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Abstract Background Implementation science frameworks situate intervention implementation and sustainment within the context of the implementing organization and system. Aspects of organizational context such as leadership have been defined and measured largely within US health care settings characterized by decentralization and individual autonomy. The relevance of these constructs in other settings may be limited by differences like collectivist orientation, resource constraints, and hierarchical power structures. We aimed to adapt measures of organizational context in South African primary care clinics. Methods We convened a panel of South African experts in social science and HIV care delivery and presented implementation domains informed by existing frameworks and prior work in South Africa. Based on panel input, we selected contextual domains and adapted candidate items. We conducted cognitive interviews with 25 providers in KwaZulu-Natal Province to refine measures. We then conducted a cross-sectional survey of 16 clinics with 5–20 providers per clinic (N = 186). We assessed reliability using Cronbach’s alpha and calculated interrater agreement (awg) and intraclass correlation coefficient (ICC) at the clinic level. Within clinics with moderate agreement, we calculated correlation of clinic-level measures with each other and with hypothesized predictors – staff continuity and infrastructure – and a clinical outcome, patient retention on antiretroviral therapy. Results Panelists emphasized contextual factors; we therefore focused on elements of clinic leadership, stress, cohesion, and collective problem solving (critical consciousness). Cognitive interviews confirmed salience of the domains and improved item clarity. After excluding items related to leaders’ coordination abilities due to missingness and low agreement, all other scales demonstrated individual-level reliability and at least moderate interrater agreement in most facilities. ICC was low for most leadership measures and moderate for others. Measures tended to correlate within facility, and higher stress was significantly correlated with lower staff continuity. Organizational context was generally more positively rated in facilities that showed consistent agreement. Conclusions As theorized, organizational context is important in understanding program implementation within the South African health system. Most adapted measures show good reliability at individual and clinic levels. Additional revision of existing frameworks to suit this context and further testing in high and low performing clinics is warranted.

Abstract Psychological interventions delivered by non-specialist providers have shown mixed results for treating maternal depression. mHealth solutions hold the possibility for unobtrusive behavioural data collection to identify challenges and reinforce change in psychological interventions. We conducted a proof-of-concept study using passive sensing integrated into a depression intervention delivered by non-specialists to twenty-four adolescents and young mothers (30% 15–17 years old; 70% 18–25 years old) with infants (

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.

Abstract Background Pre-exposure Prophylaxis (PrEP) and Treatment as Prevention (TasP) are effective strategies to prevent HIV transmission within serodifferent couples. However, limited usage of PrEP, knowledge and interest has been amongst the barriers for men, alongside testing and treatment adherence. We explored the perceptions of PreP for HIV prevention with Men living with HIV (MWH) who have reproductive goals, to understand awareness and experiences related to PrEP use in the context of HIV prevention with their partners. Methods We undertook a qualitative study with 25 MWH aged 18 to 65 between April and September 2021 in South Africa. Potential participants were screened for eligibility and scheduled to participate in telephonic interviews. Interviews were audio recorded, transcribed, translated and thematically analysed. Results Themes were organized into opportunities and barriers that men with HIV articulate as important for using PrEP to meet individual, couple, and community reproductive goals. At the individual level, some men were willing to discuss PrEP with their partners to protect their partners and babies from acquiring HIV. Lack of knowledge about PrEP among men was a potential barrier to promoting PrEP among their female partners. At the couple level, PrEP use was seen as a way to strengthen relationships between partners, signifying care, trust, and protection and was seen as a tool to help serodifferent couples meet their reproductive goals safely. At the community level, PrEP was viewed as a tool to promote HIV testing and prevention efforts, especially among men, but participants emphasized the need for more education and awareness. Conclusion Despite PrEP implementation in South Africa, awareness of PrEP among men with HIV in rural areas remains low. Engaging MWH to support their partners in accessing PrEP could be an innovative strategy to promote HIV prevention. Additionally, providing men with comprehensive reproductive health information can empower them to make more informed decisions, adopt safer sexual practices, and challenge societal norms and stigmas around HIV.

Background: Postpartum depression (PPD) is a common experience among mothers worldwide. Family members, especially husbands, can play an integral role in supporting and helping mothers recover from PPD. However, husbands are typically not included in interventions to address postpartum depression among women. This study explored husbands’ perspectives on engaging in a counseling intervention augmented with a digital health component for the treatment of PPD. Methods: A convergent mixed methods design was used to evaluate husbands’ attitudes and involvement in a counseling and digital intervention for mothers in a semi-urban region of Nepal.Thematic analysis of semi-structured interviews was used to derive emergent themes. A joint display examined differences in themes for husbands whose wives experienced a significant decline in PPD symptoms as measured by the Patient Health Questionnaire-9 pre and post intervention, as compared to husbands of women whose symptoms stayed the same or worsened. Results: Thirteen husbands were interviewed. Three primary themes emerged: the impact of gender norms and attitudes on engagement in the intervention, involvement and support in the intervention, and suggestions for future interventions for PPD. Among wives who experienced a reduction in depression symptoms, their husbands were more likely to endorse gender-equitable norms and attitudes and the husbands provided emotional support, as well as participating in household chores and childcare. Conclusion: When husbands are living in the same household, providing support and being involved in their wives’ PPD treatment can help them recover. Husbands describe time at home and work as barriers to being able to help their wives. PPD interventions that involve husbands might need to educate husbands about how they can provide emotional support to their partner.

Abstract Introduction Significant progress has been made in the HIV response in South Africa; however, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. The National Department of Health (NDoH) has introduced community-based and clinic-based HIV differentiated service delivery (DSD) models to tackle suboptimal adherence and retention in care. Nevertheless, differentiated care models require adaptation to better serve clients who struggle with adherence. There is limited research on the acceptability of fee for home delivery of ART in resource-constrained settings. The current study investigates the acceptability of fee for home delivery of ART among people living with HIV in South Africa. Methods Two mixed-gender focus group discussions (FGDs) took place between June and November 2019, consisting of 10 participants in each group. A purposive sampling strategy was employed to identify and select 10 people living with HIV who were ART-eligible but not in care, and 10 people living with HIV who were currently taking ART and in care. Participants were grouped according to their treatment status. A coding framework, informed by a priori categories and derived from topics in the interview guide, was developed and utilized to facilitate analysis. Results Participants expressed enthusiasm for having ART home-delivered, as it would save the time spent waiting in long queues at the clinic. However, some participants raised concerns about potential payment difficulties due to high unemployment rates in the community. Some participants believed this would be acceptable, as patients already incur costs for travel and food when visiting the clinic. Participants in both FGDs expressed strong concerns about home delivery of their ART based on fear of accidental disclosure, especially for those who have not disclosed to their immediate families and partners. Conclusion Our study suggests that charging a fee for home delivery is an acceptable and innovative approach to supporting PLHIV in maintaining adherence to their medication and remaining in care.

