This study will inform future mental health programming to prepare pregnant persons with mental health symptoms for a successful postpartum period with respect to bonding and caring for their infant., Competing Interests: Competing interests The authors report no vested interests relating to this article that could be considered a conflict of interest. Additional Declarations: No competing interests reported.

Background: There is growing recognition of obstetric violence in health facilities across the globe. With nearly one in three pregnant women living with HIV in South Africa, it is important to consider the influence of HIV status on birth experiences, including potential experience of obstetric violence as defined by the Respectful Maternity Care Charter. This qualitative analysis aims to understand the factors that shape birth experiences of women living with HIV, including experiences at the nexus of HIV status and obstetric violence, and how women react to these factors., Methods: Data were collected in a Midwife Obstetric Unit in Gugulethu, Cape Town, South Africa, through 26 in-depth interviews with women living with HIV at 6-8 weeks postpartum. Interviews included questions about labor and early motherhood, ART adherence, and social contexts. We combined template style thematic analysis and matrix analysis to refine themes and subthemes., Results: Participants described a range of social and structural factors they felt influenced their birth experiences, including lack of resources and institutional policies. While some participants described positive interactions with healthcare providers, several described instances of obstetric violence, including being ignored and denied care. Nearly all participants, even those who described instances of obstetric violence, described themselves as strong and independent during their birth experiences. Participants reacted to birth experiences by shifting their family planning intentions, forming attitudes toward the health facility, and taking responsibility for their own and their babies' safety during birth., Conclusions: Narratives of negative birth experiences among some women living with HIV reveal a constellation of factors that produce obstetric violence, reflective of social hierarchies and networks of power relations. Participant accounts indicate the need for future research explicitly examining how structural vulnerability shapes birth experiences for women living with HIV in South Africa. These birth stories should also guide future intervention and advocacy work, sparking initiatives to advance compassionate maternity care across health facilities in South Africa, with relevance for other comparable settings., (© 2024. The Author(s).)

The syndemic of HIV, sexually transmitted infections (STIs), and early pregnancy remain a key challenge to global public health. Decision-making around sexual and reproductive health (SRH) behaviours is critical to ensuring the uptake of biomedical technologies. Drawing from behavioural science theories, we propose a novel conceptual framework-the Decision Cascade-to describe the decision-making process that a user will go through as they navigate these decisions. Analogous to the HIV prevention and treatment cascade, this model describes key steps individuals go through when deciding to use HIV prevention technologies. Each step (being cued/triggered to act, reacting to the behaviour, evaluating the behaviour, assessing the feasibility of acting and the timing and final execution of the action), is influenced by a myriad of individual and socio-cultural factors, shaping the ultimate decision and behaviour outcome in a continual cycle. This framework has applications beyond HIV prevention, extending to other SRH technologies and treatments. By prioritizing human-centered design and understanding user decision-making intricacies, interventions can enhance effectiveness and address the complexities of SRH service uptake across diverse populations. The Decision Cascade framework offers a comprehensive lens to inform intervention design, emphasizing the need for nuanced approaches that resonate with the realities of decision-makers. Adopting such approaches is essential to achieving meaningful impact in HIV prevention and broader SRH initiatives., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Background: Compared with other age groups, adolescents living with HIV (ALHIV) are estimated to have lower levels of adherence to antiretroviral treatment. Despite this, we lack evidence on adolescents' adherence patterns over time to inform the customization of intervention strategies., Setting: Eastern Cape province, South Africa., Methods: We analyzed data from a cohort of ALHIV (N = 1046, aged 10-19 years at baseline) recruited from 53 public health facilities. The cohort comprised 3 waves of data collected between 2014 and 2018 and routine viral load data from the National Institute for Communicable Disease data warehouse (2014-2019). Durable viral suppression was defined as having suppressed viral load (<1000 copies/mL) at ≥2 consecutive study waves. Group-based multitrajectory model was used to identify adherence trajectories using 5 indicators of self-reported adherence. Logistic regression modeling evaluated the associations between adherence trajectories and durable viral suppression., Results: Overall, 933 ALHIV (89.2%) completed all 3 study waves (55.1% female, mean age: 13.6 years at baseline). Four adherence trajectories were identified, namely, "consistent adherence" (49.8%), "low start and increasing" (20.8%), "gradually decreasing" (23.5%), and "low and decreasing" (5.9%). Adolescents experiencing inconsistent adherence trajectories were more likely to be older, live in rural areas, and have sexually acquired HIV. Compared with the consistent adherence trajectory, the odds of durable viral suppression were lower among adolescents in the low start and increasing (adjusted odds ratio [aOR]: 0.62, 95% CI: 0.41 to 0.95), gradually decreasing (aOR: 0.40, 95% CI: 0.27 to 0.59), and the low and decreasing adherence (aOR: 0.25, 95% CI: 0.10 to 0.62) trajectories., Conclusions: Adherence to antiretroviral treatment remains a challenge among ALHIV in South Africa. Identifying adolescents at risk of nonadherence, based on their adherence trajectories may inform the tailoring of adolescent-friendly support strategies., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Traditional gender and social norms reinforce asymmetrical power relations, increase the risk of experiencing gender-based violence and mediate poor engagement with sexual and reproductive health services. This study explored gender norms and expectations amongst cisgender adolescents in rural KwaZulu-Natal, South Africa. A purposive sample of 29 adolescents aged 16-19 years old were enrolled as part of a longitudinal qualitative study. The current analysis reports on the first round of in-depth interviews, which focused on the role of men and women in their community. A theoretically informed thematic analysis identified three broad themes: 1) Adolescent interpretation and understanding of gender identity, 2) Gendered essentialism and Gender roles (two sub-themes: Young men: Power through providing, and Young women: The domestication process which highlighted that gender roles were defined by being the provider for men, and the successful fulfilment of traditional domestic behaviours amongst women), 3) Gender and fertility highlighted how participants highly valued fertility as affirming of manhood/womanhood. These norms reinforce gender roles that maintain asymmetrical power relations, carrying them over into adulthood. The subtle social pressure to prove fertility could have unintended consequences for driving teenage pregnancy. Structural, gender-based interventions emphasising positive gender-role development in early childhood are needed., Competing Interests: The authors have no conflicts of interest to declare., (Copyright: © 2024 Marshall 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.)

