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This study investigated whether young women's participation in a combination HIV-prevention intervention was associated with accessing and using condoms and other contraceptives.A cross-sectional household survey was conducted from 2017 to 2018 among a representative sample of young women aged 15-24 years old living in six South African districts in which the intervention was implemented. Cross-tabulations and multivariate regression analyses of weighted data were performed to examine access to and use of condoms and other contraceptives.In total 4399 young women participated, representing a 60.6% response rate. Of participants, 61.0% (n = 2685) reported accessing condoms and other contraceptives in the past year. Among those who ever had sex (n = 3009), 51.0% used condoms and 37.4% other contraceptives at last sex. Among 15-19 year old, participation in the combination intervention was positively associated with reporting contraceptive use other than condoms at last sex (Prevalence Ratio (PR): 1.36; 95% CI: 1.21-1.53) and reporting use of both condoms and other contraceptives at last sex (PR: 1.45; 95% CI: 1.26-1.68). No associations were observed in the age group 20-24.Our findings suggest that combination HIV prevention interventions may lead to increased access and use of condoms and other methods of contraception among adolescent women, but this needs to be confirmed in experimental studies. We need to test different or more intensive interventions to increase contraceptive use in young women aged 20-24.Participating in combination HIV prevention interventions that are delivered via multiple approaches may promote access to, and use of condoms and other methods of contraceptives among adolescent women, and thereby help reduce unintended pregnancies.

Background. Barriers to monitoring maternal HIV viral load (VL) and achieving 90% viral suppression during pregnancy and breastfeeding still need to be understood in South Africa (SA). Objectives. To measure quality of VL care and turnaround times (TATs) for returning VL results to women enrolled in the prevention of mother-to-child transmission of HIV (PMTCT) programme in primary healthcare facilities. Methods. Data were obtained from a 2018 cross-sectional evaluation of the PMTCT Option B+ programme in six SA districts with high antenatal and infant HIV prevalence. Quality of VL care was measured as the proportion of clients reporting that results were explained to them. TATs for VL results were calculated using dates abstracted from four to five randomly selected facility-based client records to report overall facility ‘short TAT’ (≥80% of records with TAT ≤7 days). Logistical regression and logit-based risk difference statistics were used. Results. Achieving overall short TAT was uncommon. Only 50% of facilities in one rural district, zero in one urban metro district and 9 - 38% in other districts had short TAT. The significant difference between districts was influenced by the duration of keeping results in facilities after receipt from the laboratory. Expected quality of VL care received ranged between 66% and 85%. Client-related factors significantly associated with low quality of care, observed in two urban districts and one rural district, included lower education, recent initiation of antiretroviral treatment and experiencing barriers to clinic visits. Experiencing clinic visit barriers was also negatively associated with short TATs. Conclusions. We demonstrate above-average quality of care and delayed return of results to PMTCT clients. Context-specific interventions are needed to shorten TATs.

Background We aimed to develop and validate a tool to identify which pregnant/lactating young South African women (≤ 24 years) are at risk of HIV infection. Methods Data from three national South African Prevention of Mother-to-Child Transmission (PMTCT) evaluations were used to internally validate three HIV acquisition risk models for young postpartum women. We used univariate and multivariable logistic regression analysis to determine which risk factors were significant. Model coefficients were rounded and stratified into risk groups and the area under the receiver operating curve (AUROC) was computed. Models were developed to determine which risk factors provided the most predictive accuracy whilst remining clinically meaningful. Results Data from 9 456 adult and 4 658 young pregnant and lactating women were included in the development and validation data sets, respectively. The optimal model included the following risk factors: age (20–24 years old), informal house structure, two or more pregnancies, mothers who had knowledge of when they received their last HIV test result, no knowledge of the infant’s father’s HIV status, no knowledge of breastfeeding as a mode of MTCT and knowledge of PMTCT programme. The mean AUROC was 0.71 and 0.72 in the development and validation datasets respectively. The optimum cut off score was ≥ 27, having 84% sensitivity, 44% specificity, and identifying 44% of high-risk women eligible for PrEP. Conclusion The optimal model to be used as a possible risk scoring tool to allow for early identification of those pregnant/lactating women most at-risk of HIV acquisition included both statistically as well as clinically meaningful risk factors. A field-based study is needed to test and validate the effectiveness of this targeted approach.