Abstract Artificial intelligence (AI) systems for detection of COVID-19 using chest X-Ray (CXR) imaging and point-of-care blood tests were applied to data from four low resource African settings. The performance of these systems to detect COVID-19 using various input data was analysed and compared with antigen-based rapid diagnostic tests. Participants were tested using the gold standard of RT-PCR test (nasopharyngeal swab) to determine whether they were infected with SARS-CoV-2. A total of 3737 (260 RT-PCR positive) participants were included. In our cohort, AI for CXR images was a poor predictor of COVID-19 (AUC = 0.60), since the majority of positive cases had mild symptoms and no visible pneumonia in the lungs. AI systems using differential white blood cell counts (WBC), or a combination of WBC and C-Reactive Protein (CRP) both achieved an AUC of 0.74 with a suggested optimal cut-off point at 83% sensitivity and 63% specificity. The antigen-RDT tests in this trial obtained 65% sensitivity at 98% specificity. This study is the first to validate AI tools for COVID-19 detection in an African setting. It demonstrates that screening for COVID-19 using AI with point-of-care blood tests is feasible and can operate at a higher sensitivity level than antigen testing.

Abstract Background Chest X-ray offers high sensitivity and acceptable specificity as a tuberculosis screening tool, but in areas with a high burden of tuberculosis, there is often a lack of radiological expertise to interpret chest X-ray. Computer-aided detection systems based on artificial intelligence are therefore increasingly used to screen for tuberculosis-related abnormalities on digital chest radiographies. The CAD4TB software has previously been shown to demonstrate high sensitivity for chest X-ray tuberculosis-related abnormalities, but it is not yet calibrated for the detection of non-tuberculosis abnormalities. When screening for tuberculosis, users of computer-aided detection need to be aware that other chest pathologies are likely to be as prevalent as, or more prevalent than, active tuberculosis. However, non­-tuberculosis chest X-ray abnormalities detected during chest X-ray screening for tuberculosis remain poorly characterized in the sub-Saharan African setting, with only minimal literature. Case presentation In this case series, we report on four cases with non-tuberculosis abnormalities detected on CXR in TB TRIAGE + ACCURACY (ClinicalTrials.gov Identifier: NCT04666311), a study in adult presumptive tuberculosis cases at health facilities in Lesotho and South Africa to determine the diagnostic accuracy of two potential tuberculosis triage tests: computer-aided detection (CAD4TB v7, Delft, the Netherlands) and C-reactive protein (Alere Afinion, USA). The four Black African participants presented with the following chest X-ray abnormalities: a 59-year-old woman with pulmonary arteriovenous malformation, a 28-year-old man with pneumothorax, a 20-year-old man with massive bronchiectasis, and a 47-year-old woman with aspergilloma. Conclusions Solely using chest X-ray computer-aided detection systems based on artificial intelligence as a tuberculosis screening strategy in sub-Saharan Africa comes with benefits, but also risks. Due to the limitation of CAD4TB for non-tuberculosis-abnormality identification, the computer-aided detection software may miss significant chest X-ray abnormalities that require treatment, as exemplified in our four cases. Increased data collection, characterization of non-tuberculosis anomalies and research on the implications of these diseases for individuals and health systems in sub-Saharan Africa is needed to help improve existing artificial intelligence software programs and their use in countries with high tuberculosis burden.

Objectives Use of computer-aided detection (CAD) software is recommended to improve tuberculosis screening and triage, but threshold determination is challenging if reference testing has not been performed in all individuals. We aimed to determine such thresholds through secondary analysis of the 2019 Lesotho national tuberculosis prevalence survey. Methods Symptom screening and chest radiographs were performed in participants aged ≥15 years; those symptomatic or with abnormal chest radiographs provided samples for Xpert MTB/RIF and culture testing. Chest radiographs were processed using CAD4TB version 7. We used six methodological approaches to deal with participants who did not have bacteriological test results to estimate pulmonary tuberculosis prevalence and assess diagnostic accuracy. Results Among 17 070 participants, 5214 (31%) had their tuberculosis status determined; 142 had tuberculosis. Prevalence estimates varied between methodological approaches (0.83–2.72%). Using multiple imputation to estimate tuberculosis status for those eligible but not tested, and assuming those not eligible for testing were negative, a CAD4TBv7 threshold of 13 had a sensitivity of 89.7% (95% CI 84.6–94.8) and a specificity of 74.2% (73.6–74.9), close to World Health Organization (WHO) target product profile criteria. Assuming all those not tested were negative produced similar results. Conclusions This is the first study to evaluate CAD4TB in a community screening context employing a range of approaches to account for unknown tuberculosis status. The assumption that those not tested are negative – regardless of testing eligibility status – was robust. As threshold determination must be context specific, our analytically straightforward approach should be adopted to leverage prevalence surveys for CAD threshold determination in other settings with a comparable proportion of eligible but not tested participants.

Introduction Heavy alcohol use among people living with HIV in sub-Saharan Africa can hinder the success of HIV treatment programmes, impacting progress towards United Nations Programme on HIV/AIDS goals. Primary partners can provide critical forms of social support to reduce heavy drinking and could be included in motivational interviewing (MI) interventions to address heavy drinking; however, few studies have evaluated MI interventions for couples living with HIV in sub-Saharan Africa. We aim to evaluate the feasibility and acceptability of a couple-based MI intervention with mobile breathalyser technology to reduce heavy alcohol use and improve HIV treatment outcomes among HIV-affected couples in South Africa.Methods and analysis We will employ a three-arm randomised controlled trial to assess the efficacy of couple-based MI (MI-only arm) and in conjunction with mobile breathalysers (MI-plus arm) to address alcohol use and HIV outcomes, as compared with enhanced usual care (control arm). We will enrol heterosexual couples aged 18–49 in a primary relationship for at least 6 months who have at least one partner reporting hazardous alcohol use and on antiretroviral therapy for 6 months. Participants in both MI arms will attend three manualised counselling sessions and those in the MI-plus arm will receive real-time feedback on blood alcohol concentration levels using a mobile breathalyser. Couples randomised in the control arm will receive enhanced usual care based on the South African ART Clinical Guidelines. Feasibility and acceptability indicators will be analysed descriptively, and exploratory hypotheses will be examined through regression models considering time points and treatment arms.Ethics and dissemination The study was approved by the University of California, San Francisco (HRPP; protocol number 21-35034) and Human Sciences Research Council Research Ethics Committee (REC: protocol number 1/27/20/21). We will disseminate the results at local community meetings, community-level health gatherings and conferences focused on HIV and alcohol use.Trial registration number NCT05756790.

BackgroundThere is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa. ObjectiveThis study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing. MethodsAn iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development. ResultsA total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules (“episodes”) played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement. ConclusionsThe Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention’s feasibility, acceptability, and efficacy in reducing depressive symptoms.

Abstract 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.