Transfers between health facilities for postpartum women living with HIV are associated with disengagement from care. In South Africa, women must transfer from integrated antenatal/HIV care to general HIV services post-delivery. Thereafter, women transfer frequently e.g. due to geographic mobility. To explore barriers to transfer, we conducted in-depth interviews >2 years post-delivery in 28 participants in a trial comparing postpartum HIV care at primary health care (PHC) antiretroviral therapy (ART) facilities versus a differentiated service delivery model, the adherence clubs, which are the predominant model implemented in South Africa. Data were thematically analysed using inductive and deductive approaches. Women lacked information including where they could transfer to and transfer processes. Continuity mechanisms were affected when women transferred silently i.e. without informing facilities or obtaining referral letters. Silent transfers often occurred due to poor relationships with healthcare workers and were managed inconsistently. Fear of disclosure to family and community stigma led to transfers from local PHC ART facilities to facilities further away affecting accessibility. Mobility and the postpartum period presented unique challenges requiring specific attention. Information regarding long-term care options and transfer processes, ongoing counselling regarding disclosure and social support, and increased health system flexibility are required.

Background: While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence., Methods: Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory., Results: The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers., Conclusions: This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs., (© 2023. The Author(s).)

Adolescence and young adulthood are important periods of transition and therefore for action and intervention to ensure future sexual and reproductive health (SRH). Caregiver-adolescent communication about sex and sexuality is a protective factor for SRH, but there are often barriers to this. Adults' perspectives are limited within the literature but important as they should lead this process. This paper uses exploratory qualitative data from in-depth interviews with 40 purposively sampled community stakeholders and key informants to explore their insights into the perceived, experienced or expected challenges adults' experience when having these conversations within a high HIV prevalence, South African context. Findings suggest that respondents recognised the value of communication and were generally willing to try it. However, they identified barriers such as fear, discomfort and limited knowledge and perceived capacity to do so. They show that in high prevalence contexts adults grapple with their own personal risks, behaviours and fears that may affect their ability to have these conversations. This demonstrates the need to equip caregivers with the confidence and ability to communicate about sex and HIV, alongside managing their own complex risks and situations to overcome barriers. It is also necessary to shift the negative framing of adolescents and sex.

The timely identification of ART non-adherence among adolescents living with HIV presents a significant challenge, particularly in resource-limited settings where virologic monitoring is suboptimal. Using South African adolescent cohort data (N = 933, mean age 13.6 ± 2.89 years, 55.1% female, follow-up = 2014-2018), we examined the association between elevated viral load (VL ≥ 1000 copies/mL) and seven self-reported adherence measures on missed doses, and clinic appointments -with varying recall timeframes. The best performing measures, which were significantly associated with elevated viral load in covariate-adjusted models are: any missed dose -past 3 days (sensitivity = 91.6% [95%CI: 90.3-92.8], positive predictive value (PPV) = 78.8% [95%CI: 77.2-80.4]), -past week (sensitivity = 87% [95%CI: 85.4-88.6], PPV = 78.2% [95%CI: 76.5-79.9]), -past month (sensitivity = 79.5% [95%CI: 77.5-81.4], PPV = 78.2% [95%CI: 76.4-79.9]), any past-month days missed (sensitivity = 86.7% [95%CI: 85.1-88.3], PPV = 77.9% [95%CI:76.2-79.6]), and any missed clinic appointment (sensitivity = 88.3% [95%CI: 86.8-89.8], PPV = 78.4% [95%CI: 76.8-79.9]). Combining the three best performing measures missed dose -past 3 days, -past week, and any past-year missed clinic appointment increased sensitivity to 96.4% while maintaining a PPV of about 78%. The discriminatory power of simple and easy-to-administer self-reported adherence measures in detecting elevated viral load warrants consideration in resource-limited settings and may contribute to the aims of the new Global Alliance to End AIDS in children and adolescents by 2030., (© 2023. The Author(s).)

Background: Adolescents and young women are at high risk for sexually transmitted infections (STIs) and unintended pregnancies. However, conversations about sexual and reproductive health (S&RH) are difficult and stigmatised. Visual art-based approaches have been a useful adjunct to language-dependent interviews, encouraging embodied memory recall. Here, we explored a novel visual art-based methodology-"Stories from the Edge"-with a cohort of young women to understand how artmaking might facilitate dialogue of how S&RH experiences influenced behaviour, to enrich dialogues captured in the individual in-depth interviews (IDIs)., Methods: Seven isiXhosa-speaking young women (aged 21-25 years) were recruited into a six-session art-based engagement, painting the stories of their S&RH experiences. Large format artmaking and IDIs contributed to the data set. IDIs were audio recorded, transcribed, and translated and then analysed thematically., Results: Young women felt that the visual art-based methodology eased barriers to communicating experiences of S&RH-seeking behaviours, with one woman commenting that "words are too small" to capture lived experiences. Artmaking provided the opportunity to express emotional complexities of the pleasures of intimate relationships and the heartbreak of betrayal for which they had no language. Significant social relationships (family, partners, peers) influenced sexual and reproduction attitudes and practices more than healthcare facilities and staff and more distal socio-cultural attitudes/practices. These influences shifted from adolescence to adulthood-from family to peer and partners., Conclusion: Young women valued using the art-based methodology, which facilitated recall and verbalising their S&RH experiences more fully than language-only research. The process outlined here could provide a creative method that builds communication skills to negotiate the needs and desires of young women with partners and staff at S&RH services., 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. The handling editor LM declared a past coauthorship with the authors J-AP and L-GB., (© 2023 Hartley, Knight, Humphries, Trappler, Gill, Bekker, MacKenny and Passmore.)

