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Background: Inadequate numbers of children under five years of age who are exposed to tuberculosis (TB) in the home (child contact) are initiated on TB preventive treatment (TPT) in South Africa. We assessed barriers of initiating isoniazid preventive therapy (IPT) in this age group., Methods: We conducted a qualitative study at two primary health clinics in the Ekurhuleni district in Gauteng Province. Between April and July 2019, we enrolled facility managers, TB staff and parents or legal guardians of child contacts (caregivers) attending for care, at the two facilities. Semi-structured questionnaires, facility observations and in-depth interviews using a semi-structured interview guide were used to collect data. Findings from the semi-structured questionnaires with facility staff and facility observations were summarized. Thematic analysis with a deductive approach was used to analyse the data from the in-depth interviews with caregivers., Results: Two facility managers took part in the study and were assisted to complete the semi-structured questionnaires by TB staff. Fifteen caregivers aged between 18 and 43 years were interviewed of which 13 (87%) were female. Facility managers and TB staff (facility staff) felt that even though caregivers knew of family members who were on TB treatment, they delayed bringing their children for TB screening and TPT. Facility staff perceived caregivers as not understanding the purpose and benefits of TB prevention strategies such as TPT. Caregivers expressed the desire for their children to be screened for TB. However, caregivers lacked knowledge on TB transmission and the value of TB prevention in children at high risk of infection., Conclusion: While facility staff perceived caregivers to lack responsibility, caregivers expressed limited knowledge on the value of screening their children for TB as reasons for not accessing TB preventive services. Health education on TB transmission, screening, and TB prevention strategies at a community level, clinics, creches, schools and via media are important to achieve the global end TB goal of early detection and prevention of TB., (© 2023. The Author(s).)

Background: The introduction of digital adherence technologies (DATs) such as medication monitors in tuberculosis (TB) programmes supports treatment adherence among people with tuberculosis (PWTB). We evaluated the acceptability of using medication monitors (Wisepill evriMED) prompting a stepwise differentiated care approach (DCA), involving short message service (SMS), phone calls, home visits and motivational counselling, among PWTB in South Africa., Methods: We conducted 62 in-depth interviews with participants in local languages across three provinces (January-October 2020), purposively selected by treatment month, adherence history and gender. Interviews were audio recorded, transcribed verbatim and translated. Using a deductive approach and the Theoretical Framework for Acceptability (TFA), we explored acceptability across the sample attributes., Results: PWTB across adherence histories showed a positive attitude to using the evriMED device and receiving the DCA support. PWTB described the SMS reminders and phone calls as effective reminders, though home visits were less acceptable, due to perceived stigma. Despite willingness to participate in the intervention, the large size of the monitor and sound of the alarm drew attention, potentially causing embarrassment and stigma. Due to perceived stigma, some PWTB adapted the intervention by leaving the monitor at home after removing the pills to ensure that someone else tracked usage, while the PWTB used alternative reminders such as cell phones to take their medication., Conclusion: Although PWTB showed a positive attitude towards the intervention, perceived stigma contributed to participants adapting their lifestyle to meet treatment adherence requirements without using the monitor. However, the medication monitor was a tool that seemed to prompt this personal change in behaviour. Achieving people-centered TB care, including the introduction of DATs, will require that TB programmes incorporate PWTB insights to maximize their use and effectiveness., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Mukora et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Tuberculosis (TB) stigma is a barrier to active case finding and delivery of care in fighting the TB epidemic. As part of a project exploring different models for delivery of TB contact tracing, we conducted a qualitative analysis to explore the presence of TB stigma within communities across South Africa., Methods: We conducted 43 in-depth interviews with 31 people with TB and 12 household contacts as well as five focus group discussions with 40 ward-based team members and 11 community stakeholders across three South African districts., Results: TB stigma is driven and facilitated by fear of disease coupled with an understanding of TB/HIV duality and manifests as anticipated and internalized stigma. Individuals are marked with TB stigma verbally through gossip and visually through symptomatic identification or when accessing care in either TB-specific areas in health clinics or though ward-based outreach teams. Individuals' unique understanding of stigma influences how they seek care., Conclusion: TB stigma contributes to suboptimal case finding and care at the community level in South Africa. Interventions to combat stigma, such as community and individual education campaigns on TB treatment and transmission as well as the training of health care workers on stigma and stigmatization are needed to prevent discrimination and protect patient confidentiality., (© 2023. The Author(s).)