The rate of mother-to-child transmission (MTCT) of HIV from breastfeeding is increasing relative to other causes of MTCT. Early effective preconception and antenatal antiretroviral therapy (ART) reduces intrauterine and intrapartum MTCT, whereas maternal post-partum HIV acquisition, untreated maternal HIV, and suboptimal postnatal maternal ART adherence increase the risk of MTCT through breastfeeding. Although the absolute number of cases of MTCT acquired through breastfeeding is decreasing, the rate of decrease is less than the decrease in intrauterine and intrapartum MTCT. Unless current strategies are universally applied, they might not be sufficient to eliminate MTCT due to breastfeeding. Urgent action is needed to evaluate and implement additional preventive biomedical strategies in high HIV prevalence and incidence settings to eliminate MTCT from breastfeeding. Preventive strategies include: pre-exposure prophylaxis in breastfeeding women who have an increased risk of acquiring HIV; postnatal reinforcement strategies, such as maternal retesting for HIV, maternal care reinforcement, and prophylaxis in infants exposed to HIV via breastmilk; and active (vaccine) or passive immunoprophylaxis with long-acting broadly neutralising antibodies. acceptedVersion

International audience; Ameena Goga and colleagues argue that frequent testing of maternal viral load is needed to eliminate HIV transmission through breast milk in low and middle income settings

Objectives: This paper examines factors associated with happiness and to estimate happy life expectancy for older people in South Africa. Methods: The study uses data from the first wave of the Study on Ageing and Adult Health (SAGE) survey, which is a nationally representative population-based survey with a sample of 3,840 individuals aged 50 years and above. The Sullivan method and multivariate linear regression analysis were used in the analysis. Results: The prevalence of happiness was the same for men (55.5%) and women (55.4%) at the youngest of the age groups (50–59). However, this prevalence was higher in men than women across older ages. Women demonstrated longer life expectancy and happy life expectancy, but also unhappy life expectancy, compared to men, across all the ages. However, men had greater proportions of happy life expectancies compared to women. In multivariate analysis, wealth status, health, activity limitation, race and age were significantly associated with happiness among men and women. Conclusions: Gender disparities in happiness are demonstrated in this study. It is important to understand the factors that promote happiness in older people as this may point to areas that need intervention for improving overall quality of life

BackgroundWe analysed the impact of breastfeeding, antiretroviral drugs and health service factors on cumulative (6 weeks to 18 months) vertical transmission of HIV (MTCT) and ‘MTCT-or-death’, in South Africa, and compared estimates with global impact criteria to validate MTCT elimination: (1) Methods9120 infants aged 6 weeks were enrolled in a nationally representative survey. Of 2811 HIV-exposed uninfected infants (HEU), 2644 enrolled into follow-up (at 3, 6, 9, 12, 15 and 18 months). Using Kaplan-Meier analysis and weighted survey domain-based Cox proportional hazards models, we estimated cumulative risk of MTCT and ‘MTCT or death’ and risk factors for time-to-event outcomes, adjusting for study design and loss-to-follow-up.ResultsCumulative (final) MTCT was 4.3% (95% CI 3.7% to 5.0%); case rate was 1290. Postnatal MTCT (>6 weeks to 18 months) was 1.7% (95% CI 1.2% to 2.4%). Cumulative ‘MTCT-or-death’ was 6.3% (95% CI 5.5% to 7.3%); 81% and 62% of cumulative MTCT and ‘MTCT-or-death’, respectively, occurred by 6 months. Postnatal MTCT increased with unknown maternal CD4-cell-count (adjusted HR (aHR 2.66 (1.5–5.6)), undocumented maternal HIV status (aHR 2.21 (1.0–4.7)) and exclusive (aHR 2.3 (1.0–5.2)) or mixed (aHR 3.7 (1.2–11.4)) breastfeeding. Cumulative ‘MTCT-or death’ increased in households with ‘no refrigerator’ (aHR 1.7 (1.1–2.9)) and decreased if infants used nevirapine at 6 weeks (aHR 0.4 (0.2–0.9)).ConclusionsWhile the