Introduction: In South Africa, public perceptions of the COVID-19 pandemic and risk mitigation measures remain mixed. To better understand health behaviours in the context of COVID-19, a qualitative study was conducted, which aimed to investigate perceptions relating to the COVID-19 pandemic among the South African adult population., Methods: Twelve online focus groups were conducted across the following age groups: 18-34, 35-54, 55 + years old (total n = 70) in December 2021. Diversity across socioeconomic status, geographical areas, and urban and rural settings was maximised, with an equal representation of men and women. Focus groups were conducted, and audio recorded using an online platform, transcribed verbatim and thematically analysed using MAXQDA., Results: There were mixed perceptions around the pandemic, however, the majority of participants appreciated government actions at the onset of the pandemic and as a result government trust was reported to have initially been high. Nevertheless, as the pandemic progressed, challenges relating to government communication around the pandemic, the inconsistent application of preventative measures by government, the use of soldiers to enforce preventative measures, the banning of alcohol and cigarettes, government corruption and the pervasiveness of social media were reported to have eroded government trust, negatively impacting the uptake of preventative measures. Economic and psychological impacts were experienced differently across income groups. Low-income earners, who already had pre-existing economic challenges reported increased psychological and financial strain. While the once cushioned middle class reported an increase in job insecurity accompanied by psychological challenges. High income earners did not report economic challenges but reported being affected psychologically. Though, low-income earners reported an appreciation of the government financial relief afforded to them middle income earners appeared to not have received adequate financial support., Conclusion: With the existing mistrust of government, there is need for government to leverage existing trusted sources in communities to aid in the implementation of preventative measures. These findings support the development of context specific solutions to address challenges faced at different socioeconomic levels., (© 2023. The Author(s).)

Background: COVID-19 has greatly affected the delivery of all health care services globally. Antenatal care is one area of care that has been impacted, despite the fact that attending antenatal check-ups is essential for pregnant women and cannot be postponed. Little is known about how exactly ANC provision has changed in the Netherlands, or how the changes have impacted midwives and gynaecologists providing those services., Methods: This study used a qualitative research design to investigate changes in individual and national practice following the onset of the COVID-19 pandemic. The study involved a document analysis of protocols and guidelines for ANC provision to evaluate how those changed following the onset of the COVID-19 pandemic and semi-structured interviews with ANC care providers (i.e., gynaecologists and midwives)., Results: Guidance was issued by multiple organizations, during the pandemic, on how to approach the risk of infection in pregnant women, recommending several changes to ANC to protect both pregnant women and ANC providers. Both midwives and gynaecologists reported changes in their practice. With less face-to-face consultations happening, digital technologies became critical in the care of pregnant women. Shorter and fewer visits were reported, with midwifery practices adjusting their guidelines further than hospitals. Challenges, with high workloads and lack of personal protective equipment were discussed., Conclusions: The COVID-19 pandemic has had an immense impact on the health care system. This impact has had both negative and positive effects on the provision of ANC in the Netherlands. It is important to learn from the current COVID-19 pandemic and adapt ANC, as well as health care systems as a whole, to be better prepared for future health crises and ensure continuous provision of good quality care., (© 2023. The Author(s).)

Purpose: This study aims to compare low socioeconomic status, urban early adolescents' (EAs) attitudes toward gender, gender diversity and sexual diversity in two contexts with similar progressive legal frameworks for gender equality and nondiscrimination, South Africa and Belgium, to understand the ways in which adolescents modify or conform to prevailing attitudes., Methods: The study used a cross-sectional design and sampled 1,102 and 569 EAs (between 11 and 15 years old) in Belgium and South Africa respectively. Quantitative data were collected using tablets. Sample characteristics and gender attitude scales are described and compared in the two countries, and between boys and girls within each country. Comparisons are conducted on the mean score for the 5-point Likert scale items on the gender attitude scales., Results: Girls in both countries expressed more tolerant attitudes toward same-sex romantic relationships and experienced more gender diverse emotional attraction and physical attraction to same-sex individuals than boys. Generally, boys endorsed more heteronormative relationship norms and other stereotypical attitudes than girls. Conversely, girls tended to embrace sexual double standards more than boys. South African EAs exhibited more sexual diversity but less tolerant attitudes toward gender and gender diversity. Belgian EAs, especially girls, tended to exhibit more tolerant attitudes toward diversity in gender identity., Discussion: There were important differences in attitudes toward gender, gender diversity, and sexual diversity among EAs, despite the countries' similar progressive legislative frameworks. In the future, sociocultural and other determinants of EAs' attitudes should be further explored at different levels from the individual to the societal., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Pregnant and postpartum women (PPW) in sub-Saharan Africa are at disproportionately high risk of HIV infection compared to non-pregnant women. When used consistently, pre-exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW., Discussion: PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross-cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource-limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV., Conclusions: For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use., (© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Introduction: The scale-up of access to antiretroviral therapy has transformed HIV from an acute, terminal disease to a manageable chronic illness. Yet, sustaining high levels of antiretroviral therapy adherence remain a challenge, especially in the sub-Saharan Africa region which is disproportionately affected by HIV. This protocol proposes a scoping review to explore literature reporting on the antiretroviral therapy adherence levels among people who experience substance abuse and violence (SAVA) syndemics, as well as mood disorders such as anxiety and depression among people living with HIV in sub-Saharan Africa., Methods and Analysis: This proposed scoping review will follow Arksey and O'Malley's methodological framework for conducting scoping reviews as refined by Levac et al. The review will follow the Joanna Briggs Institute's manual for conducting scoping reviews. Literature searches will be conducted using six databases: Academic search complete; APA PsycArticles; CINAHL; MEDLINE; SocINDEX and Web of science. Title screening will see the "Participant, Concept, Context" framework applied to identify relevant literature and will not include the appraisal of search results. Data charting will follow an adapted version of Trico and colleagues' PRISMA-ScR and results will be mapped descriptively and in tabular format. Furthermore, results will be discussed within the syndemics model of health, and summarised as a biosocial conceptual model., Ethics and Dissemination: The study will make use of secondary data that are readily available to the public and will not require ethical approval. We intend to publish our results in a peer-reviewed journal and disseminate our findings at relevant conferences and seminars., Competing Interests: The authors have declared that no competing interests exist.

