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AHEAD feasibility trial assessed the feasibility and acceptability of an 8-session group drumming programme aiming to improve executive function, depression and anxiety symptoms, and perceived social support in adolescents living with HIV in a rural low-income South African setting. Sixty-eight 12- to 19-year-old adolescents participated. They were individually randomised. The intervention arm (n = 34) received weekly hour-long group drumming sessions. Controls (n = 34) received no intervention. Feasibility and acceptability were assessed using rates of: enrolment; retention; attendance; logistical problems; adolescent-reported acceptability. Secondary measures included: five Oxford Cognitive Screen-Executive Function (OCS-EF) tasks; two Rapid Assessment of Cognitive and Emotional Regulation (RACER) tasks; the Self-Reporting Questionnaire-20 (SRQ-20) measuring depression and anxiety symptoms; the Multidimensional Scale of Perceived Social Support (MSPSS). All feasibility criteria were within green progression limits. Enrolment, retention, and acceptability were high. There was a positive effect on adolescent depressed mood with signal for a working memory effect. There were no significant effects on executive function or socio-emotional scales. Qualitative findings suggested socio-emotional benefits including: group belonging; decreased internalised stigma; improved mood; decreased anxiety. Group drumming is a feasible and acceptable intervention amongst adolescents living with HIV in rural South Africa. A full-scale trial is recommended.

BACKGROUND: Sub-Saharan Africa is undergoing an epidemiologic transition from infectious diseases to cardiovascular diseases. From 2014 to 2019, sociodemographic surveillance was performed in a large cohort in rural South Africa. METHODS: Disease prevalence and incidence were calculated using inverse probability weights. Poisson regression was used to identify disease predictors. The percentage of individuals with controlled ( RESULTS: Compared with 2014 (n=5059), study participants in 2019 (n=4176) had similar rates of obesity (mean body mass index, 27.5±10.0 versus 27.0±6.5) but higher smoking (9.1% versus 11.5%) and diabetes (11.1% versus 13.9%). There was no significant increase in hypertension prevalence (58.4% versus 59.8%; age adjusted, 64.3% versus 63.3%), and there was a significant reduction in mean systolic blood pressure (138.0 versus 128.5 mm Hg; P CONCLUSIONS: The hypertension prevalence and incidence are plateauing in this aging cohort. There was a statistically and clinically significant decline in mean blood pressure and a substantial increase in individuals with controlled hypertension on medication. The prevalence of cardiometabolic risk factors did not decrease over time, suggesting that the blood pressure decrease is likely due to increased medication access and adherence, promoted by local health systems.

Background: Physical and mental health problems are common among older adults living with HIV (OALWH). Adaptive coping strategies play a vital role in improving these adults' mental health and well-being despite the deleterious effects of HIV and ageing. However, in sub-Saharan Africa, limited evidence exists on the commonly utilized coping strategies in this population. We explore the coping strategies used by Kenyan OALWH to improve their mental health and wellbeing. Methods: Semi-structured in-depth interviews were conducted between October and December 2019 with 56 participants: 34 OALWH (53% female), 11 healthcare providers (63% female) and 11 primary caregivers (73% female) in Kilifi County. All interviews were audio-recorded and transcribed verbatim. We used the framework approach to synthesize the qualitative data. Results: Five major themes emerged from the analysis of participants’ narratives, including self-care practices, religion and spirituality, relational living (social connectedness), generativity, identity, and mastery. Our study further revealed maladaptive coping strategies, including reliance on over-the-counter medications, self-isolation, waiting to see if symptoms would subside despite doing nothing, and HIV treatment interruptions during prolonged periods of prayer and fasting. Conclusions: Our findings provide an initial understanding of the coping strategies used by OALWH to confront HIV and ageing challenges in a low-literacy, low socio-economic Kenyan setting. Our results suggest that interventions designed to enhance personal capacity, social support, positive religiosity and spirituality, and intergenerational connections may be beneficial in improving the mental health and well-being of OALWH.