BackgroundMental health status assessment is mostly limited to clinical or research settings, but recent technological advances provide new opportunities for measurement using more ecological approaches. Leveraging apps already in use by individuals on their smartphones, such as chatbots, could be a useful approach to capture subjective reports of mood in the moment. ObjectiveThis study aimed to describe the development and implementation of the Identifying Depression Early in Adolescence Chatbot (IDEABot), a WhatsApp-based tool designed for collecting intensive longitudinal data on adolescents’ mood. MethodsThe IDEABot was developed to collect data from Brazilian adolescents via WhatsApp as part of the Identifying Depression Early in Adolescence Risk Stratified Cohort (IDEA-RiSCo) study. It supports the administration and collection of self-reported structured items or questionnaires and audio responses. The development explored WhatsApp’s default features, such as emojis and recorded audio messages, and focused on scripting relevant and acceptable conversations. The IDEABot supports 5 types of interactions: textual and audio questions, administration of a version of the Short Mood and Feelings Questionnaire, unprompted interactions, and a snooze function. Six adolescents (n=4, 67% male participants and n=2, 33% female participants) aged 16 to 18 years tested the initial version of the IDEABot and were engaged to codevelop the final version of the app. The IDEABot was subsequently used for data collection in the second- and third-year follow-ups of the IDEA-RiSCo study. ResultsThe adolescents assessed the initial version of the IDEABot as enjoyable and made suggestions for improvements that were subsequently implemented. The IDEABot’s final version follows a structured script with the choice of answer based on exact text matches throughout 15 days. The implementation of the IDEABot in 2 waves of the IDEA-RiSCo sample (140 and 132 eligible adolescents in the second- and third-year follow-ups, respectively) evidenced adequate engagement indicators, with good acceptance for using the tool (113/140, 80.7% and 122/132, 92.4% for second- and third-year follow-up use, respectively), low attrition (only 1/113, 0.9% and 1/122, 0.8%, respectively, failed to engage in the protocol after initial interaction), and high compliance in terms of the proportion of responses in relation to the total number of elicited prompts (12.8, SD 3.5; 91% out of 14 possible interactions and 10.57, SD 3.4; 76% out of 14 possible interactions, respectively). ConclusionsThe IDEABot is a frugal app that leverages an existing app already in daily use by our target population. It follows a simple rule-based approach that can be easily tested and implemented in diverse settings and possibly diminishes the burden of intensive data collection for participants by repurposing WhatsApp. In this context, the IDEABot appears as an acceptable and potentially scalable tool for gathering momentary information that can enhance our understanding of mood fluctuations and development.

Abstract Background Of the 8 million people in South Africa living with HIV, 74% of persons living with HIV are on antiretroviral therapy (ART) and 65% are virally suppressed. Detectable viral load results in HIV-associated morbidity and mortality and HIV transmission. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load. HIV differentiated service delivery (DSD) has simplified ART delivery for clients who achieve viral suppression and engage in care. However, DSD needs adaptation to serve clients who are not engaged in care. Methods A Sequential Multiple Assignment Randomized Trial will be undertaken in KwaZulu-Natal, South Africa, to test adaptive ART delivery for persons with detectable viral load and/or who are not engaged in care. The types of differentiated service delivery (DSD) which will be examined in this study are clinic-based incentives, community-based smart lockers, and home delivery. The study plans to enroll up to 900 participants-people living with HIV, eligible for ART, and who are not engaged in care. The study aims to assess the proportion of ART-eligible persons living with HIV who achieve viral suppression at 18 months. The study will also evaluate the preferences of clients and providers for differentiated service delivery and evaluate the cost-effectiveness of adaptive HIV treatment for those who are not engaged in care. Discussion To increase population-level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates the evaluation of a stepped, adaptive approach to achieving viral suppression with “right-sized” interventions for patients most in need of effective and efficient HIV care delivery strategies. Trial registration ClinicalTrials.gov NCT05090150. Registered on October 22, 2021

Abstract Background There is an increasingly urgent gap in knowledge regarding the translation of effective HIV prevention and care programming into scaled clinical policy and practice. Challenges limiting the translation of efficacious programming into national policy include the paucity of proven efficacious programs that are reasonable for clinics to implement and the difficulty in moving a successful program from research trial to scaled programming. This study aims to bridge the divide between science and practice by exploring health care providers’ views on what is needed to implement new HIV programs within existing HIV care. Methods We conducted 20 in-depth interviews with clinic managers and clinic program implementing staff and five key informant interviews with district health managers overseeing programming in the uMgungundlovu District of KwaZulu-Natal Province, South Africa. Qualitative data were analyzed using a template approach. A priori themes were used to construct templates of relevance, including current care context for HIV and past predictors of successful implementation. Data were coded and analyzed by these templates. Results Heath care providers identified three main factors that impact the integration of HIV programming into general clinical care: perceived benefits, resource availability, and clear communication. The perceived benefits of HIV programs hinged on the social validation of the program by early adopters. Wide program availability and improved convenience for providers and patients increased perceived benefit. Limited staffing capacity and a shortage of space were noted as resource constraints. Programs that specifically tackled these constraints through clinic decongestion were reported as being the most successful. Clear communication with all entities involved in clinic-based programs, some of which include external partners, was noted as central to maximizing program function and provider uptake. Conclusions Amid the COVID-19 pandemic, new programs are continuously being developed for implementation at the primary health care level. A better understanding of the factors that facilitate and prevent programmatic success will improve public health outcomes. Implementation is likely to be most successful when programs capitalize on endorsements from early adopters, tackle resource constraints, and foster greater communication among partners responsible for implementation.

Background: Continuous monitoring of glucose (CGM) via subcutaneous patch is an accurate self-monitoring tool of blood glucose, but also introduces a range of additional benefits such as real-time feedback. While its value among pregnant women with gestational diabetes mellitus (GDM) is established in high-income countries, little is known about the feasibility and acceptability among pregnant women without GDM in low-resource settings in low- and middle-income countries. Objectives: This study aims to assess the feasibility and acceptability of CGM with pregnant mothers in South Africa and to explore the value of a collected data set for GDM prevention. Methods: Ten women between 12 and 18 weeks pregnant were recruited from the antenatal clinic at Chris Hani Baragwanath Academic Hospital into a prospective mixed-methods pilot study. Demographic and anthropometric data, HbA1c and a lipid panel were collected. Women then wore two consecutive Freestyle Libre 2 patches for a total of 28 days. In-depth interviews were undertaken with all 10 women on study exit to explore themes of acceptability and the use of technology during pregnancy. Thematic analysis was performed on the qualitative data while exploratory data-analysis techniques were applied to the CGM data. Results: Pregnant women (n = 10) had a mean (SD) age of 29.81 years (4.39), with most being unemployed (8), unmarried (8) and without a tertiary degree (7). Analysis suggests that fear of use was greater than the actual discomfort experienced during use of the CGM patch. The main barrier to use was the patch falling off and women being uncomfortable to reapply it. This was borne out by all 10 women wearing the first patch for at least 12 of the 14 days, but only 4 managing the same with patch two – primarily applied by themselves at home. Women expressed support for the use of technology during pregnancy, especially as it related to feeling that their pregnancy was being monitored and that they were being supported. Conclusion: In this pilot study, women overwhelmingly found the wearing of a CGM patch during pregnancy to be acceptable. Feasibility was reasonable with most data being successfully retrieved from the devices over a two-week period. Longer use was found to have additional challenges. The use of CGM patches appear to be a possible candidate for inclusion in GDM prevention or behavioural interventions during pregnancy in South Africa.