BackgroundIn June 2015, South Africa introduced early infant HIV diagnosis (EID) at birth and ten weeks postpartum. Guidelines recommended return of birth results within a week and ten weeks postpartum results within four weeks. Task shifting was also suggested to increase service coverage. This study aimed to understand factors affecting return of EID results to caregivers.MethodsSecondary analysis of data gathered from 571 public-sector primary health care facilities (PHCs) during a nationally representative situational assessment, was conducted. The assessment was performed one to three months prior to facility involvement in the 2010 evaluation of the South African programme to prevent mother-to-child HIV transmission (SAPMTCTE). Self-reported infrastructural and human resource EID-related data were collected from managers and designated staff using a structured questionnaire. The main outcome variable was ‘EID turn-around-time (TAT) to caregiver’ (caregiver TAT), measured as reported number of weeks from infant blood draw to caregiver receipt of results. This was dichotomized as either short (≤3 weeks) or delayed (> 3 weeks) caregiver TAT. Logit-based risk difference analysis was used to assess factors associated with short caregiver TAT. Analysis included TAT to facility (facility TAT), defined as reported number of weeks from infant blood draw to facility receipt of results.ResultsOverall, 26.3% of the 571 PHCs reported short caregiver TAT. In adjusted analyses, short caregiver TAT was less achieved when facility TAT was > 7 days (versus ≤7 days) (adjusted risk difference (aRD): − 0.2 (95% confidence interval − 0.3-(− 0.1)),p = 0.006 for 8–14 days and − 0.3 (− 0.5-(− 0.1)), p = 0.006 for > 14 days), and in facilities with staff nurses (compared to those without) (aRD: − 9.4 (− 16.6-(− 2.2),p = 0.011).ConclusionAlthough short caregiver TAT for EID was only reported in approximately 26% of facilities, these facilities demonstrate that achieving EID TAT of ≤3 weeks is possible, making timely ART initiation within 3 weeks of diagnosis feasible within the public health sector. Our adjusted analyses underpin the need for quick return of results to facilities. They also raise questions around staff mentoring: we hypothesise that facilities with staff nurses were likely to have fewer professional nurses, and thus inadequate senior support.