Background: The burden and determinants of frailty in sub-Saharan Africa (SSA) are largely unknown despite a rapidly aging population in the region. To address the gap in Kenya, we: a) determined the prevalence of frailty among older adults living with HIV (OALWH) and compared to their uninfected peers; b) investigated HIV status as an independent predictor of frailty in the older adults; c) investigated the correlates of frailty in these adults. Methods: This cross-sectional study was conducted between 2020 and 2021 at the Kenyan coast among 440 older adults aged ≥50 years (257 OALWH). Frailty was assessed using the Reported Edmonton Frail Scale, which comprises nine domains of frailty, including cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and self-reported functional performance. We also collected biopsychosocial information from the respondents. Logistic regression was used to examine the correlates of frailty. Results: The prevalence of frailty was significantly higher among OALWH (24%) compared to their uninfected peers (13%), p01. However, after adjusting for biopsychosocial factors, HIV seropositivity was not independently associated with frailty. Among OALWH, sleeping difficulties, ageism, higher waist/hip ratio, visiting traditional healers, a history of combination antiretroviral therapy (cART) regimen change/interruption and prolonged illness following HIV diagnosis were significantly associated with higher odds of frailty. Residing in larger households, higher household income, having a social network of friends, and light physical activities were significantly associated with reduced odds of frailty. Among HIV uninfected older adults, sleeping difficulties, self-reported diabetes and light physical activities were significantly associated with elevated odds of frailty, while being male was significantly associated with reduced odds of frailty. Conclusions: The prevalence of frailty is elevated among older adults living with HIV when compared to their uninfected peers; however, factors other than HIV are predominant, particularly psychosocial factors. Our findings provide the foundation for further research on frailty and developing culturally appropriate interventions and healthcare strategies to prevent, delay and manage frailty at the Kenyan Coast and other similar settings.

Purpose The PHIRST study (Prospective Household cohort study of Influenza, Respiratory Syncytial virus, and other respiratory pathogens community burden and Transmission dynamics in South Africa) aimed to estimate the community burden of influenza and respiratory syncytial virus (RSV) including the incidence of infection, symptomatic fraction, and to assess household transmission. Participants We enrolled 1684 individuals in 327 randomly selected households in a rural and an urban site over three consecutive influenza and two RSV seasons. A new cohort of households was enrolled each year. Participants were sampled with nasopharyngeal swabs twice‐weekly during the RSV and influenza seasons of the year of enrolment. Serology samples were collected at enrolment and before and after the influenza season annually. Findings to Date There were 122 113 potential individual follow‐up visits over the 3 years, and participants were interviewed for 105 783 (87%) of these. Out of 105 683 nasopharyngeal swabs, 1258 (1%) and 1026 (1%) tested positive on polymerase chain reaction (PCR) for influenza viruses and RSV, respectively. Over one third of individuals had PCR‐confirmed influenza each year. Overall, there was influenza transmission to 10% of household contacts of an index case. Future Plans Future planned analyses include analysis of influenza serology results and RSV burden and transmission. Households enrolled in the PHIRST study during 2016–2018 were eligible for inclusion in a study of SARS‐CoV‐2 transmission initiated in July 2020. This study uses similar testing frequency to assess the community burden of SARS‐CoV‐2 infection and the role of asymptomatic infection in virus transmission.