Abstract Background Between 2012 and 2015, the Uthando Lwethu (UL) study demonstrated that a theory-based behavioural couples-focused intervention significantly increased participation in couples HIV testing and counselling (CHTC) among South African couples who had never previously tested for HIV together or mutually disclosed their HIV status, 42% compared to 12% of the control group at 9 months follow-up. Although effective, we were nonetheless concerned that in this high prevalence setting the majority (58%) of intervention couples chose not to test together. In response we optimised the UL intervention and in a new study, ‘Igugu Lethu’, we are evaluating the success of the optimised intervention in promoting CHTC. Methods One hundred eighty heterosexual couples, who have been in a relationship together for at least 6 months, are being recruited and offered the optimised couples-focused intervention. In the Igugu Lethu study, we have expanded the health screening visit offered to couples to include other health conditions in addition to CHTC. Enrolled couples who choose to schedule CHTC will also have the opportunity to undertake a random blood glucose test, blood pressure and BMI measurements, and self-sample for STI testing as part of their health screening. Individual surveys are administered at baseline, 4 weeks and 4 months follow-up. The proportion of couples who decide to test together for HIV will be compared to the results of the intervention arm in the UL study (historical controls). To facilitate this comparison, we will use the same recruitment and follow-up strategies in the same community as the previous UL study. Discussion By strengthening communication and functioning within the relationship, the Igugu Lethu study, like the previous UL study, aims to transform the motivation of individual partners from a focus on their own health to shared health as a couple. The Igugu Lethu study findings will answer whether the optimised couples-focused behavioural intervention and offering CHTC as part of a broader health screening for couples can increase uptake of CHTC by 40%, an outcome that would be highly desirable in populations with high HIV prevalence. Trial registration Retrospectively registered. ISRCTN Registry ISRCTN 46162564 Registered on 26th May 2022.

IntroductionSouth Africa has the highest burden of HIV in the world with over 8 million people living with HIV. Young women and girls account for a quarter of new HIV infections while making up only 10% of the population. A key driver of HIV incidence is transactional and survival sex between adolescent girls or young women and older men (the latter referred to as ‘sugar-daddies’ or ‘blessers’). This paper expands on the existing literature on age-disparate and intergenerational relationships to provide social and behavioural interpretations of how young men, commonly omitted from studies on this topic, and women in concurrent relationships with both their peers and older partners perceive and navigate sexual risk.MethodWe conducted a qualitative study in a rural setting of uMgungundlovu District, KwaZulu-Natal Province, with purposively selected male and female participants aged 18–24 years old in age-disparate relationships. Semi-structured in-depth interviews (IDI) were conducted and analysed using interpretative phenomenological analysis (IPA) to explore existing information, motivations, and behavioural practices around relationships and sexual risk.ResultsThe themes and related sub-themes found through IPA included the following: (1) navigating dating: narratives that show a strong preference for being in an age-disparate relationship; the challenges that young people face when choosing an older person as a side partner; and social media applications seen as creating opportunities to meet side partners; and (2) the distribution of love and trust in a multi-party sexual network: condom (mis)use differentiates between straights—those in a serious relationship—and sides; and the power of eye-test seroguessing, the praxis of testing people visually for HIV in nullifying existing knowledge about sexual and reproductive health risk.DiscussionThis research offers an understanding of how schemas of non-condom use are organised. We observed that while condom-less sex is often viewed as essential to building social capital in a serious relationship, it is not the only factor that determines sexual relationship power. Eye-test seroguessing not only develops consortium (trust, reciprocity, and solidarity), but it fulfils the psycho-social need to belong to a network of serious relationships. Moreover, it is critical to the enactment of masculinities because it consolidates femininity to keep men happy, i.e., by being passive in the sexual encounter, women constrain their self-efficacy to act contrary to the conventions of reputable women. Therefore, it is plausible that in the serosorting that occurs prior to unprotected sexual acts, the power of eye-test seroguessing limits the ability to engage in safe sexual practices.

BackgroundMaternal and child health (MCH) is a global health concern, especially impacting low- and middle-income countries (LMIC). Digital health technologies are creating opportunities to address the social determinants of MCH by facilitating access to information and providing other forms of support throughout the maternity journey. Previous reviews in different disciplines have synthesized digital health intervention outcomes in LMIC. However, contributions in this space are scattered across publications in different disciplines and lack coherence in what digital MCH means across fields. ObjectiveThis cross-disciplinary scoping review synthesized the existing published literature in 3 major disciplines on the use of digital health interventions for MCH in LMIC, with a particular focus on sub-Saharan Africa. MethodsWe conducted a scoping review using the 6-stage framework by Arksey and O’Malley across 3 disciplines, including public health, social sciences applied to health, and human-computer interaction research in health care. We searched the following databases: Scopus, PubMed, Google Scholar, ACM Digital Library, IEEE Xplore, Web of Science, and PLOS. A stakeholder consultation was undertaken to inform and validate the review. ResultsDuring the search, 284 peer-reviewed articles were identified. After removing 41 duplicates, 141 articles met our inclusion criteria: 34 from social sciences applied to health, 58 from public health, and 49 from human-computer interaction research in health care. These articles were then tagged (labeled) by 3 researchers using a custom data extraction framework to obtain the findings. First, the scope of digital MCH was found to target health education (eg, breastfeeding and child nutrition), care and follow-up of health service use (to support community health workers), maternal mental health, and nutritional and health outcomes. These interventions included mobile apps, SMS text messaging, voice messaging, web-based applications, social media, movies and videos, and wearable or sensor-based devices. Second, we highlight key challenges: little attention has been given to understanding the lived experiences of the communities; key role players (eg, fathers, grandparents, and other family members) are often excluded; and many studies are designed considering nuclear families that do not represent the family structures of the local cultures. ConclusionsDigital MCH has shown steady growth in Africa and other LMIC settings. Unfortunately, the role of the community was negligible, as these interventions often do not include communities early and inclusively enough in the design process. We highlight key opportunities and sociotechnical challenges for digital MCH in LMIC, such as more affordable mobile data; better access to smartphones and wearable technologies; and the rise of custom-developed, culturally appropriate apps that are more suited to low-literacy users. We also focus on barriers such as an overreliance on text-based communications and the difficulty of MCH research and design to inform and translate into policy.

