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Adverse childhood experiences (ACEs) may have a critical influence on adult outcomes and subsequent offspring development, but few data have explored the effects of ACEs in low-resource settings where the burdens of childhood adversity and HIV are high. Among mothers living with HIV in Cape Town, we examined the effects of ACEs on maternal psychosocial and HIV-related outcomes, as well as early child development in their offspring aged 36–60 months. The World Health Organization's Adverse Childhood Experiences International Questionnaire was used to measure maternal reports of ACEs, and the Ages & Stages Questionnaire to screen for developmental delays in their offspring. Among 353 women (median age: 32 years), 84% reported ≥1 ACEs. Increased report of ACEs was strongly associated with depressive symptoms, hazardous alcohol use, intimate partner violence and self-reported suboptimal adherence to antiretroviral therapy. These associations were driven by more severe childhood experiences, including abuse, neglect and exposure to collective violence. Among 255 women who reported on their child's development, maternal ACEs were associated with poorer socioemotional development. These data suggest that childhood adversity has long-term effects on maternal outcomes as well as their children's socioemotional development and point to ACEs that might be targeted for screening and intervention. [ABSTRACT FROM AUTHOR]

Up to two-thirds of South African adolescent mothers drop out of school, which increases their HIV risk and other poor health outcomes. Despite variability in adolescent mothers' schooling trajectories, we have a limited understanding of their re-enrollment in school following the life-changing circumstance of childbirth. In this paper, we draw on qualitative interviews (n = 16) and quantitative surveys (n = 109) with adolescent mothers (aged 14–19) who had recently given birth to describe how access to individual and social resources contributes to their resilience following childbirth and thus affects their ability to re-enroll in school. Nearly all the adolescent mothers in our study expressed a desire to return to school, and most of their families also emotionally supported adolescent mothers in these goals. Despite mothers' high hopes and familial emotional support, only half of the adolescent mothers re-enrolled in the first six months following childbirth. Adolescent mothers' re-entry trajectories were strongly affected by institutional support and by family members' provision of instrumental support. To a lesser extent, support from partners and peers also played a role in re-enrollment. Multilevel interventions to maximise resilience following the onset of early motherhood may facilitate return to school and positively influence adolescent mothers' health and well-being. [ABSTRACT FROM AUTHOR]

The World Health Organization (WHO) recommends tuberculosis preventive treatment (TPT) in people with HIV (PWH), yet implementation remains poor, especially in rural communities. We examined factors influencing TPT initiation in PWH on antiretroviral therapy (ART) in rural South Africa using the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify contextual factors and facilitation strategies to successfully implement TPT. Patient and clinical factors were extracted from medical records at two primary healthcare clinics (PHCs). Among 455 TPT eligible indivdiuals, only 263 (57.8%) initiated TPT. Patient-level characteristics (older age and symptoms of fever or weight loss) were significantly associated with TPT initiation in bivariate analysis, but PHC was the only independent correlate of TPT initiation (aOR: 2.24; 95% CI: 1.49–3.38). Clinic-level factors are crucial targets for implementing TPT to reduce the burden of HIV-associated TB. Gaps in knowledge of HCW, staff shortages, and non-integrated HIV/TB services were identified barriers to TPT implementation. Evidence-based strategies for facilitating TPT implementation that might be under-prioritized include ongoing reprioritization, expanding training for primary care providers, and quality improvement strategies (organisational changes, multidisciplinary teams, and monitoring and feedback). Addressing contextual barriers through these facilitation strategies may improve future TPT implementation in this setting. [ABSTRACT FROM AUTHOR]

Despite HIV testing having improved globally, men remain disproportionately less likely to test for HIV. While violence against women (VAW) and HIV risk have a strong association among women, few studies explore men around VAW perpetration, risky-sexual behaviour, and HIV testing. Males aged 18–42 years were recruited from a peri-urban settlement near Johannesburg, South Africa. Data were from an endline of a trial. We used logistic regression to assess odds of non-HIV testing using STATA 13. At endline, 1508 men participated in the study. Of these nearly one-third (31.6%, n = 475) had not tested for HIV in the past year. HIV non-testing was significantly lower among men who were single, older, did not complete high school and were less food secure. VAW perpetration retained a significant association with HIV non-testing after controlling for socio-demographics (AOR = 0.73, 95%CI = 0.58–0.93). In multivariate models, HIV non-testing was also associated with inconsistent condom use (AOR = 0.64, 95%CI = 0.48–0.85), problem drinking (AOR = 0.72, 95%CI = 0.55–0.94) and reporting of all four risky sexual behaviours (AOR = 0.70, 95%CI = 0.49–1.01). Data suggests that one-third of men who never test for HIV in this setting may represent a high-risk group. Future campaigns could consider behaviour change around non-violence, relationship quality, and gender norms alongside HIV testing. [ABSTRACT FROM AUTHOR]