The number of older people living with HIV (OPLWH) (aged 50-plus) in South Africa is increasing as people age with HIV or are newly infected. OPLWH are potentially vulnerable because of the intersection of age-related and HIV stigmas, co-morbidities, and lack of social support. Evidence from younger populations suggests that social support can improve ART adherence and retention in care. Further, HIV status disclosure plays a role in mediating social support and may reduce stigma by facilitating access to social support. This paper draws on qualitative research with OPLWH to explore the complex associations between disclosure, social support, and HIV stigma among OPLWH in urban Western Cape. The findings demonstrate that OPLWH receive most of their support from their family and this support can facilitate adherence to ART and retention in care. However, social support is facilitated by participants' disclosure, thus, when perceived stigma limits disclosure, social support is less accessible. Gender, age, and pre-existing vulnerability also affect disclosure to and support from kin and community. Given that social support, particularly from family members, amplifies HIV care access and ART adherence, encouraging disclosure stimulating household HIV competency is likely to both address anticipated stigma and support improved OPLWH's health outcomes.

The chronic illness trajectory and its outcomes are well explained by the concept of illness identity; the extent to which ill individuals have integrated their diagnosed chronic illness into their identity or sense of self. The capacity to measure illness identity in people living with HIV (PLHIV) is still relatively unexplored. However, this is potentially useful to help us understand how outcomes for PLHIV could be improved and sustained. This paper aims to explore the cross-cultural adaptation of a Belgian developed Illness Identity Questionnaire (IIQ) and validate the instrument using a sample of South African adults living with HIV. We followed a phased scale adaptation and validation process which included an investigation of conceptual, item, semantic and operational equivalence and also examined the psychometric properties of the IIQ. The concept of illness identity with its four factors; engulfment, rejection, acceptance and enrichment in PLHIV, was found to be relevant within this context. Five items from the original IIQ were excluded from the adapted IIQ due to either semantic insufficiency and/or inadequate measurement equivalence. The mode of administration of the IIQ was changed to accommodate current study participants. The original four factor 25-item model did not fit current data, however, a better contextualized, four-factor, 20-item model was identified and found valid in the current setting. The results showed adequate statistical fit; χ 2 /d.f. = 1.516, RMSEA = 0.076, SRMR = 0.0893, and CFI = 0.909. Convergent and discriminant validity were also tenable. The cross-cultural adaptation and validation of the IIQ was successful, resulting in the availability of an instrument capable of measuring illness identity in PLHIV in a high HIV prevalence and resource-constrained setting. This therefore addresses the paucity of information and expands on knowledge about illness identity., (© 2022. The Author(s).)

Understanding the sexual relationships of young women is critical for preventing HIV infections. This study aimed to describe the sexual behaviour of partners, comparing the accuracy of sexual health knowledge between partners. The study took place in 2017 in KwaZulu-Natal, South Africa. Purposive sampling was used to select 18-27-year-old sexually active women. Consenting female participants completed a structured and semi-structured interview, while consenting male sexual partners identified through the female participant completed a structured questionnaire on sexual health information. Using a reflexive inductive approach and thematic analysis, we identified key discrepancies in the assumptions partners make about each other's sexual health information. Twenty-three sexual dyads were identified and four key discrepancies were identified: Age: partners either over or underestimated the age of their partners, HIV status: where partners were unaware of, or incorrectly assumed their partner's status, Lack of awareness of partner's concurrent relationships and more general knowledge of the partner's sexual health behaviours. Discussions about sexual health are mediated by relationship length, type of partner, power and perceived fidelity. While it is possible to undertake dyadic level research, ethical tensions remain. Sex-positive and egalitarian sexual health interventions that target the individual, as well as the sexual relationship, are needed.

In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV's (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019-March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June-July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Life history calendars (LHCs) are able to capture large-scale retrospective quantitative data, which can be utilized to learn about transitions of behavior change over time. The Testing and Risk History Calendar (TRHC) is a version of life history calendar (LHC) which correlates critical social, sexual and health variables with the timing of HIV testing. In order to fulfill the need for time-bound data regarding HIV testing and risk of older persons in South Africa, a pilot of the TRHC was performed using a paper fold-out grid format. Though the TRHC study in this format was effective as older persons were able to recall details about their HIV testing and risk contexts, the interview process was tedious as data were collected manually. Development of a tablet application for TRHC study will improve data quality and make data entry and collection more automated. This paper presents the development of the TRHC application prototype in order to collect TRHC data electronically and provides a platform for efficient large-scale life history calendar data collection., 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., (Copyright © 2021 Parvin, Mosa, Knight and Schatz.)