During TB-case finding, we assessed the feasibility of implementing the advanced HIV disease (AHD) care package, including VISITECT CD4 Advanced Disease (VISITECT), a semiquantitative test to identify a CD4≤200cells/μl. Adult participants with tuberculosis symptoms, recruited near-facility in Lesotho and South-Africa between 2021-2022, were offered HIV testing (capillary blood), Xpert MTB/RIF and Ultra, and MGIT culture (sputum). People living with HIV (PLHIV) were offered VISITECT (venous blood) and Alere tuberculosis-lipoarabinomannan (AlereLAM, urine) testing. AHD was defined as a CD4≤200cells/μl on VISITECT or a positive tuberculosis test. A CD4≤200cells/μl on VISITECT triggered Immy cryptococcal antigen (Immy CrAg, plasma) testing. Participants were referred with test results. To evaluate feasibility, we assessed i) acceptability and ii) intervention delivery of point-of-care diagnostics among study staff using questionnaires and group discussions, iii) process compliance, and iv) early effectiveness (12-week survival and treatment status) in PLHIV. Predictors for 12-week survival were assessed with logistic regression. Thematic content analysis and triangulation were performed. Among PLHIV (N = 676, 48.6% of 1392 participants), 7.8% were newly diagnosed, 81.8% on ART, and 10.4% knew their HIV status but were not on ART. Among 676 PLHIV, 41.7% had AHD, 29.9% a CD4≤200cells/μl and 20.6% a tuberculosis diagnosis. Among 200 PLHIV tested with Immy CrAg, 4.0% were positive. The procedures were acceptable for study staff, despite intervention delivery challenges related to supply and the long procedural duration (median: 73 minutes). At 12 weeks, among 276 PLHIV with AHD and 328 without, 3.3% and 0.9% had died, 84.8% and 92.1% were alive and 12.0% and 7.0% had an unknown status, respectively. Neither AHD nor tuberculosis status were associated with survival. Implementing AHD care package diagnostics was feasible during tuberculosis-case finding. AHD was prevalent, and not associated with survival, which is likely explained by the low specificity of VISITECT. Challenges with CD4 testing and preventive treatment uptake require addressing.

Despite significant gains in HIV testing, treatment and prevention in sub-Saharan Africa, male engagement and retention in HIV care remains a challenge. We conducted in-depth interviews with 25 men with HIV (MWH) living in rural South Africa to explore how men's reproductive goals could inform approaches to engage men and their female partners in HIV care and prevention. Themes were organised into opportunities and barriers for HIV care, treatment and prevention that men articulated as important to their reproductive goals at the individual, couple and community levels. At the individual level, men are motivated to remain healthy so they can raise a healthy child. At the couple level, the importance of maintaining a healthy partner to raise children may promote serostatus-disclosure, testing and encourage men to support partners to access HIV prevention. At the community level, men described the need to be seen as fathers who provide for their families as important motivators to engage in care. Men also articulated barriers including low knowledge about antiretroviral-based HIV prevention, lack of trust within partnerships and community stigma. Addressing reproductive goals of MWH may be an untapped path for promoting male engagement in HIV care and prevention for their partners.

Community-based delivery and monitoring of antiretroviral therapy (ART) for HIV has the potential to increase viral suppression for individual- and population-level health benefits. However, the cost-effectiveness and budget impact are needed for public health policy. We used a mathematical model of HIV transmission in KwaZulu-Natal, South Africa, to estimate population prevalence, incidence, mortality, and disability-adjusted life-years (DALYs) from 2020 to 2060 for two scenarios: 1) standard clinic-based HIV care and 2) five-yearly home testing campaigns with community ART for people not reached by clinic-based care. We parameterised model scenarios using observed community-based ART efficacy. Using a health system perspective, we evaluated incremental cost-effectiveness and net health benefits using a threshold of $750/DALY averted. In a sensitivity analysis, we varied the discount rate; time horizon; costs for clinic and community ART, hospitalisation, and testing; and the proportion of the population receiving community ART. Uncertainty ranges (URs) were estimated across 25 best-fitting parameter sets. By 2060, community ART following home testing averted 27.9% (UR: 24.3-31.5) of incident HIV infections, 27.8% (26.8-28.8) of HIV-related deaths, and 18.7% (17.9-19.7) of DALYs compared to standard of care. Adolescent girls and young women aged 15-24 years experienced the greatest reduction in incident HIV (30.7%, 27.1-34.7). In the first five years (2020-2024), community ART required an additional $44.9 million (35.8-50.1) annually, representing 14.3% (11.4-16.0) of the annual HIV budget. The cost per DALY averted was $102 (85-117) for community ART compared with standard of care. Providing six-monthly refills instead of quarterly refills further increased cost-effectiveness to $78.5 per DALY averted (62.9-92.8). Cost-effectiveness was robust to sensitivity analyses. In a high-prevalence setting, scale-up of decentralised ART dispensing and monitoring can provide large population health benefits and is cost-effective in preventing death and disability due to HIV.

Diagnostic accuracy studies in pulmonary tuberculosis (PTB) are complicated by the lack of a perfect reference standard. This limitation can be handled using latent class analysis (LCA), assuming independence between diagnostic test results conditional on the true unobserved PTB status. Test results could remain dependent, however, e.g. with diagnostic tests based on a similar biological basis. If ignored, this gives misleading inferences. Our secondary analysis of data collected during the first year (May 2018 –May 2019) of a community-based multi-morbidity screening program conducted in the rural uMkhanyakude district of KwaZulu Natal, South Africa, used Bayesian LCA. Residents of the catchment area, aged ≥15 years and eligible for microbiological testing, were analyzed. Probit regression methods for dependent binary data sequentially regressed each binary test outcome on other observed test results, measured covariates and the true unobserved PTB status. Unknown model parameters were assigned Gaussian priors to evaluate overall PTB prevalence and diagnostic accuracy of 6 tests used to screen for PTB: any TB symptom, radiologist conclusion, Computer Aided Detection for TB version 5 (CAD4TBv5≥53), CAD4TBv6≥53, Xpert Ultra (excluding trace) and culture. Before the application of our proposed model, we evaluated its performance using a previously published childhood pulmonary TB (CPTB) dataset. Standard LCA assuming conditional independence yielded an unrealistic prevalence estimate of 18.6% which was not resolved by accounting for conditional dependence among the true PTB cases only. Allowing, also, for conditional dependence among the true non-PTB cases produced a 1.1% plausible prevalence. After incorporating age, sex, and HIV status in the analysis, we obtained 0.9% (95% CrI: 0.6, 1.3) overall prevalence. Males had higher PTB prevalence compared to females (1.2% vs. 0.8%). Similarly, HIV+ had a higher PTB prevalence compared to HIV- (1.3% vs. 0.8%). The overall sensitivity for Xpert Ultra (excluding trace) and culture were 62.2% (95% CrI: 48.7, 74.4) and 75.9% (95% CrI: 61.9, 89.2), respectively. Any chest X-ray abnormality, CAD4TBv5≥53 and CAD4TBv6≥53 had similar overall sensitivity. Up to 73.3% (95% CrI: 61.4, 83.4) of all true PTB cases did not report TB symptoms. Our flexible modelling approach yields plausible, easy-to-interpret estimates of sensitivity, specificity and PTB prevalence under more realistic assumptions. Failure to fully account for diagnostic test dependence can yield misleading inferences.