Objectives: The tuberculosis (TB) MATE study evaluated whether a differentiated care approach (DCA) based on tablet-taking data from Wisepill evriMED digital adherence technology could improve TB treatment adherence. The DCA entailed a stepwise increase in adherence support starting from short message service (SMS) to phone calls, followed by home visits and motivational counselling. We explored feasibility of this approach with providers in implementing clinics., Design: Between June 2020 and February 2021, in-depth interviews were conducted in the provider's preferred language, audiorecorded, transcribed verbatim and translated. The interview guide included three categories: feasibility, system-level challenges and sustainability of the intervention. We assessed saturation and used thematic analysis., Setting: Primary healthcare clinics in three provinces of South Africa., Participants: We conducted 25 interviews with 18 staff and 7 stakeholders., Results: Three major themes emerged: First, providers were supportive of the intervention being integrated into the TB programme and were eager to be trained on the device as it helped to monitor treatment adherence. Second, there were challenges in the adoption system such as shortage of human resources which could serve as a barrier to information provision once the intervention is scaled up. Healthcare workers reported that some patients received incorrect SMS's due to delays in the system that contributed to distrust. Third, DCA was considered as a key aspect of the intervention by some staff and stakeholders since it allowed for support based on individual needs., Conclusions: It was feasible to monitor TB treatment adherence using the evriMED device and DCA. To ensure successful scale-up of the adherence support system, emphasis will need to be placed on ensuring that the device and the network operate optimally and continued support on adhering to treatment which will enable people with TB to take ownership of their treatment journey and help overcome TB-related stigma., Trial Registration Number: Pan African Trial Registry PACTR201902681157721., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: COVID-19 vaccination coverage in South Africa (RSA) remains low despite increased access to vaccines. On 1 November 2021, RSA introduced the Vooma Voucher programme which provided a small guaranteed financial incentive, a Vooma Voucher redeemable at grocery stores, for COVID-19 vaccination among older adults, a population most vulnerable to serious illness, hospitalisation and death. However, the association of financial incentives with vaccination coverage remains unclear., Methods: We evaluated the association of the conditional economic incentive programme with first-dose vaccination rates among adults (aged ≥60 years) through a quasi-experimental cohort study. The Vooma Voucher programme was a nationwide vaccination incentive programme implemented for adults aged ≥60 years from 1 November 2021 to 28 February 2022. We ran ITS models to evaluate the Vooma Voucher programme at national and provincial levels. We used data between 1 October 2021 and 27 November 2021 in models estimated at the daily level. Individuals who received their first vaccine dose received a text message to access a ZAR100 ($~7) voucher that was redeemable at grocery stores., Results: The Vooma Voucher programme was associated with a 7.15%-12.01% increase in daily first-dose vaccinations in November 2021 compared with late October 2021. Overall, the incentive accounted for 6476-10 874 additional first vaccine doses from 1 November to 27 November 2021, or 8.31%-13.95% of all doses administered to those aged ≥60 years during that period. This result is robust to the inclusion of controls for the number of active vaccine delivery sites and for the nationwide Vooma vaccination weekend initiative (12 November to 14 November), both of which also increased vaccinations through expanded access to vaccines and demand creation activities., Conclusions: Financial incentives for COVID-19 vaccination led to a modest increase in first-dose vaccinations among older adults in RSA. Financial incentives and expanded access to vaccines may result in higher vaccination coverage., Trial Registration Number Sanctr: DOH-27-012022-9116., Competing Interests: Competing interests: JM is a member of the National Ministerial Advisory Committee on COVID-19 in South Africa. All other authors have declared no conflict of interest., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Gender-based violence (GBV) toward women is widespread and has been associated with increased HIV risk. We investigated attitudes toward GBV among men living in Rustenburg, South Africa, who were enrolled in a longitudinal HIV incidence study. Participants were 18 to 49 years old, reported high risk sexual activity in the last 3 months, and were HIV-uninfected. Attitudes toward GBV were evaluated using responses to a five-item standardized questionnaire about men perpetrating physical violence on a female spouse; responses to each item were scaled from 1 ( no agreement ) to 4 ( strong agreement ) and summed. Total scores >10 were considered permissive toward GBV. Among the 535 men analyzed, nearly half ( N = 229, 42.8%) had a GBV score >10. Being young (18-24 years) (adjusted odds ratio [aOR] = 1.53, 95% confidence interval [CI] [1.06, 2.22]), having less years of education (aOR = 1.61, 95% CI [1.11, 2.32]), and reporting no current sexual partner at baseline (aOR = 2.10, 95% CI [1.06, 4.14]) were independently associated with permissive attitudes toward GBV. The following behaviors reported in the last 3 months were also associated with high GBV scores: having a new female partner (aOR = 1.78, 95% CI [1.02, 3.10]), and having had an STI (aOR = 1.85, 95% CI [1.15, 2.99]). Consuming alcohol prior to sex in the last month (aOR = 1.59, 95% CI [1.09, 2.31]) was also associated with high GBV scores. A large proportion of South African HIV-uninfected men in this analysis reported permissive attitudes toward GBV. These attitudes were associated with HIV risk behavior. Integrating GBV and HIV prevention programs is essential.