PrEP is safe and effective but requires adherence during potential HIV exposure, yet the facilitators of long-term maternal adherence are not well understood. We conducted semi-structured interviews with 25 postpartum women who reported high adherence (PrEP use ≥ 25 days in last 30-days and never missed a PrEP prescription in pregnancy/postpartum period) within a PrEP service for pregnant and postpartum women. A thematic approach guided an iterative process of coding and analysis. Themes identified as drivers of optimal PrEP use were HIV risk perception, mainly because of partner's behaviors and unknown serostatus, and a strong desire to have a baby free of HIV. Reported disclosure of PrEP use facilitated PrEP adherence. Women discussed having partner and family support, which included reminders to take PrEP daily. Primary barriers were anticipated or experienced stigma, overcome through education of partners and family about PrEP. Pregnant women experienced transient side-effects, but found ways to continue, including taking PrEP at night. PrEP programs for pregnant and postpartum women should integrate strategies to assist women with realistic appraisals of risk and teach skills for disclosure and securing support from significant others., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The process of adapting to a life with a chronic illness, is a well-researched phenomenon for a number of common chronic illnesses. The construct, adaptation, embeds the notions of integration of the chronic illness into identity and self-management. Integration precedes self-management and is key to living positively with a chronic illness. Adaptation is an important concept in understanding trajectory and outcomes of living with a chronic illness. Applicability of these concepts to HIV as a chronic illness; when suppressive adherence has been achieved, however, is unknown. Specifically, the adaptation process to living with HIV as a chronic illness, the integration of HIV into identity and the resulting self-management behaviours by adults living with HIV are relatively unexplored. We describe a protocol for a scoping review of adaptation to living with HIV, we structure the enquiry around integration of HIV into identity and self-management and interrogate theories, models and frameworks that have been proposed and studied and we evaluate them for relevance and usefulness in the care and management of HIV., Methods and Analysis: Methods proposed by the Johanna Briggs Institute will be followed. The protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews and was registered with the Open Science Framework. MEDLINE, SCOPUS, Cochrane Library, CINHAL and SocINDEX databases will be searched. A search in Social Science Research Network eLibrary and Open Access Theses and Dissertations will gather grey literature and reference lists of included sources will be screened. Study selection process will involve a title and abstract review and full text review, guided by clearly defined inclusion and exclusion criteria., Ethics and Dissemination: Ethical approval is not required because this is a proposed review and collection of data on publicly available materials. The results will be published in a topic relevant journal and presented at related scientific events., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use., Materials and Methods: The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013-2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index., Results: The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health., Conclusions: This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa., Competing Interests: The authors have declared that no competing interests exist.

Nationwide rollout of antiretroviral treatment (ART) is increasing the number of older persons living with HIV (OPLWH) in South Africa. Yet, little is known about how the sociological aspects of ageing - stigma, finances and family dynamics - impact access to ART. Qualitative interviews with 23 persons aged 50-plus living near Cape Town highlight the barriers and facilitators to the acceptability, affordability and availability of ART access among OPLWH. Key age-related barriers included perceived shame of sexuality and disclosing HIV status to others, perceived disrespect by clinical staff, affording transportation to clinics and pre-existing co-morbidities. Key age-related facilitators included family moral and financial support, particularly from children and grandchildren, and access to social grants. Importantly, many barriers and facilitators had feedback loops, for example social grants reduced transportation barriers to clinics when ageing and poor health limited mobility. As the population living with HIV ages, it is critical to assess the ways ageing, as a social process, impacts ART access and to address these to improve older persons' HIV care., (© 2021 Foundation for the Sociology of Health & Illness.)

Background: Rational medicines use (RMU) is the prescribing/dispensing of good quality medicines to meet individual patient's clinical needs. Policy-makers, managers and frontline providers play critical roles in safeguarding medicine usage thus ensuring their rational use. This study investigated perspectives of key health system actors on prescribing practices and factors influencing these in Eswatini. Public sector healthcare service delivery is through health facilities (public sector, not-for-profit faith-based, industrial) and community-based care., Methods: A qualitative, exploratory study using semi-structured in-depth interviews with seven policymakers and managers, and 32 facility-based actors was conducted. Drawing on Social Practice Theory, material (health system context), competence (provider) and cultural (patient and provider) factors influencing prescribing practices were explored., Results: Participants were aged between 21-57years, had been practicing for 1-30 years, and were a mix of doctors, nurses, pharmacists and pharmacy-technicians. Factors contributing to irrational medicines use included: poor use of treatment guidelines, lack of RMU policies, poorly-functioning pharmaceutical and therapeutics committees, stock-outs of medicines, lack of pharmacy personnel in primary healthcare facilities, and restrictions of medicines by level of care. Provider-related factors included: knowledge, experience and practice ethic, symptomatic prescribing, high patient numbers. Patient-related factors included late presentation, language, and the need to be prescribed many medicines., Conclusion: In Eswatini, prescribing practices are influenced by the interaction of factors (health system, provider and patient) that span levels (facility, region, and policy-making) of the health system. Promoting RMU thus goes beyond the availability of guidelines and provider training and requires concerted efforts of multiple stakeholders., Competing Interests: The authors have declared that no competing interests exist.

Conducting formative research is a scientific, ethical, and community engagement imperative. This article describes how formative research refined ethical processes for a family-based home-based counseling and testing (FBCT) intervention in KwaZulu-Natal. In-depth interviews were conducted to explore community ( n = 20) and key stakeholders' ( n = 20) needs, concerns, and perspectives on the FBCT model, including ethical issues for working with children and families. Data were analyzed thematically using NVivo software. Four key ethical considerations emerged, namely, respect for community norms and cultural practices; confidentiality, privacy, and forced disclosure; identifying potential risks and benefits; and voluntariness and capacity to consent. Data were used to refine the intervention and address participants' concerns by engaging the community, providing ethics training for intervention staff, and incorporating independent consent mechanisms for adolescent HIV testing that supported opportunities for family-based testing and disclosure.

Despite the Universal Test and Treat program and widespread antiretroviral treatment rollout, South Africa is still facing HIV prevention and treatment challenges, which are aggravated by human resource shortages in the healthcare sector. Individual- and community-level responses to these HIV-related challenges are increasingly being explored, for example, in community and home-based care. The role of the household as a crucial mediating social level has, however, largely been omitted. This paper outlines the design of an intervention to stimulate the involvement of the household in support for people living with HIV in South Africa. The 6SQuID model guided the intervention development process in four phases: (1) formative research, theory formulation, and a review of the existing literature, (2) integration of the results from the formative research into the "Positive Communication Process" (P 2 CP model) as a mechanism of change, (3) design of a community-health-worker-led intervention as the way to deliver the change mechanism, and (4) testing and revision of the developed intervention material-called Sinako -in a small-scale pilot study. The Sinako intervention anticipates that the future of chronic HIV care in resource-constrained settings will need to integrate the patient's household into the fight against HIV., (Copyright © 2020 Masquillier, Wouters, Campbell, Delport, Sematlane, Dube and Knight.)