BackgroundHIV testing rates in sub-Saharan Africa remain below the targeted threshold, and primary care facilities struggle to provide adequate services. Innovative approaches that leverage digital technologies could improve HIV testing and access to treatment. ObjectiveThis study aimed to examine the feasibility and acceptability of Nolwazi_bot. It is an isiZulu-speaking conversational agent designed to support HIV self-testing (HIVST) in KwaZulu-Natal, South Africa. MethodsNolwazi_bot was designed with 4 different personalities that users could choose when selecting a counselor for their HIVST session. We recruited a convenience sample of 120 consenting adults and invited them to undertake an HIV self-test facilitated by the Nolwazi_bot. After testing, participants completed an interviewer-led posttest structured survey to assess their experience with the chatbot-supported HIVST. ResultsParticipants (N=120) ranged in age from 18 to 47 years, with half of them being men (61/120, 50.8%). Of the 120 participants, 111 (92.5%) had tested with a human counselor more than once. Of the 120 participants, 45 (37.5%) chose to be counseled by the female Nolwazi_bot personality aged between 18 and 25 years. Approximately one-fifth (21/120, 17.5%) of the participants who underwent an HIV self-test guided by the chatbot tested positive. Most participants (95/120, 79.2%) indicated that their HIV testing experience with a chatbot was much better than that with a human counselor. Many participants (93/120, 77.5%) reported that they felt as if they were talking to a real person, stating that the response tone and word choice of Nolwazi_bot reminded them of how they speak in daily conversations. ConclusionsThe study provides insights into the potential of digital technology interventions to support HIVST in low-income and middle-income countries. Although we wait to see the full benefits of mobile health, technological interventions including conversational agents or chatbots provide us with an excellent opportunity to improve HIVST by addressing the barriers associated with clinic-based HIV testing.

Introduction Scalable psychological treatments to address depression among adolescents are urgently needed. This is particularly relevant to low-income and middle-income countries where 90% of the world’s adolescents live. While digital delivery of behavioural activation (BA) presents a promising solution, its feasibility, acceptability and effectiveness among adolescents in an African context remain to be shown.Methods and analysis This study is a two-arm single-blind individual-level randomised controlled pilot trial to assess the feasibility, acceptability and initial efficacy of digitally delivered BA therapy among adolescents with depression. The intervention has been coproduced with adolescents at the study site. The study is based in the rural northeast of South Africa in the Bushbuckridge subdistrict of Mpumalanga province. A total of 200 adolescents with symptoms of mild to moderately severe depression on the Patient Health Questionnaire Adolescent Version will be recruited (1:1 allocation ratio). The treatment group will receive BA therapy via a smartphone application (the Kuamsha app) supported by trained peer mentors. The control group will receive an enhanced standard of care. The feasibility and acceptability of the intervention will be evaluated using a mixed methods design, and signals of the initial efficacy of the intervention in reducing symptoms of depression will be determined on an intention-to-treat basis. Secondary objectives are to pilot a range of cognitive, mental health, risky behaviour and socioeconomic measures; and to collect descriptive data on the feasibility of trial procedures to inform the development of a further larger trial.Ethics and dissemination This study has been approved by the University of the Witwatersrand Human Research Ethics Committee (MED20-05-011) and the Oxford Tropical Research Ethics Committee (OxTREC 34-20). Study findings will be published in scientific open access peer-reviewed journals, presented at scientific conferences and communicated to participants, their caregivers, public sector officials and other relevant stakeholders.Trial registration numbers This trial was registered on 19 November 2020 with the South African National Clinical Trials Registry (DOH-27-112020-5741) and the Pan African Clinical Trials Registry (PACTR202206574814636).

Background: In application studies of latent class analysis (LCA) evaluating imperfect diagnostic tests, residual dependence among the diagnostic tests still remain even after conditioning on the true disease status due to measured variables known to affect prevalence and/or alter diagnostic test accuracy. Presence of severe comorbidities such as HIV in pulmonary tuberculosis (PTB) diagnosis alter the prevalence of PTB and affect the diagnostic performance of the available imperfect tests in use. This violates two key assumptions of LCA: (1) that the diagnostic tests are independent conditional on the true disease status (2) that the sensitivity and specificity remain constant across subpopulations. This leads to incorrect inferences. Methods: Through simulation we examined implications of likely model violations on estimation of prevalence, sensitivity and specificity among passive case-finding presumptive PTB patients with or without HIV. Jointly conditioning on PTB and HIV, we generated independent results for five diagnostic tests and analyzed using Bayesian LCA with Probit regression, separately for sets of five and three diagnostic tests using four working models allowing: (1) constant PTB prevalence and diagnostic accuracy (2) varying PTB prevalence but constant diagnostic accuracy (3) constant PTB prevalence but varying diagnostic accuracy (4) varying PTB prevalence and diagnostic accuracy across HIV subpopulations. Vague Gaussian priors with mean 1 and unknown variance were assigned to the model parameters with unknown variance assigned Inverse Gamma prior. Results: Models accounting for heterogeneity in diagnostic accuracy produced consistent estimates while the model ignoring it produces biased estimates. The model ignoring heterogeneity in PTB prevalence only is less problematic. With five diagnostic tests, the model assuming homogenous population is robust to violation of the assumptions. Conclusion: Well-chosen covariate-specific adaptations of the model can avoid bias implied by recognized heterogeneity in PTB patient populations generating otherwise dependent test results in LCA.

Background: South Africa currently has the greatest number of people with HIV globally. The country has not yet met its 95-95-95 goals, with different gaps in the HIV care cascade for women and men. This paper reports on a protocol to pilot test a couple-based intervention designed to improve women's antiretroviral therapy (ART) adherence and men's engagement in care in heterosexual couples living in the Vulindlela area of KwaZulu-Natal, South Africa. Study goals are two-fold: (1) assess the acceptability, feasibility, and fidelity of the experimental intervention, START Together, and (2) collect efficacy data on START Together for women's ART adherence, men's engagement in HIV care, and the couple's relationship functioning. Methods: Women (N = 20) who were not engaged with ART adherence (defined via self-reported ART difficulties, record of missed clinic visits, or viral non-suppression) are the target patients; male partners are not required to know or disclose their HIV status to be part of the study. Couples are randomized 1:1 to the experimental treatment (START Together) or treatment as usual (referrals to the local clinic to support ART adherence or any other HIV-related care). START Together is a 5-session intervention based in cognitive-behavioral couple therapy, which is a skill-based intervention focusing on communication and problem-solving skills, and Life Steps, a problem-solving intervention identifying barriers and solutions to medication adherence. Couples are assessed at baseline, post-treatment (8 weeks post-randomization), and follow-up (12 weeks post-randomization). Conclusion: This study will provide preliminary implementation and efficacy data on whether this novel approach has potential to improve women and men's HIV and healthcare-related needs.