Background Despite improved policies to prevent mother-to-child HIV transmission (MTCT), adherence to maternal antiretroviral therapy (ART) and infant Nevirapine prophylaxis (NVP) is low in South Africa. We describe ART adherence amongst a cohort of HIV-positive mothers and HIV-exposed but uninfected infants from 6 weeks until 18 months post-delivery and identify risk factors for nonadherence. Methods Data were collected in 2012–2014 through a nationally representative survey of PMTCT effectiveness. Mother-infant pairs were enrolled during the infant’s first immunization visit at 6 weeks. Mothers and HIV-exposed infants (2811 pairs) were followed to 18 months at 3-month intervals. Mothers who self-reported being on ART at 6 weeks postpartum (N = 1572 (55.9%)) and infants on NVP at 6 weeks (N = 2370 (84.3%)) were eligible for this analysis and information about their adherence was captured at each interview they attended thereafter. We defined nonadherence within each 3-month interval as self-report of missing > 5% of daily ART/NVP doses, estimated adherence using a Cox survival curve with Andersen & Gill setup for recurring events, and identified risk factors for nonadherence with an extended Cox regression model (separately for mothers and infants) in Stata 13. Results are not nationally representative as this is a subgroup analysis of the follow-up cohort. Results Amongst mothers on ART at 6 weeks postpartum, cumulative adherence to maternal ART until 18 months was 63.4%. Among infants on NPV at 6 weeks postpartum, adherence to NVP was 74.5%.. Risk factors for nonadherence to maternal ART, controlling for other factors, included mother’s age (16–24 years vs. ≥34 years, adjusted Hazard Ratio (aHR): 1.9, 95% CI: 1.4–2.5), nondisclosure of HIV status to anyone (nondisclosure vs. disclosure: aHR: 1.7, 95% CI: 1.3–2.1), and timing of ART initiation (initiated ART after delivery vs. initiated ART before delivery: aHR: 1.6, 95% CI: 1.3–2.0). Provincial variation was seen in nonadherence to infant NVP, controlling for other factors. Conclusion Maintaining ART adherence until 18 months postpartum remains a crucial challenge, with maternal ART adherence among the six week maternal ART cohort below 65% and infant NVP adherence among breastfeeding infants in this cohort below 75%.This is gravely concerning, given the global policy shift to lifelong ART amongst pregnant and lactating women, and the need for extended infant prophylaxis amongst mothers who are not virally suppressed. Our findings suggest that young mothers and mothers who do not disclose their status should be targeted with messages to improve adherence, and that late maternal ART initiation (after delivery) increases the risk of maternal nonadherence.

Background The 2016 ‘Start Free, Stay Free, AIDS Free’ global agenda, builds on the 2011-2015 ‘Global Plan’. It prioritises 22 countries where 90% of the world’s HIV-positive pregnant women live and aims to eliminate vertical transmission of HIV (EMTCT) and to keep mothers alive. By 2019, no Global Plan priority country had achieved EMTCT; however, 11 non-priority countries had. This paper synthesises the characteristics of the first four countries validated for EMTCT, and of the 21 Global Plan priority countries located in Sub-Saharan Africa (SSA). We consider what drives vertical transmission of HIV (MTCT) in the 21 SSA Global Plan priority countries. Methods A literature review, using PubMed, Science direct and the google search engine was conducted to obtain global and national-level information on current HIV-related context and health system characteristics of the first four EMTCT-validated countries and the 21 SSA Global Plan priority countries. Data representing only one clinic, hospital or region were excluded. Additionally, key global experts working on EMTCT were contacted to obtain clarification on published data. We applied three theories (the World Health Organisation’s building blocks to strengthen health systems, van Olmen’s Health System Dynamics framework and Baral’s socio-ecological model for HIV risk) to understand and explain the differences between EMTCT-validated and non-validated countries. Additionally, structural equation modelling (SEM) and linear regression were used to explain associations between infant HIV exposure, access to antiretroviral therapy and two outcomes: (i) percent MTCT and (iii) number of new paediatric HIV infections per 100 000 live births (paediatric HIV case rate). Results EMTCT-validated countries have lower HIV prevalence, less breastfeeding, fewer challenges around leadership, governance within the health sector or country, infrastructure and service delivery compared with Global Plan priority countries. Although by 2016 EMTCT-validated countries and Global Plan priority countries had adopted a public health approach to HIV prevention, recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and lactating women, EMCT-validated countries had also included contact tracing such as assisted partner notification, and had integrated maternal and child health (MCH) and sexual and reproductive health (SRH) services, with services for HIV infection, sexually transmitted infections, and viral hepatitis. Additionally, Global Plan priority countries have limited data on key SRH indicators such as unmet need for family planning, with variable coverage of antenatal care, HIV testing and triple antiretroviral therapy (ART) and very limited contact tracing. Structural equation modelling (SEM) and linear regression analysis demonstrated that ART access protects against percent MTCT (pppp=0.074). Conclusion Reducing infant HIV exposure, is critical to reducing the paediatric HIV case rate; increasing ART access is critical to reduce percent MTCT. Additionally, our study of four validated countries underscores the importance of contact tracing, strengthening programme monitoring, leadership and governance, as these are potentially-modifiable factors.