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH's ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH's ART adherence should take structural factors into account to have maximum impact., Competing Interests: The authors declare no conflict of interest.

Objectives: This study explores the barriers to accessing antenatal care (ANC) services amongst pregnant adolescents within a particular community of South Africa., Methods: An exploratory qualitative design was applied to examine the views of pregnant adolescents. In-depth interviews were conducted with pregnant adolescents at the Mitchells Plain Midwifery Obstetric Unit, as well as nursing staff working at the facility. Thematic analysis was then used and analysis was framed using the social-ecological model for health-seeking behaviour., Results: This study found that barriers to adolescents seeking ANC often centered on a discourse of adolescent pregnancy being deviant, irresponsible, and shameful. Pregnant adolescents often absorbed these beliefs and were fearful of other's reaction within their family, the community, at school, and within the ANC facilities., Conclusions: Stigma regarding adolescent pregnancy participates in the perpetuation of a culture of non-disclosure and shame, which stands in the way of young pregnant people seeking the care they require. Such beliefs and attitudes need to be challenged at a community and national level.

Objective: This study uses health and non-health sector data sources to select and assess available indicators for service provision along the continuum of care for maternal health at subnational levels in South Africa. It applies the adequacy approach established in another study to assess the multi-dimensionality of available indicators. Using adequacy and the process of assessment in the study, the comprehensiveness of the continuum of care for improving maternal health outcomes can be assessed., Results: We found 27 indicators of care utilization and access, linkages of care, and quality of care from the routine district health information system. The General Household Survey contained 11 indicators for the social determinants of health on the continuum of care framework. Indicator gaps include health promotion during and after pregnancy, maternal nutrition, empowerment and quality of care. At present, the available indicators measure about 74% of the interventions on the continuum of care framework. We make recommendations regarding improvements needed to better measure and monitor the continuum of care for maternal health. These involve actions within the health system and include integration of non-health system indicators.

Background: The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low- and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context., Methods: We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4., Results: Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges., Conclusion: Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low- and middle-income countries using the continuum of care framework and locally available indicators.

Background: With 7.7 million South Africans currently infected with human immunodeficiency virus (HIV) and 4.8 million currently receiving antiretroviral treatment (ART), the epidemic represents a considerable burden for the country's resource-limited health system. In response to the health and human resource shortages, task shifting to community health workers (CHWs) and empowering people living with HIV (PLWH) are integral parts of a sustainable ART strategy. Despite the success of the ART programme, South Africa still faces both prevention and treatment challenges. To tackle these challenges, future endeavours need to focus on the role played by the households of PLWH in mediating between the community and PLWH themselves. Building health-enabling "HIV competent" households with the capacity to actively stimulate lifestyles that foster health, offers a potential strategy to tackle South Africa's HIV-related challenges. The aim of the "Sinako: Households and HIV" study is to investigate to what extent and how an intervention can increase HIV competence in PLWH and their households, and subsequently optimise the impact of CHW support on individual ART outcomes., Methods: The "Sinako" study is a cluster-randomised controlled trial with two arms. In the control arm, CHWs offer a standard package of support to PLWH during home visits, focused on the individual. The intervention arm includes both a focus on the individual and the household to enable the patient to self-manage their treatment within an HIV competent household. A longitudinal mixed methods design is adopted to analyse the data. For the quantitative data analysis, methods including latent cross-lagged modelling, multilevel modelling and logistic regression will be used. To assess the acceptability and feasibility of the intervention and to construct a comprehensive picture of the mechanisms underlying the impact on the household and the PLWH, qualitative data (in-depth interviews and focus group discussions) will be collected and analysed., Discussion: Stimulating HIV competence in households could be a feasible and sustainable strategy to optimise the outcomes of CHW interventions and thus be important for HIV treatment interventions in resource-limited settings., Trial Registration: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Life history calendars capture patterns of behavior over time, uncovering transitions and trajectories. Despite the growing numbers of older persons living with HIV in southern Africa, little is known about how HIV testing and risk unfold in this population. Operationalizing a life course approach with the use of an innovative Testing and Risk History Calendar [TRHC], we collected pilot data on older South Africans' risk and HIV testing. We found older persons were able to provide (1) reference points to facilitate recall over a 10-year period, (2) specifics about HIV tests during that decade, and (3) details that contextualize the testing data, such as living arrangements, relationships, and health status. Interviewer debriefing sessions after each interview captured information on context and links across domains. On a larger scale, the TRHC has potential to reveal pathways between sexual behavior, HIV testing and risk perception, and health at older ages., Competing Interests: The authors have declared that no competing interests exist.

South Africa has increasing numbers of persons living with HIV on antiretroviral treatment (ART). There is evidence for a relationship between food, food security and HIV. Despite increasing rates of people older than 50 living with HIV coinciding with greater levels of co-morbidity, the existing research is largely limited to those aged 15-49 years. In this paper, we therefore explore how older people living with HIV (OPLWH) in two urban communities within South Africa negotiate and ensure they have sufficient access to food and how food insecurity may affect their retention in care and ART adherence. This study used exploratory qualitative semi-structured in-depth interviews with 23 OPLWH to collect data in isiXhosa. Data were analysed using thematic content analysis. Factors at the community, household and individual levels influence (a) access to sufficient and quality food, and (b) beliefs about ART and food based on (mis)understandings of messaging from health care providers. The results demonstrate the need to explore further and clarify the nutritional guidelines that OPLWH receive from providers to ensure this does not result in reduced adherence or retention in care. They also demonstrate the role that social welfare and family or kin obligations plays in ensuring the food security of OPLWH.