Abstract Background Passive sensor data from mobile devices can shed light on daily activities, social behavior, and maternal-child interactions to improve maternal and child health services including mental healthcare. We assessed feasibility and acceptability of the Sensing Technologies for Maternal Depression Treatment in Low Resource Settings (StandStrong) platform. The StandStrong passive data collection platform was piloted with adolescent and young mothers, including mothers experiencing postpartum depression, in Nepal. Methods Mothers (15–25 years old) with infants (

BackgroundTo reach 95% of persons living with HIV (PLWH) knowing their HIV status, alternative testing approaches such as HIV self-testing (HIVST) and secondary HIVST kit distribution are needed. We investigated if secondary HIVST kit distribution from male and female PLWH in South Africa would successfully lead to their contacts testing for HIV and linking to care if positive.MethodsMale and female PLWH participating in an HIV treatment trial between July and November 2018 in KwaZulu-Natal, South Africa were offered participation as “HIVST kit distributors” in a pilot of secondary distribution of HIVST kits to give to sexual partners and social networks. Univariate descriptive statistics were used to describe the characteristics of volunteer distributors, proportion of HIVST recipients who reported their results, and linkage to care among those who tested positive using HIVST were assessed.ResultsSixty-three participant kit distributors accepted kits to disperse to contacts, of whom 52% were female, median age was 34 years (IQR 26-42.5), 84% reported 1 sexual partner and 76% did not know their partner's HIV status. HIVST kit distributors took 218 kits, with 13/218 (6%) of kits reported to be intended to be given to a sexual partner. A total of 143 HIVST recipients reported their HIVST results; 92% reported their results were negative, 11 recipients reported positive results and 1 HIVST-positive recipient was linked to HIV care.ConclusionSecondary distribution of HIVST to social networks and sexual partners from South African PLWH is feasible, with two thirds of contacts reporting use of the HIVST kits. Additional support is necessary to facilitate linkage to care.

IntroductionTo sustainably provide good quality care to increasing numbers of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in resource-limited settings, care delivery must shift from a "one-size-fits-all" approach to differentiated service delivery models. Such models should reallocate resources from PLHIV who are doing well to groups of PLHIV who may need more attention, such as those with treatment failure. The VIral load Triggered ART care Lesotho (VITAL) trial assesses a viral load (VL)-, participant's preference-informed, electronic health (eHealth)-supported, automated differentiated service delivery model (VITAL model). With VITAL, we aim to assess if the VITAL model is at least non-inferior to the standard of care in the proportion of participants engaged in care with viral suppression at 24 months follow-up and if it is cost-saving.MethodsThe VITAL trial is a pragmatic, multicenter, cluster-randomized, non-blinded, non-inferiority trial with 1:1 allocation conducted at 18 nurse-led, rural health facilities in two districts of northern Lesotho, enrolling adult PLHIV taking ART. In intervention clinics, providers are trained to implement the VITAL model and are guided by a clinical decision support tool, the VITALapp. VITAL differentiates care according to VL results, clinical characteristics, sub-population and participants' and health care providers' preferences.Expected outcomesEvidence on the effect of differentiated service delivery for PLHIV on treatment outcomes is still limited. This pragmatic cluster-randomized trial will assess if the VITAL model is at least non-inferior to the standard of care and if it is cost saving.Trial registrationThe study has been registered with clinicaltrials.gov (Registration number NCT04527874; August 27, 2020).

The impacts of early pregnancy and young motherhood on everyday life, including interpersonal and individual behavior, are not well-known. Passive digital sensing on mobile technology including smartphones and passive Bluetooth beacons can yield information such as geographic movement, physical activity, and mother-infant proximity to illuminate behavioral patterns of a mother's everyday in Nepal. We contribute to mixed-methods research by triangulating passive sensing data (GPS, accelerometry, Bluetooth proximity) with multiple forms of qualitative data to characterize behavioral patterns and experiences of young motherhood in the first year postpartum. We triangulated this digital information in a constant comparative analysis with in-depth interviews, daily diaries, and fieldnotes. We reveal typical behavioral patterns of rural young mothers and highlight opportunities for integrating this information to improve health and well-being.

BackgroundAlcohol is a teratogen; its consumption during pregnancy can lead to negative birth outcomes, collectively referred to as fetal alcohol spectrum disorders. Neurodevelopmental delays in higher-order cognitive functions that affect development of executive functions are a common feature. Studies on executive function in children have focused on children diagnosed with fetal alcohol spectrum disorder, and there is a lack of information on the impact on children not diagnosed with fetal alcohol spectrum disorder but who had been exposed to alcohol. ObjectiveThe aim of this study was to compare the development of executive function in children between 4 and 6 years of age with and without prenatal exposure to alcohol. MethodsChildren both exposed and not exposed to alcohol were recruited as part of a feasibility RCT evaluating a computer-based cognitive training program for improving executive function development. The study was conducted in a low–socioeconomic status community in South Africa with a high prevalence of fetal alcohol spectrum disorder. Neurodevelopment was assessed in participating children; NEPSY-II standardized scores for executive function domains were compared using a multivariate analysis of variance with group membership as the predictor variable. ResultsNo significant differences in executive functions assessments (P=.39) were found between children in the alcohol-exposed group (n=76) and those in the nonexposed group (n=40). Both groups showed moderate to severe delays in domains. In all but one subtest, the average score for both groups was below the 25th percentile of expected norms. ConclusionsWe expected that alcohol exposure would have a measurable impact on executive function development. The lack of differences highlights the prevalence of developmental delays in low–socioeconomic status communities in South Africa and suggests that children are exposed to various threats to cognitive development. International Registered Report Identifier (IRRID)RR2-10.2196/14489

Background: With the growing ubiquity of smartphones and wearable devices, there is an increased potential of collecting passive sensing data in mobile health. Passive data such as physical activity, Global Positioning System (GPS), interpersonal proximity, and audio recordings can provide valuable insight into the lives of individuals. In mental health, these insights can illuminate behavioral patterns, creating exciting opportunities for mental health service providers and their clients to support pattern recognition and problem identification outside of formal sessions. In the Sensing Technologies for Maternal Depression Treatment in Low Resource Settings (StandStrong) project, our aim was to build an mHealth application to facilitate the delivery of psychological treatments by lay counselors caring for adolescent mothers with depression in Nepal. Methods: This paper describes the development of the StandStrong platform comprising the StandStrong Counselor application, and a cloud-based processing system, which can incorporate any tool that generates passive sensing data. We developed the StandStrong Counselor application that visualized passively collected GPS, proximity, and activity data. In the app, GPS data displays as heat maps, proximity data as charts showing the mother and child together or apart, and mothers’ activities as activity charts. Lay counselors can use the StandStrong application during counseling sessions to discuss mothers’ behavioral patterns and clinical progress over the course of a five-week counseling intervention. Achievement Awards based on collected data can also be automatically generated and sent to mothers. Additionally, messages can be sent from counselors to mother’s personal phones through the StandStrong platform. Discussion: The StandStrong platform has the potential to improve the quality and effectiveness of psychological services delivered by non-specialists in diverse global settings.