Home visiting by community health workers (CHW) improves child outcomes in efficacy trials, there is however limited evidence of impact evaluating CHW programmes when operating outside of a research project. A CHW programme, previously demonstrated efficacious in a peri-urban township, was evaluated in a deeply rural context in a non-randomised comparative cohort study. Two non-contiguous, rural areas in the Eastern Cape of South Africa of about equal size and density were identified and 1469 mother-infant pairs were recruited over 33 months. In one area, CHWs conducted perinatal home visits (intervention group). Mothers in the comparison group received standard clinic care. Maternal and child outcomes were compared between the groups at one year. Mothers in the intervention group had significantly fewer depressive symptoms than mothers in the comparison group. Children of intervention mothers attained a higher proportion of their developmental milestones, compared to children in the comparison group. There were no other significant differences between mothers and children in the two groups. It is important to establish key parameters for implementing efficacious CHW programmes, especially as the numbers of CHWs are rapidly increased and are becoming critical components of task-shifting strategies of health departments in low and middle income countries (LMIC). [ABSTRACT FROM AUTHOR]

South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on 'new' evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation. [ABSTRACT FROM AUTHOR]

Inadequate toilet facilities may increase women's risk of experiencing non-partner sexual violence. We sought to assess the association between young (18–24 year-olds) women's access to toilets and past year non-partner rape experience, in deprived communities in South Africa. Data came from cross-sectional, population-based survey from poor communities from four health districts in two provinces, namely, City of Johannesburg, and Ekurhuleni in Gauteng, and eThekwini and uMgungundlovu, in KwaZulu-Natal. Descriptive, unadjusted and adjusted associations, were estimated in STATA/IC16, accounting for study design. In total, 10,635 young women provided data on toilet access. Past year non-partner rape prevalence was 5.7%. In adjusted analyses, those reporting a shared toilet were more likely to report past year experience of non-partner rape (adjusted odds ratio: 1.45, 95% confidence intervals [1.17, 1.80]), compared to those with their own toilet indoors. Improving access to private, secure toilets is an important component for the prevention of non-partner sexual violence. [ABSTRACT FROM AUTHOR]

The STRiDE project sets out to support the development of effective dementia policy in middle-income countries (Brazil, India, Indonesia, Jamaica, Kenya, Mexico, and South Africa). As part of this it will generate new data about the prevalence of dementia for a subset of these countries. This study aims to identify the current estimates of dementia prevalence in these countries and where the gaps lie in the current literature. A systematic review was completed on 30th April 2019 across electronic databases, identifying dementia prevalence literature originating from any of the seven countries. Four hundred and twenty-nine records were identified following de-duplication; 28 studies met the inclusion criteria and were included in the systematic review. Pooled estimates of dementia prevalence ranged from 2% to 9% based on DSM-IV criteria; these figures were generally higher in studies using other diagnostic criteria (e.g. the 10/66 algorithm). Available prevalence data varied between countries. Only Brazil, Mexico and India had data derived from studies judged as having a low risk of bias. Irrespective of country, studies often were not explicit in detailing the representativeness of their sample, or whether there was non-response bias. Further transparent and externally valid dementia prevalence research is needed across the STRiDE countries. [ABSTRACT FROM AUTHOR]

Alcohol and drug misuse (ADM) pose a significant disease burden globally. Yet, there remains a gap in understanding risk factors associated with women's ADM, particularly those in marginalised settings. We investigated risk factors associated with ADM amongst young women in urban informal settlements in South Africa. Bivariate and multivariable logistic regression analyses were conducted on a sample of 680 young women assessing associations between sociodemographic factors, mental health, relationship factors and past year ADM. Alcohol misuse was assessed using the 10 item Alcohol Use Disorders Identification Test (AUDIT) scale, with scores ≥8 defining misuse, a single item assessed past year illegal drug use. Alcohol and drug misuse were reported by 23.1% and 31.8% of the women respectively. In multivariable regression, alcohol misuse was associated with experiencing past year non-partner sexual violence, transactional sex with a main partner, past year drug use, and past week depressive symptoms, while drug misuse was associated with alcohol misuse, transactional sex with a casual partner, past year experience of physical and/or sexual IPV and having a functional limitation (disability). Results indicate ADM in informal settlements are shaped by violence and poor mental health. Interventions geared towards strengthening women's economic position and mental healthcare are recommended. [ABSTRACT FROM AUTHOR]