Summary Background Improving hypertension control is an important global health priority, yet, to our knowledge, there is no direct evidence on the relationship between blood pressure and mortality in sub-Saharan Africa. We aimed to investigate the relationship between systolic blood pressure and mortality in South Africa and to assess the comparative effectiveness of different systolic blood pressure targets for clinical care and population-wide hypertension management efforts. Methods In this country-wide, population-based cohort study, we used longitudinal data on adults aged 30 years and older from five waves (2008, 2010–11, 2012, 2014–15, and 2017) of the South African National Income Dynamics Study. We estimated the relationship between systolic blood pressure and 6-year all-cause mortality and compared the mortality reductions associated with lowering systolic blood pressure to different targets (120 mm Hg, 130 mm Hg, 140 mm Hg, 150 mm Hg). We also estimated the mean blood pressure reduction required to achieve each target, the share of the population in need of management, and the number needed to treat (NNT) to avert one death under different hypothetical population-wide scale-up scenarios. Findings Of the 8338 age-eligible respondents in the 2010–11 survey, 4993 had all required data and were included in our study. We found a weak, non-linear relationship between systolic blood pressure and 6-year mortality, with larger incremental mortality benefits at higher systolic blood pressure values: reducing systolic blood pressure from 160 mm Hg to 150 mm Hg was associated with a relative risk of mortality of 0·95 (95% CI 0·90 to 0·99; p=0·033), reducing systolic blood pressure from 150 mm Hg to 140 mm Hg had a relative risk of 0·96 (0·91 to 1·01; p=0·12), with no evidence of incremental benefits of reducing systolic blood pressure below 140 mm Hg. At the population level, reducing systolic blood pressure to 150 mm Hg among all those with a starting systolic blood pressure of more than 150 mm Hg was associated with the lowest NNT (n=50), 3·3 deaths averted (95% CI −0·6 to 0·3) per 1000 population, blood pressure management for 16% (95% CI 15·2 to 17·3) of individuals, and a −2·7 mm Hg mean change in systolic blood pressure required to achieve the 150 mm Hg scale-up target (−3·0 to −2·5; p Interpretation The relationship between systolic blood pressure and mortality is weaker in South Africa than in high-income and many low-income and middle-income countries. As such, we do not find compelling evidence in support of targets below 140 mm Hg and find that scaling up management based on a 150 mm Hg target is more efficient in terms of the NNT compared with strategies to reduce systolic blood pressure to lower values. Funding None

Introduction: Despite rapid population aging, there are currently limited data on the incidence of aging-related cognitive impairment in sub-Saharan Africa. We aimed to determine the incidence of cognitive impairment and its distribution across key demographic, social, and health-related factors among older adults in rural South Africa. Methods: Data were from in-person interviews with 3,856 adults aged ≥40 who were free from cognitive impairment at baseline in the population-representative cohort, “Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa” (HAALSI), in Agincourt sub-district, Mpumalanga province, South Africa (2014–19). Cognitive impairment was defined as scoring

Objective To understand the risk of HIV acquisition through occupational exposure among rural South African traditional healers, notably via the practice of traditional skin incisions with razors. Design A random sample of traditional healers living in South Africa participated in a cross-sectional survey that included a rapid HIV test. Setting Rural Bushbuckridge district of Mpumalanga, South Africa. Participants Traditional healers. Intervention Pretest counseling, posttest counseling, and referral to care if HIV seropositive. Main outcome measure(s) HIV infection. Results Among healers who reported a previous positive test result or accepted an HIV test (96%), HIV prevalence was 30% (95% confidence interval: 23-37%). During their careers, 98% of healers reported conducting at least one 'vaccination' (as traditional incisions are called), 32% reported always using gloves when conducting these procedures, 29 (14%) reported patient blood touching their bare skin. Healers who reported exposure to patient blood had a higher HIV prevalence than their nonexposed colleagues (adjusted risk ratio: 2.35, 95% confidence interval: 1.55-3.56, P = 0.001). Conclusion Nearly all traditional healers are routinely performing minimally invasive skin incisions that could expose them to patient blood. The lack of training and access to personal protective equipment increase their risk of acquisition of blood-borne pathogens, including HIV. Given the widespread practice of traditional skin incisions across southern Africa, and the higher levels of HIV among traditional healers exposed to patient blood, it is likely that traditional healers are a hitherto unrecognized key population at disproportionate risk of acquiring HIV.

Research on early life adversity and later-life cognitive function is conflicting, with little evidence from low-income settings. We investigated associations between adverse childhood experiences and cognitive function in an older population who grew up under racial segregation during South African apartheid. Data were from 1,871 adults aged 40-79 in the population-representative "Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" in 2015. The adverse childhood experiences were having a parent unemployed for > 6 months; having parents who argued or fought often; having a parent who drank excessively, used drugs, or had mental health problems; and physical abuse from parents. Executive function, language, visuospatial ability, and memory were assessed with the Oxford Cognitive Screen-Plus, a validated cognitive assessment designed for low-income, low-literacy settings. We estimated associations between adverse childhood experiences and latent cognitive domain z-scores using multiple-indicator, multiple-cause structural equation models. Childhood adversities were reported by 15% (parental unemployment for > 6 months), 25% (parents argued or fought often), 25% (a parent drank excessively, used drugs, or had mental health problems), and 35% (physical abuse from parent) of respondents. They were not associated with cognition, except that having a parent who drank excessively, used drugs, or had mental health problems was associated with lower memory z-scores (-0.07; 95% CI [-0.13, -0.01]). This is one of the first investigations into later-life cognitive outcomes associated with early adversity in a population with a historical context of pervasive trauma, and suggests that later-life memory may be vulnerable to early adversity. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