Background: HIV remains a major public health challenge in many low- and middle-income countries (LMICs). The initiation of a greater number of people living with HIV (PLHIV) onto antiretroviral therapy (ART) following the World Health Organization's 'universal test and treat' recommendation has the potential to overstretch already challenged health systems in LMICs. While various mainstream and community-based care models have been implemented to improve the treatment outcomes of PLHIV, little effort has been made to harness the potential of the families or households of PLHIV to enhance their treatment outcomes. To this end, we sought to explore the characteristics and effectiveness of household-focused interventions in LMICs on the management of HIV as measured by levels of adherence, viral suppression and different dimensions of HIV competence. Additionally, we sought to explore the mechanisms of change to explain how the interventions achieved the expected outcomes., Methods: We systematically reviewed the literature published from 2003 to 2018, obtained from six electronic databases. We thematically analysed the 11 selected articles guided by the population, intervention, comparison and outcome (PICO) framework. Following the generative causality logic, whereby mechanisms are postulated to mediate an intervention and the outcomes, we applied a mechanism-based inferential reasoning, retroduction, to identify the mechanisms underlying the interventions to understand how these interventions are expected to work., Results: The identified HIV-related interventions with a household focus were multi-component and multi-dimensional, incorporating aspects of information sharing on HIV; improving communication; stimulating social support and promoting mental health. Most of the interventions sought to empower and stimulate self-efficacy while strengthening the perceived social support of the PLHIV. Studies reported a significant positive impact on improving various aspects of HIV competent household - positive effects on HIV knowledge, communication between household members, and improved mental health outcomes of youths living in HIV-affected households., Conclusion: By aiming to strengthen the perceived social support and self-efficacy of PLHIV, household-focused HIV interventions can address various aspects of household HIV competency. Nevertheless, the role of the household as an enabling resource to improve the outcomes of PLHIV remains largely untapped by public HIV programmes; more research on improving household HIV competency is therefore required., Trial Registration: PROSPERO registration: CRD42018094383.

Background: As South Africa's (SA) HIV programme increases in size, HIV/TB cases occur that are often beyond the clinical scope of primary healthcare clinicians. In SA's Eastern Cape (EC) province, health facilities are geographically widespread, with a discrepancy in specialist availability outside of academic institutions. The aim of this study is to describe WhatsApp and its use as an alternative learning tool to improve clinicians' access to specialised management of complicated HIV/TB cases., Objectives: To analyse clinicians' use of the WhatsApp chat group as a learning tool; to assess clinicians' confidence in managing complicated HIV and TB patients after participating in the WhatsApp case discussion group; to describe the perceived usefulness of the chat group as a learning tool; to understand clinicians' knowledge and use of informed consent when sharing patient case details on a public platform such as WhatsApp., Method: An observational, cross-sectional study was conducted among a group of clinicians from the EC that formed part of a WhatsApp HIV/TB clinical discussion group. Data were collected using a structured anonymous Internet questionnaire and analysed with Epi Info, using descriptive and analytic statistics., Results: The analysis found the majority of participants had gained new clinical confidence from group participation. This was associated with the increased group engagement in group follow-up (odds ratio [OR] 48.13 [95% confidence interval [CI] 4.99-464.49]); in posting questions (OR 3.81 [95% CI 1.02-18.48]); in reports of 'new' clinical insights (OR 23.75 [95% CI 3.95-142.88]); in referencing old case material (OR 21.42 [95% CI 4.39-104.84]) and in the use of peer guidance to manage cases (OR 48.13 [95% CI 4.99-464.49]). However, there was a discrepancy in participants' knowledge and actual use of informed consent when posting patient details on social media., Conclusions: Our study findings support the use of WhatsApp in a medical setting as an effective means of communication, long distance learning and support between peers and specialists., Competing Interests: The authors have declared that no competing interest exist.

Background: Understanding sexual activity is necessary to prevent sexually transmitted infections. Evidence from Sub-Saharan Africa suggests that 10-20% of youth aged 15-24 are sexually active before reaching 15 years, yet estimating sexual activity remains challenging. This study explored the use of multiple sexual health outcomes to identify sexually-active young women in rural KwaZulu-Natal, South Africa., Methods: Using a multi-component sexual activity profile (MSAP), we aimed to identify sexually active students. Based on data from 2675 grade 9 and 10 students attending 14 high schools) in rural KwaZulu-Natal, we constructed a descriptive diagram identifying students who were sexually active by self-report vs MSAP profile. T-tests for two independent samples was performed to compare by sex and ecological variables that characterise students newly-identified as sexually active., Results: Using self-report only, 40.3% self-reported as sexually active, whilst the MSAP identified 48.7% (223 additional students). More females were identified than males. Younger adolescents were more likely to underreport sexual activity but were identified using MSAP. Newly-identified as sexually active were more likely to be female (p = < 0.000), 15 years old or younger (p = 0.008), less likely to perceive being at risk (p = 0.037) or have ever used alcohol (p = < 0.000). At a relational level, they were less likely to report having ever had a boyfriend/girlfriend (p = 0.000) or to have felt pressured to have sex by their peers (p = < 0.000) or partners (p = 0.008). At a familial level they more likely to be of medium socioeconomic (SES) status (p = 0.037) whilst at a school and community level they were less likely to have repeated a grade (p = 0.024) and were more likely to be engaged in social activities (p = 0.032)., Conclusions: The MSAP profile identified more potentially sexually active students, and gave insight into the characteristics of students who may be unwilling to self-report sexual activity Future work should investigate how this approach could enhance and describe sexually-active adolescents for research and healthcare provision.

The use of vaginal products may increase the risk of HIV infection by affecting the vaginal biome. Understanding what vaginal products young women are using, and why, is key to assessing the complexity of sexual health and risk. This study reports on findings from research with adolescent and young women in rural KwaZulu-Natal about the vaginal products they use and motivations for using them. The study identified over 26 products that young women used to enhance their sexual experience and found some young women spent time preparing and sourcing vaginal products in order to pleasure and retain partners. Opinions differed about vaginal product use. While some women perceived that vaginal products could provide a means of out-performing other women, retaining a partner and providing sexual autonomy, there was a stigma attached to using them. Study findings highlight the social value of using vaginal products, especially in settings where partner retention is linked to economic survival. Expanding our understanding of what products are used and the reasons young women use them warrants continued investigation.