Despite advances made in HIV prevention and treatment interventions in South Africa, barriers to their utilization continue to exist. Understanding perspectives from patients and providers of healthcare can shed light on the necessary strategies to enhance uptake of HIV services. A cross-sectional qualitative study was conducted in July 2020 in Ekurhuleni District. Based on HIV prevalence estimates from a national survey, male condom use coverage and antiretroviral treatment (ART) initiation rates from routinely collected clinical data for 2012, we selected facilities from geographical areas with varying HIV prevalence and uptake of HIV services. In-depth interviews were conducted with adult (≥18 years) patients and healthcare workers in selected primary healthcare facilities. Thematic analysis was performed following a framework built around the social cognitive theory to describe behavioural, personal, and social/environmental factors influencing utilization of HIV services. Behavioural factors facilitating uptake of HIV services included awareness of the protective value of condoms, and the benefits of ART in suppressing viral load and preventing mother-to-child HIV transmission which was evident across geographical areas. Barriers in high prevalence areas included suboptimal condom use, fears of a positive HIV result, and anticipated HIV-related stigma while seeking healthcare services. Across the geographical areas, personal factors included ability to correctly use available services enhanced by knowledge acquired during counselling sessions and community-based health promotion activities. Further, social support from family reinforced engagement in care. Compared to low uptake areas, clinics in high uptake areas used care-facilitators, outreach teams and decanting programs to address the environmental barriers including staff shortages and long queues. Barriers at multiple levels prevent optimal utilization of HIV services, calling for strategies that target and address the different levels and tailored to needs of specific settings. Overall, improved delivery of HIV prevention or treatment interventions can be achieved through strengthening training of healthcare providers in facilities and communities and addressing negative sequelae from utilising services in low uptake areas., Competing Interests: All authors declare no conflicts of interest., (Copyright: © 2022 Chimoyi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: The proliferation of false information on COVID-19 mostly through social media is adversely affecting control efforts. The objective of this study was to identify areas where targeted effective messaging can be useful in demystifying misinformation against COVID-19., Results: The study showed high levels of misinformation on COVID-19 in the study area [mean score 2.71; standard deviation (SD) 1.5]. The highest levels of misinformation were observed in Dr. Ruth Segomotsi Mompati district, North West province (mean score: 3.84; SD: 2.1) and Sedibeng district, Gauteng province (mean score: 3.56; SD 1.7). Higher levels of misinformation were reported by those aged 18-24 years (mean score: 3.48; SD: 1.8), and men (mean score: 2.73; SD: 1.8). Across the two provinces, we identified geospatial hot and coldspots of misinformation highlighting the need to implement point of care strategies such as targeted messaging. Findings showed the need for targeted interventions to young people, students, those with low levels of education and the self-employed in the two districts more importantly, as South Africa expands its nationwide vaccination roll-out., (© 2021. The Author(s).)

Background: Studies estimate that circumcising men between the ages of 20-30 years who have exhibited previous risky sexual behaviour could reduce overall HIV prevalence. Demand creation strategies for medical male circumcision (MMC) targeting men in this age group may significantly impact these prevalence rates., Objectives: The objective of this study is to evaluate the cost-effectiveness and cost-benefit of an implementation science, pre-post study designed to increase the uptake of male circumcision for ages 25-49 at a fixed MMC clinic located in Gauteng Province, South Africa., Methods: A health care provider perspective was utilised to collect all costs. Costs were compared between the standard care scenario of routine outreach strategies and a full intervention strategy. Cost-effectiveness was measured as cost per mature man enrolled and cost per mature man circumcised. A cost-benefit analysis was employed by using the Bernoulli model to estimate the cases of HIV averted due to medical male circumcision (MMC), and subsequently translated to averted medical costs., Results: In the 2015 intervention, the cost of the intervention was $9445 for 722 men. The total HIV treatment costs averted due to the intervention were $542,491 from a public care model and $378,073 from a private care model. The benefit-cost ratio was 57.44 for the public care model and 40.03 for the private care model. The net savings of the intervention were $533,046 or $368,628 - depending on treatment in a public or private setting., Conclusions: The intervention was cost-effective compared to similar MMC demand interventions and led to statistically significant cost savings per individual enrolled., (© 2021. The Author(s).)

Background: Clinical trials showed strong evidence that voluntary medical male circumcision (VMMC) reduces the acquisition of HIV among heterosexual men by up to 60%. However, VMMC uptake in East and Southern Africa remains suboptimal, with safety concerns identified as a barrier to uptake. We investigated the occurrence and severity of adverse events (AEs) in a routine VMMC programme implemented in Gauteng and North West provinces of South Africa., Methods: We describe the frequency and characteristics of AEs using routinely collected data from a VMMC programme implemented between 01 May 2013 and 31 December 2014. The surgical procedure was provided at fixed clinics and mobile units in three districts. Adult men undertaking the procedure were referred for follow-up appointments where AEs were monitored., Results: A total of 7,963 adult men were offered the VMMC service with 7,864 (98.8%) met the age and consent requirements for inclusion in a research follow-up after the surgical procedure and were followed-up for potential AEs. In total, 37 (0.5%) patients reported AEs post-surgery with infection [11 (29.7%)] and excessive bleeding [11 (29.7%)] commonly reported AEs. In terms of severity, 14 (37.8%) were classified as mild, 13 (35.1%) as moderate, and 10 (27.0%) as severe. Further, 32 (86.5%) of the AEs were classified as definitely related to the surgical procedure, with 36 (97.5%) of all AEs resolving without sequelae., Conclusion: The VMMC programme was able to reach adult men at high risk of HIV acquisition. Reported AEs in the programme were minimal, with the observed safety profile comparable to clinical trial settings, suggesting that VMMC can be safely administered in a programmatic setting., Competing Interests: The authors have declared that no competing interests exist.