In 2018, nearly 800,000 HIV positive individuals in South Africa were unaware of their status. Traditional healers see patients who avoid health clinics, including those who refuse HIV testing. This manuscript details the results of a qualitative study to understand traditional healer perspectives on performing healer-initiated HIV counseling and testing HIV in rural South Africa. We conducted 30 structured in-depth, in-person interviews between April and June 2019 to elicit traditional healer attitudes towards partnering with local health services to perform HIV counseling and testing with their patients. Healers reported that while some patients are open about their HIV status, others lie about it due to stigma around the disease. This creates challenges with concurrent treatment, which healers believe leads to allopathic and/or traditional medication treatment failure. Most healers expressed both an interest and a willingness to perform HIV counseling and testing. Healers felt that by performing testing in the community, it would overcome issues related to HIV stigma, as well as a lack of confidentiality and trust with health care workers at the clinic. Trained traditional healers may be able to bridge the testing gap between “non-testers” and the allopathic health system, essentially “opening” thousands of new testing locations with little financial investment.

Objectives Direction and magnitude of gender differences in late-life cognitive function are inextricably tied to sociocultural context. Our study evaluates education and literacy as primary drivers of gender equality in cognitive performance among middle-aged and older adults in rural South Africa. Method Data were collected on 1,938 participants aged 40–79 from Agincourt, South Africa. Cognitive function was measured via the Oxford Cognitive Screen-Plus, a tablet-based assessment with low literacy demands. Four cognitive domains were derived through confirmatory factor analysis: episodic memory, executive function, visual spatial, and language. Structural equation models tested domain-specific gender effects, incrementally controlling for demographic, education, health, and socioeconomic variables. Results In the model adjusting only for demographic factors, men outperformed women on executive function and visual-spatial domains. Adding education and literacy to the model revealed a robust female advantage in episodic memory, and reduced the magnitude of male advantage in executive function and visual and spatial by 47% and 42%, respectively. Health and socioeconomic factors did not alter patterns of gender associations in subsequent models. Discussion In this older South African cohort, gender inequality in cognitive performance was partially attributable to educational differences. Understanding biopsychosocial mechanisms that promote cognitive resilience in older women is critically important given the predominantly female composition of aging populations worldwide.

BackgroundKenya, like many sub-Saharan African countries (SSA), is experiencing a rise in the number of HIV infected adults aged ≥50 years (recognized as older adults living with HIV [OALWH]). This trend has created a subgroup of vulnerable older adults demanding a prompt response in research, policy, and practice to address their complex and transitioning needs. Unfortunately, little is known about the health and wellbeing of these adults in Kenya. As such, we explore the experiences of OALWH and key stakeholders at the coast of Kenya to understand the health challenges facing the OALWH.Material and methodsWe utilized the biopsychosocial model to explore views from 34 OALWH and 22 stakeholders (11 health care providers and 11 primary caregivers) on the physical, mental, and psychosocial health challenges of ageing with HIV in Kilifi County, Kenya, between October and December 2019. Data were drawn from semi-structured in-depth interviews, which were audio-recorded and transcribed. A framework approach was used to synthesize the data.ResultsSymptoms of common mental disorders (e.g. stress, worry, thinking too much), comorbidities (especially ulcers/hyperacidity, hypertension, visual and memory difficulties), somatic symptoms (especially pain/body aches, fatigue, and sleep problems), financial difficulties, stigma, and discrimination were viewed as common across the participants. Suicidal ideation and substance use problems (especially ‘mnazi’ – the local palm wine and ‘ugoro’ – snuff) were also raised. There was an overlap of perceived risk factors across the three health domains, such as family conflicts, poverty, lack of social support, stigma, and the presence of comorbid health complaints.ConclusionOur findings provide a preliminary understanding of challenges, using the biopsychosocial model, facing OALWH in a low-literacy Kenyan setting. We found that OALWH at the Kenyan coast are at risk of multiple physical, mental, and psychosocial challenges, likely affecting their HIV treatment and overall health. Before programmes can have any lasting impact on these adults, improved access to basic needs, including food, financial support, and caregiving, and a reduction of stigma and discrimination must be addressed. Future research should quantify the burden of these challenges and examine the resources available to these adults before piloting and testing feasible interventions.