Depressive symptoms are common among pregnant women living with HIV, and an unintended pregnancy may heighten vulnerability. HIV-status disclosure is thought to improve psychological well-being, but few quantitative studies have explored the relationships among disclosure, pregnancy intention and depression. Using multivariable linear regression models, we examined the impact of disclosure on depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) during pregnancy and postpartum among women who tested HIV-positive during the pregnancy in South Africa; and explored the role of pregnancy intention in this relationship. Among 350 women (median age: 27 years; 70% reporting that their current pregnancy was unintended), neither disclosure to a male partner nor disclosure to ≥1 family/community member had a consistent effect on depressive symptoms. However, pregnancy intention modified the association between disclosure to a male partner and depression during pregnancy: disclosure was associated with higher depression scores among women who reported that their current pregnancy was unintended but was associated with lower depression scores among women who reported that their pregnancy was intended. During the early postpartum period, disclosure to ≥1 family/community member was associated with higher depression scores. Counselling around disclosure in pregnancy should consider the heightened vulnerability that women face when experiencing an unintended pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of cormorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50.Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents.Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p = .03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8;p < .001) and respondents from rural settings (OR 2.9;p < .01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care.Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services – which can inform South Africa’s development of a national health insurance scheme. [ABSTRACT FROM AUTHOR]

South Africa faces the challenge of supporting the well-being of adults caring for growing numbers of AIDS-orphaned children. These adults play a critical role in responses to the epidemic, but little information exists in regard to their mental health needs. This paper reports on findings from n=1599 adults, recruited through representative household sampling, who serve as primary carers for children in Umlazi Township, an HIV-endemic community. Overall, 22% of participants were carers of AIDS-orphaned children, 11% were carers of other-orphaned children and 67% were carers of non-orphaned children. Prevalence of depression was 30.3%. Orphan carers, regardless of whether they cared for AIDS-orphaned or other-orphaned children, were significantly more likely than carers of non-orphaned children to meet the clinical threshold for depression (35.2% vs. 27.9%, p < 0.01). In multivariate logistic regressions, food insecurity and being a female carer were identified as additional risk factors for greater depression. In contrast, households with access to running water and households dependent on salaries as the main source of income were identified as protective factors for disparities in depression. Mental health interventions are urgently needed to address an increased risk for depression among all orphan carers, not just those caring for AIDS-orphaned children. [ABSTRACT FROM AUTHOR]

Public health and social-historical changes have had multiple effects on South African children and families. This study examines the association between challenging family dynamics, such as child orphan status, and educational delay, as defined by being below proper grade-for-age. Analysing the 2003/2004 South Africa Demographic and Health Surveys (DHS) dataset, we estimate orphan prevalence, maternal and paternal household presence, other household characteristics, and schooling variables in a nationally representative household sample. Among 5592 children ages 8–14 in South Africa, 21% had experienced parental death, 33% did not have their mother present in the household, and 63% of the children were not living with their father. Twenty per cent were behind proper grade-for-age. A bivariate analysis shows that orphaned children experienced 35% greater odds of being behind in school (p<0.001). After adjusting for parental presence, household characteristics, and socio-demographic factors, orphan status does not remain significantly associated with being behind in school. However, maternal presence, relationship to the household head, number of children in a household, and socio-demographic characteristics each independently affect a child's likelihood of educational delay. Findings offer a more nuanced understanding of household dynamics that may protect against or exacerbate educational delays among vulnerable youth. [ABSTRACT FROM PUBLISHER]

Globally, the poor are consistently at greater risk of suffering from depression and anxiety. Yet in resource-poor countries, mental health remains a neglected topic. This interdisciplinary study explored the potential for a poverty alleviation programme to contribute to breaking the vicious cycle between poverty and common mental disorders (CMD). Quantitatively, beneficiaries of a cash-transfer programme were found to have a lower risk of CMD. Qualitative interviews indicated that Child Support Grants acted as a psychological safety net, but that negative stereotypes of grant recipients could detract from the positive mental health outcomes of the grants. It was concluded that poverty alleviation programmes such as cash transfers could have both positive and negative impacts on mental health. In order to achieve mental health benefits for programme beneficiaries, aspects of programme design and implementation that promote mental health should be enhanced and aspects detrimental to mental health modified. [ABSTRACT FROM AUTHOR]