Background: Tuberculosis (TB) household contact tracing is a form of targeted active case-finding for which community health workers ('outreach teams') in South Africa are primarily responsible for its implementation. We conducted an exploratory qualitative study to understand the role of outreach teams in delivering TB household contact tracing., Methods: The study took place in three districts of South Africa between May 2016 and February 2017. We conducted 78 in-depth interviews (IDI) (comprising 35 key stakeholders, 31 TB index patients and 12 HHCs) and five focus group discussions (FGD) (40 outreach team members in four FGDs and 12 community stakeholders in one FGD)., Results: Outreach teams contributed positively by working across health-related programmes, providing home-based care and assisting with tracing of persons lost to TB care. However, outreach teams had a limited focus on TB household contact tracing activities, likely due to the broad scope of their work and insufficient programmatic support. Outreach teams often confused TB household contact tracing activities with finding persons lost to TB care. The community also had some reservations on the role of outreach teams conducting TB household contact tracing activities., Conclusions: Creating awareness among outreach workers and clinic personnel about the importance of and activities related to TB household contact tracing would be required to strengthen the delivery of TB household contact tracing through the community-based primary health care teams. We need better monitoring and evaluation systems, stronger integration within a realistic scope of work, adequate training on TB household contact tracing and TB infection prevention control measures. Involving the community and educating them on the role of outreach teams could improve acceptance of future activities. These timely results and lessons learned should inform contact tracing approaches in the context of COVID-19., Competing Interests: The authors have declared that no competing interests exist.

Background: Stigma affects engagement with HIV healthcare services. We investigated the prevalence and experience of stigma among incarcerated people living with HIV (PLHIV) in selected South African correctional settings during roll-out of universal test and treat., Methods: A cross-sectional mixed-methods study design included 219 incarcerated PLHIV and 30 in-depth interviews were conducted with four different types of PLHIV. HIV-related stigma was assessed through survey self-reporting and during the interviews. A descriptive analysis of HIV-related stigma was presented, supplemented with a thematic analysis of the interview transcripts., Results: ART uptake was high (n = 198, 90.4%) and most reported HIV-related stigma (n = 192, 87.7%). The intersectional stigma occurring due to individual and structural stigma around provision of healthcare in these settings mostly contributed to perceived stigma through involuntary disclosure of HIV status. Interpersonal and intrapersonal factors led to negative coping behaviours. However, positive self-coping strategies and relationships with staff encouraged sustained engagement in care., Conclusion: We encourage continuous peer support to reduce stigmatization of those infected with HIV and whose status may be disclosed inadvertently in the universal test and treat era., Competing Interests: The authors have declared that no competing interests exist.

Background: Beliefs about gender roles and high-risk sexual behaviours underlie the human immunodeficiency virus (HIV) epidemic in South Africa. Yet, there is limited information on the relationships between beliefs about gender roles and risky sexual behaviours. Few studies have explored the association between beliefs about gender roles, high risk sexual behaviour, and health-seeking behaviour among men., Methods: We investigated associations between gender beliefs (dichotomised as traditional or progressive) and high-risk sexual behaviour among South African men presenting for medical male circumcision (Apr 2014 to Nov 2015)., Results: Of 2792 enrolled men, 47.4% reported traditional gender beliefs. Participant ages ranged between 18-46 years (median age 26 years; interquartile range, 21-31 years). Most participants had at least one sex partner over the last 12 months (68.2%). Younger men (18-24 years old vs. 25-46 years old) (odds ratio [OR], 1.5 [95% confidence interval (CI) 1.0-2.0]), those with multiple partners ([OR], 1.5 (CI) 1.3-1.8]) and participants unsure of their last partner's HIV status (OR, 1.4 [95% CI 1.1-1.7]) were more likely to have traditional beliefs on gender roles., Conclusion: Young men with traditional beliefs on gender roles may be more likely to engage in high-risk sexual behaviour and could be good candidates for HIV prevention programmes. N = 206 (max 350) Trial registration Name of registry: Clinicaltrials.gov; Trial registration number: NCT02352961; Date of registration: 30 January 2015 "Retrospectively registered"; URL of trial registry record: https://www.clinicaltrials.gov/.

Background: South Africa has achieved drug-susceptible TB (DS-TB) treatment success of only 77% among people with new and previously treated TB. Alternative approaches are required to improve medication adherence and treatment completion to limit transmission, TB relapse and the development of resistance. This study aims to implement and evaluate the use of adherence medication monitors (Wisepill evriMED 1000) with a differentiated response to patient care, among DS-TB patients in three provinces of South Africa., Methods: In total, 18 public health clinics across three provinces were selected. Clinics were randomised to intervention or standard of care clinics. In each clinic, approximately 145 DS-TB patients are being enrolled to reach a total of 2610. All patients have their daily adherence monitored using medication monitors. In the intervention arm, patients are receiving medication monitor reminders and differentiated care in response to adherence data. This weekly review of daily real-time monitoring will be undertaken from a central database. The differentiated care model includes automated SMS reminders with a missed dose, research staff-initiated phone call to the patient with a second or third missed dose, a home visit if four or more doses are missed, and motivational counselling if four or more doses are missed repeatedly. Fidelity of the intervention will be measured through process evaluation. Patients in control clinics will receive medication monitors for adherence tracking, standard of care TB education, and normal clinic follow-up procedures. The primary outcome is the proportion of patients by arm with >80% adherence, as measured by the medication monitor. The feasibility and acceptability of the intervention will be assessed by in-depth interviews with patients, stakeholders, and study staff. A cost effectiveness analysis of the intervention and standard of care clinics will be conducted., Significance: This trial will provide evidence for the use of an intervention, including medication monitors and differentiated care package, to improve adherence to TB treatment. Improved adherence should also improve TB treatment completion rates, thus reducing loss to follow-up rates, and TB relapse among people with TB. The intervention is intended to ultimately improve overall TB control and reduce TB transmission in South Africa., Trial Registration: Pan African Trial Registry PACTR201902681157721 . Registered on 11 February 2019.