ObjectiveIn this systematic review, we aimed to summarise the empirical evidence on common mental disorders (CMDs), cognitive impairment, frailty and health-related quality of life (HRQoL) among people living with HIV aged ≥50 years (PLWH50 +) residing in sub-Saharan Africa (SSA). Specifically, we document the prevalence and correlates of these outcomes.Design, data sources and eligibility criteriaThe following online databases were systematically searched: PubMed, CINAHL, PsycINFO, Embase and Scopus up to January 2021. English-language publications on depression, anxiety, cognitive function, frailty and quality of life among PLWH50+ residing in SSA were included.Data extraction and synthesisWe extracted information, including study characteristics and main findings. These were tabulated, and a narrative synthesis approach was adopted, given the substantial heterogeneity among included studies.ResultsA total of 50 studies from fifteen SSA countries met the inclusion criteria. About two-thirds of these studies emanated from Ethiopia, Uganda and South Africa. Studies regarding depression predominated (n=26), followed by cognitive impairment (n=13). Overall, PLWH50+ exhibited varying prevalence of depression (6%–59%), cognitive impairments (4%–61%) and frailty (3%–15%). The correlates of CMDs, cognitive impairment, frailty and HRQoL were rarely investigated, but those reported were sociodemographic variables, many of which were inconsistent.ConclusionsThis review documented an increasing number of published studies on HIV and ageing from SSA. However, the current evidence on the mental and well-being outcomes in PLWH50+ is inadequate to characterise the public health dimension of these impairments in SSA, because of heterogeneous findings, few well-designed studies and substantial methodological limitations in many of the available studies. Future work should have sufficiently large samples of PLWH50+, engage appropriate comparison groups, harmonise the measurement of these outcomes using a standardised methodology to generate more robust prevalence estimates and confirm predictors.PROSPERO registration numberCRD42020145791.

Background: Sub-Saharan Africa is undergoing an epidemiological transition fueled by the interaction between infectious and cardiovascular diseases. Our cross-sectional study aimed to characterize the spectrum of abnormalities suggesting end-organ damage on ECG and transthoracic echocardiograms (TTE) among older adults with cardiovascular diseases in rural South Africa. Methods: The prevalence of ECG and TTE abnormalities was estimated; χ 2 analyses and multivariable logistic regressions were performed to test their association with sex, hypertension, and other selected comorbidities. Results: Overall, 729 ECGs and 155 TTEs were completed, with 74 participants completing both. ECG evaluation showed high rates of left ventricular hypertrophy (LVH, 36.5%) and T wave abnormalities (13.6%). TTE evaluation showed high rates of concentric LVH (31.6%), with moderate-severe (56.8%) diastolic dysfunction. Participants with hypertension showed more cardiac remodeling on ECG by LVH (45.4% versus 22.1%, P P P P P =0.001). Male participants (n=326, 40.2%) were more likely than females (n=484, 59.8%) to show ECG abnormalities like LVH (45% versus 30.8%, P P P Conclusions: Our findings suggest that cardiovascular diseases are widespread in rural South Africa, with a larger burden of hypertensive heart disease than previously appreciated, and define the severity of end-organ damage that is already underway. Local health systems must adapt to face the growing burden of hypertension, as suboptimal rates of hypertension diagnosis and treatment may dramatically increase the heart failure burden.