Background: The social environment, comprised of social support, social burden, and quality of interactions, influences a range of health outcomes, including mental health. Passive audio data collection on mobile phones (e.g., episodic recording of the auditory environment without requiring any active input from the phone user) enables new opportunities to understand the social environment. We evaluated the use of passive audio collection on mobile phones as a window into the social environment while conducting a study of mental health among adolescent and young mothers in Nepal.Methods: We enrolled 23 adolescent and young mothers who first participated in qualitative interviews to describe their social support and identify sounds potentially associated with that support. Then, episodic recordings were collected for 2 weeks from the mothers using an app to record 30 s of audio every 15 min from 4 A.M. to 9 P.M. Audio data were processed and classified using a pretrained model. Each classification category was accompanied by an estimated accuracy score. Manual validation of the machine-predicted speech and non-speech categories was done for accuracy.Results: In qualitative interviews, mothers described a range of positive and negative social interactions and the sounds that accompanied these. Potential positive sounds included adult speech and laughter, infant babbling and laughter, and sounds from baby toys. Sounds characterizing negative stimuli included yelling, crying, screaming by adults and crying by infants. Sounds associated with social isolation included silence and TV or radio noises. Speech comprised 43% of all passively recorded audio clips (n = 7,725). Manual validation showed a 23% false positive rate and 62% false-negative rate for speech, demonstrating potential underestimation of speech exposure. Other common sounds were music and vehicular noises.Conclusions: Passively capturing audio has the potential to improve understanding of the social environment. However, a pre-trained model had the limited accuracy for identifying speech and lacked categories allowing distinction between positive and negative social interactions. To improve the contribution of passive audio collection to understanding the social environment, future work should improve the accuracy of audio categorization, code for constellations of sounds, and combine audio with other smartphone data collection such as location and activity.

Current approaches to longitudinal assessment of children’s developmental and psychological well-being, as mandated in the United Nations Sustainable Development Goals, are expensive and time consuming. Substantive understanding of global progress toward these goals will require a suite of new robust, cost-effective research tools designed to assess key developmental processes in diverse settings. While first steps have been taken toward this end through efforts such as the National Institutes of Health’s Toolbox, experience-near approaches including naturalistic observation have remained too costly and time consuming to scale to the population level. This perspective presents 4 emerging technologies with high potential for advancing the field of child health and development research, namely (1) affective computing, (2) ubiquitous computing, (3) eye tracking, and (4) machine learning. By drawing attention of scientists, policy makers, investors/funders, and the media to the applications and potential risks of these emerging opportunities, we hope to inspire a fresh wave of innovation and new solutions to the global challenges faced by children and their families.

Sub-Saharan Africa has been heavily impacted by the HIV/AIDS epidemic. Social data (e.g., social media, internet search, wearable device, etc) show great promise assisting in public health and HIV surveillance. However, research on this topic has primarily focused in higher resource settings, such as the United States. It is especially important to study the prevalence and potential use of these data sources and tools in low- and middle-income countries (LMIC), such as Sub-Saharan Africa, which have been heavily impacted by the HIV epidemic, to determine the feasibility of using these technologies as surveillance and intervention tools. Accordingly, we 1) described the prevalence and characteristics of various social technologies within South Africa, 2) using Twitter, Instagram, and YouTube as a case study, analyzed the prevalence and patterns of social media use related to HIV risk in South Africa, and 3) mapped and statistically tested differences in HIV-related social media posts within regions of South Africa. Geocoded data were collected over a three-week period in 2018 (654,373 tweets, 90,410 Instagram posts and 14,133 YouTube videos with 1,121 comments). Of all tweets, 4,524 (0.7%) were found to related to HIV and AIDS. The percentage was similar for Instagram 95 (0.7%) but significantly lower for YouTube 18 (0.1%). We found regional differences in prevalence and use of social media related to HIV. We discuss the implication of data from these technologies in surveillance and interventions within South Africa and other LMICs.

Background: The pre-pubertal socioeconomic environment may be an important determinant of age at menarche, adult height, body proportions and adiposity: traits closely linked to adolescent and adult health. Aims: This study explored differences in age at menarche, adult height, relative leg-length and waist circumference between rural and urban black South African young adult women, who are at different stages of the nutrition and epidemiologic transitions. Subjects and methods: We compared 18–23 year-old black South African women, 482 urban-dwelling from Soweto and 509 from the rural Mpumalanga province. Age at menarche, obstetric history and household socio-demographic and economic information were recorded using interview-administered questionnaires. Height, sitting-height, hip and waist circumference were measured using standardised techniques. Results: Urban and rural black South African women differed in their age at menarche (at ages 12.7 and 14.5 years, respectively). In urban women, a one-year increase in age at menarche was associated with a 0.65 cm and 0.16% increase in height and relative leg-length ratio, respectively. In both settings, earlier age at menarche and shorter relative leg-length were independently associated with an increase in waist circumference. Conclusions: In black South African women, the earlier onset of puberty, and consequently an earlier growth cessation process, may lead to central fat mass accumulation in adulthood.

We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy through the infant's first year of life.In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy.WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months.WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6-12 months.ClinicalTrials.gov NCT00972699.

There is increased focus on HIV prevention with African men who report experiencing childhood sexual (CSA) or physical abuse (CPA).To better understand the effects of a community-based intervention (Project Accept HPTN 043) on HIV prevention behaviors among men who report CSA or CPA experiences.Project Accept compared a community-based voluntary mobile counseling and testing (CBVCT) intervention with standard VCT. The intervention employed individual HIV risk reduction planning with motivational interviewing in 34 African communities (16 communities at 2 sites in South Africa, 10 in Tanzania, and 8 in Zimbabwe). Communities were randomized unblinded in matched pairs to CBVCT or SVCT, delivered over 36 months. The post-intervention assessment was conducted using a single, cross-sectional random survey of 18-32 year-old community members (total N = 43,292). We analyzed the effect of the intervention on men with reported CSA or CPA across the African sites. Men were identified with a survey question asking about having experienced CSA or CPA across the lifespan. The effect of intervention on considered outcomes of the preventive behavior was statistically evaluated using the logistic regression models.Across the sites, the rates of CSA or CPA among men indicated that African men reflected the global prevalence (20%) with a range of 13-24%. The statistically significant effect of the intervention among these men was seen in their increased effort to receive their HIV test results (OR 2.71; CI: (1.08, 6.82); P: 0.034). The intervention effect on the other designated HIV prevention behaviors was less pronounced.The effect of the intervention on these men showed increased motivation to receive their HIV test results. However, more research is needed to understand the effects of community-based interventions on this group, and such interventions need to integrate other keys predictors of HIV including trauma, coping strategies, and intimate partner violence.