Human Immunodeficiency Virus (HIV) prevalence among South African youth is high, yet HIV testing remains suboptimal. We explored how perceptions of HIV risk and behaviours informed decisions to test for HIV. This study was conducted from April 2018 to March 2019 in Ekurhuleni district, Gauteng Province with males and females aged between 15-24 years. Twenty-five youth with unknown HIV status participated in in-depth interviews (IDIs); while four focus group discussions (FGDs) were conducted with those that previously tested for HIV. Probes used in the guides included types of incentives that youth would value when testing for HIV or receiving treatment; barriers and motivators to HIV testing; enablers and challenges to using cellphone technology and preferences on type of social media that could be used to create awareness about HIV testing services. IDIs and FGDs were audio-recorded, transcribed, and translated. QSR NVIVO 10 was used for the analysis. The majority of the youth perceived that their risk of HIV infection was low due to factors such as being young, lacking physical signs of HIV, being sexually inactive and parents not being HIV positive. However, youth identified high risk behaviours such as unprotected sex, multiple sexual partners, excessive drinking of alcohol, being victims of sexual abuse, road accidents and violent behaviour as increasing their vulnerability to HIV. Most youth highlighted cues to action that would motivate them to test for HIV such as support of parents, receiving incentives, improved confidentiality during HIV testing and receiving information about HIV via social media (Facebook, Twitter and Whatsapp). Despite perceptions of low risk to HIV, youth remain vulnerable to HIV. Disseminating HIV information via digital platforms; giving youth options to choose between testing locations that they consider to be private; providing incentives and equipping parents/guardians to encourage youth to test could optimise HIV testing., Competing Interests: The authors have declared that no competing interests exist.

We conducted a discrete choice experiment (DCE) and quantified preferences for HIV testing among South African youth (Nov 2018 to Mar 2019). Six attributes and levels were identified through qualitative methods: source of HIV information; incentive amount and type; social support; testing method; and location. Each participant chose one of two options that comprised six attributes across 18 questions. Conditional logistic regression estimated the degree of preference [β]. Of 130 participants, median age was 21 years (interquartile range 19-23 years), majority female (58%), and 85% previously tested for HIV. Testing alone over accompanied by a friend (β = 0.22 vs. - 0.35; p < 0.01); SMS text over paper brochures (β = 0.13 vs. - 0.10; p < 0.01); higher incentive values (R50) over no incentive (β = 0.09 vs. - 0.07; p = 0.01); and food vouchers over cash (β = 0.06 vs. β =  - 0.08; p = 0.01) were preferred. Testing at a clinic or home and family encouragement were important. Tailoring HTS to youth preferences may increase HIV testing.