Funder: Department of Health, BACKGROUND: Levels of obesity are rising in South Africa, notably among adolescent females. Excessive energy-dense diets and physical inactivity are among the factors contributing to this increase. Given that these factors are largely behavioural, understanding young people's views of obesity can contribute to more targeted behavioural interventions. Yet little is known of how rural South African adolescents view obesity. OBJECTIVES: The aim of this study was to explore rural South African adolescents' views of obesity, including their understanding of its causes, consequences, and solutions. METHODS: This qualitative study took place within the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) study area, in rural northeast South Africa. Three focus group discussions were held with male (n = 16) and female adolescents (n = 15), aged 14-19 years in 2018. Data were analysed using thematic analysis and the Social Cognitive Theory used to frame the findings. RESULTS: Participants presented conflicting views of obesity, with both positive and negative opinions expressed. Causes of obesity were seen to be multifactorial, including genetics, diet, lack of physical activity, and HIV treatment. Adolescents proposed medication and hospitalisation as ways to address obesity. When discussing interventions to address obesity, adolescents expressed the need for more information, suggesting that providing information to both themselves and their family members as part of interventions would be important. CONCLUSIONS: Rural South African adolescents have a complex perspective of obesity, likely driven in part by the current nutrition transition underway and do not inherently see individual behaviour as a driver or mitigator of obesity. Complex interventions including the involvement of other household members are needed to change adolescents' views on the role of the individual, and ultimately, change both individual and household behaviour to prevent obesity.

IntroductionPregnancy-related health services, an important mediator of global health priorities, require robust health infrastructure. We described pregnancy-related healthcare utilisation among rural South African women from 1993 to 2018, a period of social, political and economic transition.MethodsWe included participants enrolled in the Agincourt Health and Socio-Demographic Surveillance System in Mpumalanga Province, South Africa, a population-based longitudinal cohort, who reported pregnancy between 1993 and 2018. We assessed age, antenatal visits, years of education, pregnancy intention, nationality, residency status, previous pregnancies, prepregnancy and postpregnancy contraceptive use, and student status over the study period and modelled predictors of antenatal care utilisation (ordinal), skilled birth attendant presence (logistic) and delivery at a health facility (logistic).ResultsBetween 1993 and 2018, 51 355 pregnancies occurred. Median antenatal visits, skilled birth attendant presence and healthcare facility deliveries increased over time. Delivery in 2018 vs 2004 was associated with an increased likelihood of ≥1 additional antenatal visits (adjusted OR (aOR) 10.81, 95% CI 9.99 to 11.71), skilled birth attendant presence (aOR 4.58, 95% CI 3.70 to 5.67) and delivery at a health facility (aOR 3.78, 95% CI 3.15 to 4.54). Women of Mozambican origin were less likely to deliver with a skilled birth attendant (aOR 0.42, 95% CI 0.39 to 0.45) or at a health facility (aOR 0.43, 95% CI 0.41 to 0.46) versus South Africans. Temporary migrants reported fewer antenatal visits (aOR 0.35, 95% CI 0.33 to 0.38) but were more likely to deliver with a skilled birth attendant (aOR 1.91, 95% CI 1.66 to 2.2) or at a health facility (aOR 1.4, 95% CI 1.24 to 1.58) versus permanent residents.ConclusionPregnancy-related healthcare utilisation and skilled birth attendant presence at delivery have increased steadily since 1993 in rural northeastern South Africa, aligning with health policy changes enacted during this time. However, mothers of Mozambican descent are still less likely to use free care, which requires further study and policy interventions.