Ameena Goga and colleagues argue that more realistic targets are needed to maintain momentum on reducing vertical transmission in countries with a high HIV prevalence

Ameena Goga and colleagues describe how five countries in sub-Saharan Africa are monitoring the effectiveness of national programmes to prevent vertical transmission of HIV

Number of facilities using each transportation system within each province, in 2010. (DOCX 37 kb)

Background Continuity of care is important for child well-being in all settings where postnatal retention of mother-infant pairs in care remains a challenge. This analysis reports on completeness of patient-held infant Road to Health Booklets (RtHBs), amongst HIV exposed and unexposed infants during the first two years after the RtHB was launched country-wide in South Africa. Methods Secondary data were analysed from two nationally representative, cross-sectional surveys, conducted in 2011-12 and 2012-13. These surveys aimed to measure early effectiveness of the national programme for preventing vertical HIV transmission. Participants were eligible for this analysis if they were 4-8 weeks old, receiving their six-week immunisation, not needing emergency care and had their RtHBs reviewed. Caregivers were interviewed and data abstracted from RtHBs. RtHB completeness across both surveys was defined as the proportion of RtHBs with any of the following indicators recorded: infant birth weight, BCG immunisation, maternal syphilis results and maternal HIV status. A partial proportional odds logistic regression model was used to identify factors associated with completeness. Survey sampling weights were included in all analyses. Results Data from 10 415 (99.6%) participants in 2011-12 and 9529 (99.2%) in 2012-13 were analysed. Overall, recording of all four indicators increased from 23.1% (95% confidence interval (CI) = 22.2-24.0) in 2011-12 to 43.3% (95% CI = 42.3-44.4) in 2012-13. In multivariable models, expected RtHB completeness (ie, recording all four indicators vs recording of

Background Achieving World Health Organization (WHO) recommendations for postnatal care (PNC) within the first few weeks of life is vital to eliminating early mother–to–child transmission of HIV (MTCT) and improving infant health. Almost half of the annual global deaths among children under five occur during the first six weeks of life. This study aims to identify uptake of three PNC visits within the first six weeks of life as recommended by WHO among South African mother–infant pairs, and factors associated with uptake. Methods We analyzed data from three facility–based, nationally representative surveys (2010, 2011/12 and 2012/13) primarily designed to determine the effectiveness of the South African program to prevent MTCT. This analysis describes the proportion of infants achieving the WHO recommendation of at least 3 PNC visits. Interviews from 27 699 HIV–negative and HIV–positive mothers of infants aged 4–8 weeks receiving their six week immunization were included in analysis. Data were analyzed using STATA 13.0 and weighted for sample ascertainment and South African live births. We fitted a multivariable logistic regression model to estimate factors associated with early PNC uptake. Results Over half (59.6%, 95% confidence interval (CI) = 59.0–60.3) of mother–infant pairs received the recommended three PNC visits during the first 6 weeks; uptake was 63.1% (95% CI = 61.9–64.3) amongst HIV exposed infants and 58.1% (95% CI = 57.3–58.9) amongst HIV unexposed infants. Uptake of early PNC improved significantly with each survey, but varied significantly by province. Multivariable analysis of the pooled data, controlling for survey year, demonstrated that number of antenatal visits (4+ vs 12 weeks, aOR = 1.13, 95% CI = 1.04–1.23), place of delivery (clinic vs hospital aOR = 1.5, 1.3–1.6), and infant HIV exposure (exposed vs unexposed aOR = 1.2, 95% CI = 1.1–1.2) were the key factors associated with receiving recommended PNC visits. Conclusions Approximately 40% of neonates did not receive three or more postnatal care visits in the first 6 weeks of life from 2010–2013. To improve uptake of early PNC, early antenatal booking, more frequent antenatal care attendance, and attention to HIV negative women is needed.