Background: Despite the global scale-up of antiretroviral therapy (ART), incarcerated people have not benefited equally from test-and-treat recommendations for HIV. To improve access to ART for incarcerated people with HIV, we introduced a universal test-and-treat (UTT) intervention in correctional facilities in South Africa and Zambia, and aimed to assess UTT feasibility and clinical outcomes., Methods: Treatment as Prevention (TasP) was a multisite, mixed methods, implementation research study done at three correctional complexes in South Africa (Johnannesburg and Breede River) and Zambia (Lusaka). Here, we report the clinical outcomes for a prospective cohort of incarcerated individuals who were offered the TasP UTT intervention. Incarcerated individuals were eligible for inclusion if they were aged 18 years or older, with new or previously diagnosed HIV, not yet on ART, and were expected to remain incarcerated for 30 days or longer. To enable the implementation of UTT at the included correctional facilities, we first strengthened on-site HIV service delivery. All participants were offered same-day ART initiation, and had two study-specific follow-up visits scheduled to coincide with routine clinic visits at 6 and 12 months. The main outcomes were ART uptake, time from cohort enrolment to ART initiation, and retention in care and viral suppression at 6 and 12 months. We estimated the association between baseline demographic characteristics and time to ART initiation using Cox proportional hazard models, and, in a post-hoc analysis, we used logistic regression models to assess the association between demographic and clinical variables, including time to ART initiation, and the proportion of participants with a composite poor outcome (defined as viral load >50 copies per mL, or for participants with a missing viral load, lack of retention in care in the on-site ART programme) at 6 months. This study is registered at ClinicalTrials.gov, NCT02946762., Findings: Between June 23, 2016, and Dec 31, 2017, we identified 1562 incarcerated people with HIV, of whom 1389 (89%) were screened, 1021 (74%) met eligibility criteria, and 975 (95%) were enrolled and followed up to March 31, 2018. At the end of follow-up, 835 (86%) of 975 participants had started ART. Median time from enrolment to ART initiation was 0 days (IQR 0-8). Of 346 participants who remained incarcerated at 6 months, 327 (95%) were retained in care and 269 (78%) had a documented viral load, of whom 262 (97%) achieved viral suppression (<1000 copies per mL). The mortality rate among the 835 participants who had initiated ART was 1·9 per 100 person-years (95% CI 0·9-3·9). No statistically significant associations were identified between any baseline characteristics and time to ART initiation or composite poor outcome., Interpretation: UTT implementation is feasible in correctional settings, and can achieve levels of same-day ART uptake, retention in care, and viral suppression among incarcerated people with HIV that are comparable to those observed in community settings., Funding: UK Department for International Development, Swedish International Development Cooperation Agency, Norwegian Agency for Development Cooperation., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Household contract tracing (HHCT) is an important strategy for active tuberculosis case finding and offers an opportunity for testing of other diseases such as HIV. However, there is limited data on the patient-centered approach to HHCT. Our study aimed to describe experiences and preferences of household contacts (HHCs) for HHCT., Methods: We conducted a qualitative study in Rustenburg, South Africa from September 2013 to March 2015. Twenty-four HHCs (≥18 years) had audio-recorded in-depth interviews. We used an inductive thematic analysis approach to develop themes. We made an a priori assumption that we would reach saturation with at least 20 interviews., Results: There were 16 (66.7%) females (median age = 36 years) and eight (33.3%) males (median age = 34 years). Two themes developed: (i) Positive attitude of HHCs towards TB services provided at home and (ii) HHCs relationship to and acceptance of people living with TB (PLTB). The first main theme emphasized that HHCs appreciated the home visits. Participants preferred home visits because they had negative experiences at the clinic such as delayed waiting times and long queues. HHCs supported the screening of children for TB at home. Participants suggested that the research staff could expand their services by screening for diabetes and hypertension alongside TB screening. In the second main theme, there was a sense of responsibility from the HHCs towards accepting the diagnosis of PLTB and caring for them. A sub-theme that emerged was that as their knowledge on TB disease improved, they accepted the TB status of the PLTB empowering them to take care of the PLTB., Conclusions: HHCs are supportive of HHCT and felt empowered by receiving TB education that ultimately allowed them to better understand and care for PLTB. HHCs were supportive of screening children for TB at home. Future HHCT activities should consider raising community awareness on the benefits of TB contact tracing at households.

Background: Tuberculosis (TB) treatment loss to follow up (LTFU) plays an important contributory role to the staggering TB epidemic in South Africa. Reasons for treatment interruption are poorly understood. Treatment interruption appears to be the culmination of poor health literacy of patients and inadequate health education provided by clinicians. We explored clinician and patient perspectives of the gaps in TB messaging that influence TB treatment LTFU., Methods: We conducted semi-structured in-depth interviews between January and May 2018 with a sample of 15 clinicians managing TB and 7 patients identified as LTFU in public clinics in the Free State Province, South Africa. Thematic analysis using a mixed deductive/inductive thematic approach was used., Results: Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Patients felt that the TB messaging received was inadequate. Many of the clinicians interviewed felt that improving patient's TB knowledge would reinforce adherence to treatment and thus focused on sharing information on treatment completion, side effects and infection control. However, the inability of clinicians to establish rapport with patients or to identify social support challenged TB treatment adherence by patients. Clinicians perceived this as patients not following their instructions despite what they considered lengthy TB education. Having said this, clinicians concurred that their medical management of TB lacked the psycho-social dimension to treat a social disease of this magnitude., Conclusions: Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Clinicians concurred that poor patient understanding of TB and that biomedical management lacking a psycho-social dimension further exacerbated the poor treatment outcome. TB remains a social disease, the successful management of which hinges on patient-centred care.

Background: Sub-Saharan African correctional facilities concentrate large numbers of people who are living with HIV or at risk for HIV infection. Universal test and treat (UTT) is widely recognized as a promising approach to improve the health of individuals and a population health strategy to reduce new HIV infections. In this study, we explored the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa., Methods: Nested within a UTT implementation research study, our qualitative evaluation of feasibility and sustainability used a case-comparison design based on data from 1 Zambian and 3 South African correctional facilities. Primary data from in-depth interviews with incarcerated individuals, correctional managers, health care providers, and policy makers were supplemented by public policy documents, study documentation, and implementation memos in both countries. Thematic analysis was informed by an empirically established conceptual framework for health system analysis., Results: Despite different institutional profiles, we were able to successfully introduce UTT in the South Africa and Zambian correctional facilities participating in the study. A supportive policy backdrop was important to UTT implementation and establishment in both countries. However, sustainability of UTT, defined as relevant government departments' capacity to independently plan, resource, and administer quality UTT, differed. South Africa's correctional facilities had existing systems to deliver and monitor chronic HIV care and treatment, forming a "scaffolding" for sustained UTT despite some human resources shortages and poorly integrated health information systems. Notwithstanding recent improvements, Zambia's correctional health system demonstrated insufficient material and technical capacity to independently deliver quality UTT. In the correctional facilities of both countries, inmate population dynamics and their impact on HIV-related stigma were important factors in UTT service uptake., Conclusion: Findings demonstrate the critical role of policy directives, health service delivery systems, adequate resourcing, and population dynamics on the feasibility and likely sustainability of UTT in corrections in Zambia and South Africa., (© Topp et al.)