Background Evidence on cognitive function in older South Africans is limited, with few population-based studies. We aimed to estimate baseline associations between cognitive function and cardiometabolic disease risk factors in rural South Africa. Methods We use baseline data from “Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa” (HAALSI), a population-based study of adults aged 40 and above in rural South Africa in 2015. Cognitive function was measured using measures of time orientation, immediate and delayed recall, and numeracy adapted from the Health and Retirement Study cognitive battery (overall total cognitive score range 0–26). We used multiple linear regression to estimate associations between cardiometabolic risk factors (including BMI, hypertension, dyslipidemia, diabetes, history of stroke, alcohol frequency, and smoking status) and the overall cognitive function score, adjusted for potential confounders. Results In multivariable-adjusted analyses (n = 3018; male = 1520; female = 1498; median age 59 (interquartile range 50–67)), cardiometabolic risk factors associated with lower cognitive function scores included: diabetes (b = − 1.11 [95% confidence interval: − 2.01, − 0.20] for controlled diabetes vs. no diabetes); underweight BMI (b = − 0.87 [CI: − 1.48, − 0.26] vs. normal BMI); and current and past smoking history compared to never smokers. Factors associated with higher cognitive function scores included: obese BMI (b = 0.74 [CI: 0.39, 1.10] vs. normal BMI); and controlled hypertension (b = 0.53 [CI: 0.11, 0.96] vs. normotensive). Conclusions We provide an important baseline from rural South Africa on the associations between cardiometabolic disease risk factors and cognitive function in an older, rural South African population using standardized clinical measurements and cut-offs and widely used cognitive assessments. Future studies are needed to clarify temporal associations as well as patterns between the onset and duration of cardiometabolic conditions and cognitive function. As the South African population ages, effective management of cardiometabolic risk factors may be key to lasting cognitive health.

BACKGROUND: This paper describes a pilot study to assess the feasibility of a novel intervention to improve the management of hypertension among older people in rural South Africa. Older South Africans have the highest rates of uncontrolled hypertension recorded for any country. Notably, South Africa has a widely-available old age grant (pension), which is delivered on a monthly basis to citizens living in rural villages. METHODS: We assessed the feasibility of engaging with older people at the point of pension delivery in the Agincourt sub-district of Mpumalanga Province. This included providing information about hypertension, measuring blood pressure, referral to primary care services, and providing a monthly supply of low sodium salt. We recruited 20 people aged 60 and over to participate in the pilot intervention, which was conducted over three months in two villages. Towards the end of the intervention, we conducted focus groups with study participants and held a meeting with local stakeholders, including the district health office and the state social security agency. RESULTS: The pilot study demonstrated (i) Sustained engagement with the original 20 participants. Of these, 19 continued to participate in the intervention during subsequent monthly pension days. (ii) A high level of acceptance of the low sodium salt product reflected in repeat usage and comments made in the focus groups. (iii) Strong support for the intervention and a willingness to collaborate with local stakeholders. (iv) A perception among participants that symptoms they associated with hypertension had abated. This is supported by blood pressure readings made over the three months of follow-up. CONCLUSION: Though limited in scope, this pilot study provided evidence of the feasibility of the intervention and justification for it to be tested on a larger and more robust basis.

Summary Background Cardiovascular diseases and their risk factors—particularly hypertension, dyslipidaemia, and diabetes—have become an increasing concern for middle-income countries. Using newly available, nationally representative data, we assessed how cardiovascular risk factors are distributed across subpopulations within South Africa and identified which cardiovascular treatments should be prioritised. Methods We created a demographically representative simulated population for South Africa and used data from 17 743 respondents aged 15 years or older of the 2012 South African National Health and Nutrition Examination Survey (SANHANES) to assign information on cardiovascular risk factors to each member of the simulated population. We created a microsimulation model to estimate the health and economic implications of two globally recognised treatment recommendations: WHO's package of essential non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines. The primary outcome was total disability-adjusted life-years (DALYs) averted through treatment of all cardiovascular disease or microvascular type 2 diabetes complications per 1000 population. We compared outcomes at the aspirational level of achieving access to treatment among 70% of the population. Findings Based on the SANHANES data, South Africans had a high prevalence of hypertension (24·8%), dyslipidaemia (17·5%), and diabetes (15·3%). Prevalence was disproportionately high and treatment low among male, black, and poor populations. Our simulated population experienced a burden of 40·0 DALYs (95% CI 29·5–52·0) per 1000 population per year from cardiovascular disease or type 2 diabetes complications at current treatment levels, which lowered to 32·9 DALYs (24·4–44·7) under WHO PEN implementation and to 32·5 (24·4–44·8) under SA PC 101 implementation. Under both guidelines, there were increases in blood pressure treatment (4·2 percentage points under WHO PEN vs 12·6 percentage points under SA PC 101), lipid treatment (16·0 vs 14·9), and glucose control medications (1·2 vs 0·6). The incremental cost-effectiveness of implementing SA PC 101 over current treatment would be a saving of US$24 902 (95% CI 14 666–62 579) per DALY averted compared with a saving of $17 587 (1840–42 589) under WHO PEN guidelines. Interpretation Cardiovascular risk factors are common and disproportionate among disadvantaged populations in South Africa. Treatment with blood pressure agents and statins might need greater prioritisation than blood glucose therapies, which contrasts with observed treatment levels despite a lower monthly cost of blood pressure or statin treatment than of sulfonylurea or insulin treatment. Funding Stanford University.