Background: The uptake of findings from sexual and reproductive health and rights research into policy-making remains a complex and non-linear process. Different models of research utilisation and guidelines to maximise this in policy-making exist, however, challenges still remain for researchers to improve uptake of their research findings and for policy-makers to use research evidence in their work., Methods: A participatory workshop with researchers was organised in November 2017 by the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER) to address this gap. ANSER is a consortium of experienced researchers, some of whom have policy-making experience, working on sexual and reproductive health and rights issues across 16 countries and 5 continents. The experiential learning cycle was used to guide the workshop discussions based on case studies and to encourage participants to focus on key lessons learned. Workshop findings were thematically analysed using specific stages from Hanney et al.'s (Health Res Policy Syst 1:2, 2003) framework on the place of policy-making in the stages of assessment of research utilisation and outcomes., Results: The workshop identified key strategies for translating research into policy, including joint agenda-setting between researchers and policy-makers, as well as building trust and partnerships with different stakeholders. These were linked to stages within Hanney et al.'s framework as opportunities for engaging with policy-makers to ensure uptake of research findings., Conclusion: The engagement of stakeholders during the research development and implementation phases, especially at strategic moments, has a positive impact on uptake of research findings. The strategies and stages described in this paper can be applied to improve utilisation of research findings into policy development and implementation globally.

Background: HIV and non-communicable disease (NCD) are syndemic within sub-Saharan Africa especially among older persons. The two epidemics interact with one another within a context of poverty, inequality and inequitable access to healthcare resulting in an increase in those aged 50 and older living with HIV and experiencing an NCD co-morbidity. We explore the challenges of navigating healthcare for older persons living with HIV and NCD co-morbidity., Methods: In-depth semi-structured interviews were conducted with a small sample of older persons living with HIV (OPLWH). The perspectives of key informants were also sought to triangulate the evidence of OPLWH. The research took place in two communities on the outskirts of Cape Town, South Africa. All interviews were conducted by a trained interviewer and transcribed and translated for analysis. Thematic content analysis guided data analysis., Results: OPLWH experienced an HIV-NCD syndemic. Our respondents sought care and accessed treatment for both HIV and other chronic (and acute) conditions, though these services were provided at different health facilities or by different health providers. Through the syndemic theory, it is possible to observe that OPLWH and NCDs face a number of physical and structural barriers to accessing the healthcare system. These barriers are compounded by separate appointments and spaces for each condition. These difficulties can exacerbate the impact of their ill-health and perpetuate structural vulnerabilities. Despite policy changes towards integrated care, this is not the experience of OPLWH in these communities., Conclusions: The population living with HIV is aging increasing the likelihood that those living with HIV will also be living with other chronic conditions including NCDs. Thus, it is essential that health policy address this basic need to integrate HIV and NCD care.

Background: Approximately 14% of Africans infected with HIV are over the age of 50, yet few intervention studies focus on improving access to care, retention in care, and adherence to antiretroviral therapy (ART) in this population. A review of the published literature until 2012, found no relevant ART management and care interventions for older people living with HIV (OPLHIV) in sub-Saharan Africa. The aim of this systematic review is to update the original systematic review of intervention studies on OPLHIV, with a focus on evidence from sub-Saharan Africa., Methods: We conducted a systematic review of the available published literature from 2012 to 2017 to explore behavioral and cognitive interventions addressing access to ART, retention in HIV care and adherence to ART in sub-Saharan Africa that include older adults (50+). We searched three databases (MEDLINE, EMBASE, and Education Resources Information Center) using relevant Medical Subject Headings (MeSH) terms as well as a manual search of the reference lists. No language restrictions were placed. We identified eight articles which were analyzed using content analysis with additional information obtained directly from the corresponding authors., Results and Discussion: There were no studies that exclusively focused on OPLHIV. Three studies referred only to participants being over 18 years and did not specify age categories. Therefore, it is unclear whether these studies actively considered people living with HIV over the age of 50. Although the studies sampled older adults, they lacked sufficient data to draw conclusions about the relevance of the outcomes of this group., Conclusions: These findings underscore the need to increase the evidence-base of which interventions will work for older Africans on ART.

Background: Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context., Methods: We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps., Results: We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa., Conclusions: Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources.

South Africa has a Universal Test and Treat (UTT) policy in place to ensure that everyone tests for HIV and can access treatment if they test positive. The aim of this study is to document the pathways that older South Africans who are living with HIV take to access testing and treatment in this context. Despite the aging of the HIV epidemic in South Africa and clear evidence that testing older persons (over age 50) is necessary, very little is known about the circumstances under which older persons test for HIV or their motivations for doing so. In this study, we analyze 21 qualitative, in-depth interviews with women and men aged 50 and over who are living with HIV from two townships outside of Cape Town. Using grounded theory to specify emerging themes, we find similarities and differences between older men and women in their pathways to testing. Men primarily test for HIV when their spouse is diagnosed or in connection with TB testing and treatment. Older women, who are more likely to be widowed or divorced, often test for HIV only when they are symptomatic or not responding appropriately to care for non-communicable diseases. Most importantly, we find that older South Africans do not seek testing as a response to risk. Instead, older men and women test only once they are symptomatic and referred by a provider, or as a result of a partner's status. Our respondents, particularly the women, expressed "shock" and confusion at learning they were HIV-positive because they do not see themselves as at risk of acquiring HIV. Because the benefits of UTT are greatest with early detection and treatment, older persons' tendency to test at such a late stage of illness decreases the individual and population level advantages of UTT. More research is needed to understand older persons' risk and testing behavior so that policy and programs include HIV testing messages that reach this population.