Introduction: Understanding HIV incidence and risk behaviour among populations being considered for HIV vaccine studies is necessary for the appropriate design of trials., Methods: Between May 2012 and June 2015, we recruited men aged 18-49 years from urban and peri-urban areas of Rustenburg, a mining town in the North West Province, South Africa. Men who reported HIV-risk behaviour were followed for nine to 12 months to determine HIV incidence and factors associated with condom use., Results: A total of 400 HIV uninfected men were enrolled; 366 (91.5%) had at least one follow-up visit and were included in the analysis; 47.6% were under 25 years of age. HIV incidence was 1.9 per 100 person-years (95% CI: 0.79-4.56). Among heterosexual men (N = 339), 80.8% reported having vaginal intercourse with multiple partners in the past three months, among whom 74.1% reported inconsistent condom use. Sixty-eight percent reported vaginal intercourse with new female partners, of whom 40.6% reported inconsistent condom use. Over half (55.6%) of men who had sex with men (N = 27) reported anal intercourse with multiple male partners in the past three months, of whom 68.2% reported using condoms inconsistently. Men who had more than two female partners in the last three months (n = 121) were more likely to use condoms inconsistently (aOR 4.31, 95% CI: 1.34-13.8); in contrast, those with more than one new female sex partner (aOR 0.13, 94% CI 0.04-0.44), and whose sexual debut was after 19 years of age (aOR 0.39, 95% CI: 0.15-1.01) were less likely to use condoms inconsistently., Conclusion: HIV incidence was low and similar to other studies of heterosexual men in South Africa. To identify men at high risk for HIV for enrolment in prevention trials, future researchers may need to focus on those who report early sexual debut and who report having multiple sexual partners. Men in newer relationships appear to use condoms more frequently., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men and has long-term indirect protection for women, yet VMMC uptake in South Africa remains low (49.8%) in men (25-49 years). We explored the attitude and willingness of women to start conversations on VMMC with their sexual partners in a South African peri-urban setting to increase VMMC uptake., Methods: Thirty women with median age of 30 years (inter-quartile range 26-33 years) were interviewed in a language of their choice. Key questions included: types of approach to use, gender roles, benefits and barriers to introducing the topic of VMMC, and perceptions of VMMC. Interviews were digitally-recorded, transcribed, and translated. Through a standard iterative process, a codebook was developed (QSR NVIVO 10 software) and inductive thematic analysis applied., Results: Most women were willing talk to their sexual partners about circumcision, but indicated that the decision to circumcise remained that of their sexual partner. Women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. Using magazine/newspaper articles, pamphlets or advertisements were identified as tools that could aid their discussion. Substantial barriers to initiating conversations on VMMC included accusations by partner on infidelity, fear of gender-based violence, cultural restrictions and hesitation to speak to a mature partner about circumcision., Conclusions: Women need to ensure that before talking to their partner about circumcision, the environment and approach that they use are conducive. Female social network forums could be used to educate women on conversation techniques, skills to use when talking to their partners and how to address communication challenges about circumcision. Involvement of women in VMMC awareness campaigns could encourage circumcision uptake among men., Competing Interests: The authors have declared that no competing interests exist.

Background: South Africa introduced medical male circumcision (MMC) to reduce HIV incidence. Mathematical modeling suggested that targeting MMC services to men aged 20-34 years could provide the most immediate impact on HIV incidence. However the majority of MMCs performed have been among males aged ≤25 years. We evaluated an intervention package to increase MMC uptake among men aged 25-49 years., Methods: We conducted a pre-post study to compare the proportion of men (aged 25-49 years) presenting for MMC during the formative (Phase 1) and intervention (Phase 2) phases in Ekurhuleni, Johannesburg, South Africa. The intervention included infrastructure changes that separated adults from adolescents at the MMC site, an exclusive men's health club, adult-specific demand generation materials, and discussions with community members., Results: Overall 2817 enrolled in the study with 1601 from Phase 1 and 1216 in Phase 2. A higher proportion of participants aged 25-49 years accessed MMC in Phase 2 compared to Phase 1 (59.4% vs. 54.9%; Prevalence Ratio = 1.08; 95% Confidence Interval: 1.01-1.15; p = 0.019). Participants with multiple partners in the past 12 months in Phase 2 were more likely to access MMC services compared to participants in Phase 1 (unadjusted Odds Ratio, 1.37; 95% CI:1.17-1.61; p < 0.001). After adjusting for age, multiple partners remained a risk factor in Phase 2 (adjusted OR, 1.39; 95% CI: 1.18-1.63; p < 0.001)., Conclusions: The "Exclusive Intervention Strategy" was associated with a slight increase in the proportion of participants aged 25-49 years accessing MMC services, and an increase in those with HIV risk behaviors, during the intervention phase. These findings may provide important insights to overcoming barriers for accessing MMC services among men aged 25-49 years., Trial Registration: The study is registered at ClinicalTrials.gov , number NCT02352961 .