Data characterizing older people’s life expectancy by good or poor health isimportant for policy and fiscal planning. This study aims to examine trends and investigategender differences in healthy life expectancy (HLE) for older people in South Africa for theperiod 2005–2012. Using data from three repeated cross-sectional surveys conducted in 2005,2008, and 2012, we applied a self-rated health measure to estimating HLE. The Sullivanmethod was used in the calculations. We found that unhealthy life expectancy decreased overthe period, while HLE and the proportion of life spent in good health increased more thantotal life expectancy in the same period. Gender disparities were evident: Women had higherlife expectancy than men, yet they spent a greater proportion of their lifetime in poor health.We concluded that HLE of older people in South Africa has improved over the period underinvestigation.

Background: Population ageing has become significant in South African society, increasing the need to improve understandings of health and well-being among the aged. Objective: To describe the self-reported ratings of overall health and functioning, and to identify factors associated with self-rated health among older South Africans. Design: A national population-based cross-sectional survey, with a sample of 3,840 individuals aged 50 years and older, was completed in South Africa in 2008. Self-reported ratings of overall health and functioning were measured using a single self-reported health state covering nine health domains (used to generate the Study on Global Ageing and Adult Health (SAGE) composite health state score). Disability was measured using the World Health Organization Disability Assessment Schedule II (WHODAS-II) activities of daily living (ADLs), instrumental activities of daily living (IADLs), perceptions of well-being, and the World Health Organization Quality of Life index/metric (WHOQoL). Results: Overall, more than three quarters (76.8%) of adults rated their health as moderate or good. On balance, men reported very good or good health more often than women ( p

Background. Ninety percent of the world’s HIV-positive pregnant women live in 22 countries. These 22 countries, including South Africa (SA) have prioritised the elimination of mother-to-child transmission of HIV (EMTCT). Since 2016 all 22 countries recommend lifelong antiretroviral treatment for all HIV-positive pregnant and lactating women. To measure South African national, provincial and district-level progress towards attaining EMTCT, we analysed the number of in utero (IU) paedatric HIV infections per 100 000 live births (IU case rate), and synthesised factors hindering the monitoring of EMTCT progress and attainment from the viewpoint of provincial and district-level healthcare managers and implementers. We highlight potential innovations to strengthen health systems and improve EMTCT programme delivery. Methods. We reviewed national-, provincial- and district-level birth HIV testing data from routine National Health Laboratory Services (NHLS) records between April 2016 and March 2017. To obtain a qualitative perspective from healthcare managers and implementers, we synthesised information from the nine 2016 provincial-level EMTCT stock-taking workshops. These workshops involve key provincial and district-level staff, mentors and supporting partners. Lastly, we highlight potential innovations presented at these workshops to overcome operational challenges. Results. The national IU mother-to-child transmission (MTCT) rate was 0.9%, which translated to an IU case rate of 245 HIV-positive neonates per 100 000 live births. Provincial IU percent MTCT risk ranged from 0.6% to 1.3%, with IU case rates ranging between 168 and 325 cases per 100 000 live births. District-level IU percent MTCT risk ranged from 0.4% to 1.9%. Potential game changers include: pre-conception counselling to optimise maternal-partner health, weekly dissemination of HIV polymerase chain reaction (PCR) and viral load reports from the NHLS to specific individuals who trace mothers and infants needing care, use of ward-based outreach teams and community caregivers to trace HIV-infected mothers and their infants to link them into care, inclusion of a unique identifier in patient-held infant Road to Health booklets to facilitate infant tracing and continuous quality improvement (CQI) processes within facilities and districts and implementation of an HIV-positive baby tool to understand the characteristics and risks of HIV-positive infants. On an ecological level, provinces and districts using community-based approaches and CQI methodology seemed to have lower MTCT and IU case rates. Conclusions. More quantitative analyses are needed to understand what proportion of the success can be attributed to community-based and CQI approaches and the impact of the potential game changers on progress towards EMTCT.