South Africa's public healthcare system responses seldom engage with migration. Our exploratory study investigates migration profiles and experiences of primary healthcare (PHC) users. A cross-sectional survey involving non-probability sampling was conducted with 229 PHC users at six purposively selected PHC clinics in three districts of SA. The survey captured socio-demographic information, migration histories, and PHC experiences. Chi square and Fischer's exact tests were used to compare categorical variables, whilst Mann-Whitney U tests compared continuous variables between groups. Most PHC users were migrants (22% internal South African; 45% cross-border) who generally move for reasons other than healthcare seeking. Length of time accessing services at a specific clinic was shown to be key in describing experiences of PHC use. Understanding population movement is central to PHC strengthening in SA and requires improved understanding of mobility dynamics in regard to not just nationality, but also internal mobility and length of stay.

Aim: This study examined the effects of prenatal alcohol exposure on childhood development trajectories in a rural South African community between 2003 and 2008., Methods: We assessed 121 children at 7-12 months (year one) and 5-6 years (year five) using the Griffiths Mental Developmental Scales - Extended Revised, which measures sensorimotor, cognitive and social development, with lower scores indicating developmental delay. We also interviewed their mothers or caregivers. Three groups were identified: 29 with foetal alcohol syndrome (FAS) or partial FAS (pFAS), 57 more who had been exposed to alcohol and 35 controls who had not., Results: The scale's total score was higher in the controls than in the FAS/pFAS group at year one and year five and in the alcohol-exposed group at year five. Many groups' trajectories declined when compared with global norms, but the trajectories in the FAS/pFAS and the alcohol-exposed groups declined more than the controls for eye-hand and performance and total score. Earlier pregnancy recognition in the FAS/pFAS group correlated strongly (r = -0.77) with higher GQ in year five., Conclusion: FAS/pFAS and prenatal alcohol exposure affected the Griffiths scores more than the control group. Efforts are needed to detect pregnancy early and reduce alcohol exposure., (©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Introduction: Women in HIV prevention trials often must typically agree to avoid pregnancy. Regardless, some become pregnant. Screening tools predicting pregnancy risk could maximize trial safety and efficiency., Objectives: We assessed incidence and correlates of pregnancy among women at high HIV risk., Methods: We enrolled sexually-active, HIV-negative women into an observational cohort (2008-2011). At enrollment demographic, contraceptive, reproductive, pregnancy intention and behavioural data were collected. Women reported if one or both partners wanted or intended for the couple to become pregnant. We measured gender role beliefs using a locally validated eight-point index. We tested HIV and pregnancy, and inquired about sexually transmitted infection symptoms (STIs) at enrollment and monthly. HIV testing included behavioural counselling and condom provision, but did not specifically counsel women to avoid pregnancy. Cox proportional hazard modelling evaluated the associations with pregnancy. The multivariate model included the following variables "Recent pregnancy attempts", "Gender Roles Beliefs", "Self-reported STIs" and "Age"., Results: We screened 1068 women and excluded (24.6%, 263/1068) who did not report risk behaviour. Non-pregnant, non-sterilized women aged 18-35 (median = 21 years) enrolled (n = 438). Most women reported one partner (74.7%) and a prior live birth (84.6%). Median follow-up time was 6 months (range 0.7-15.5). Pregnancy incidence was 25.1 per 100 women-years (n = 57 pregnancies). Conservative beliefs on gender roles (Adjusted Hazard Ratio (aHR) 1.8; 95% confidence interval [CI] 1.1-2.9), recent pregnancy attempts (aHR 1.9; 95% CI 1.1-3.4) and baseline self-reported STI (aHR 2.5; 95% CI 1.4-4.4) were associated with increased incident pregnancy. Report of no pregnancy intention was associated with lowered pregnancy risk (aHR 0.3; 95% CI 0.1-0.7)., Conclusions: We identified new and confirmed existing factors that can facilitate screening for pregnancy risk.

This article summarises the consensus arrived at a meeting of South African and international stakeholders on specific late phase clinical trial design issues integrating the investigation of immune correlates as an integral part of a phase III protocol for a preventative TB vaccine in an adolescent/adult population. The challenge ahead is to optimize the planning for phase 3 TB vaccine preventative trials, under resource constraints, given that there are no known correlates of protection to shorten and increase the efficiencies of efficacy trials. An adaptive, multi-arm, group sequentially designed trial protocol is proposed incorporating design features that address uncertainties arising from both advances in the field and dynamic study populations and disease states. Such a design allows modifications that protect research subjects, save time, and maximize the impact of scarce financial resources. Further, the protocol underwent joint review by regulators from several African nations at a meeting of the African Vaccine Regulatory Forum (AVAREF), a regional regulatory harmonization initiative, and recommendations are included., (Copyright © 2012 Elsevier Ltd. All rights reserved.)