Human gut microbiome research focuses on populations living in high-income countries and to a lesser extent, non-urban agriculturalist and hunter-gatherer societies. The scarcity of research between these extremes limits our understanding of how the gut microbiota relates to health and disease in the majority of the world's population. Here, we evaluate gut microbiome composition in transitioning South African populations using short- and long-read sequencing. We analyze stool from adult females living in rural Bushbuckridge (n = 118) or urban Soweto (n = 51) and find that these microbiomes are taxonomically intermediate between those of individuals living in high-income countries and traditional communities. We demonstrate that reference collections are incomplete for characterizing microbiomes of individuals living outside high-income countries, yielding artificially low beta diversity measurements, and generate complete genomes of undescribed taxa, including Treponema, Lentisphaerae, and Succinatimonas. Our results suggest that the gut microbiome of South Africans does not conform to a simple "western-nonwestern" axis and contains undescribed microbial diversity.

Short, reliable, easily administered executive function (EF) assessment tools are needed to measure EF in low- and middle-income countries, particularly in sub-Saharan Africa given the prevalence of human immunodeficiency virus (HIV)-associated neurocognitive disorder. We administered Oxford Cognitive Screen—Executive Function (OCS-EF) to 932 rural South African females (mean age 19.7 years). OCS-EF includes seven tasks: two hot inhibition tasks (a modified Iowa Gambling Task, emotional go/no-go) and five cool EF tasks, two switching tasks (visuospatial rule-finding, geometric trails) and three working memory tasks (digit recall, selection and figure drawing). We performed confirmatory factor analysis testing whether a three-factor, two-factor hot-cool, two-factor working memory and inhibition/switching, or one-factor EF model fitted the data better. The three-factor (switching, inhibition and working memory) model had the best local and global fit (χ2 (11) 24.21, p = 0.012; RMSEA 0.036; CFI 0.920; CD 0.617). We demonstrated the feasibility of OCS-EF administration by trained laypeople, the tripartite structure of EF amongst adolescent females and the factorial validity of OCS-EF in this population and context. OCS-EF tablet-based cognitive assessment tool can be administered by trained laypeople and is a valid tool for assessing cognition at scale amongst adolescents in rural South Africa and similar environments.

Objectives We investigated concordance between haemoglobin A1c (HbA1c)-defined diabetes and fasting plasma glucose (FPG)-defined diabetes in a black South African population with a high prevalence of obesity. Design Cross-sectional study. Setting Rural South African population-based cohort. Participants 765 black individuals aged 40–70 years and with no history of diabetes. Primary and secondary outcome measures The primary outcome measure was concordance between HbA1c-defined diabetes and FPG-defined diabetes. Secondary outcome measures were differences in anthropometric characteristics, fat distribution and insulin resistance (measured using Homoeostatic Model Assessment of Insulin Resistance (HOMA-IR)) between those with concordant and discordant HbA1c/FPG classifications and predictors of HbA1c variance. Results The prevalence of HbA1c-defined diabetes was four times the prevalence of FPG-defined diabetes (17.5% vs 4.2%). Classification was discordant in 15.7% of participants, with 111 individuals (14.5%) having HbA1c-only diabetes (kappa 0.23; 95% CI 0.14 to 0.31). Median body mass index, waist and hip circumference, waist-to-hip ratio, subcutaneous adipose tissue and HOMA-IR in participants with HbA1c-only diabetes were similar to those in participants who were normoglycaemic by both biomarkers and significantly lower than in participants with diabetes by both biomarkers (p

ObjectivesWe investigated concordance between haemoglobin A1c (HbA1c)-defined diabetes and fasting plasma glucose (FPG)-defined diabetes in a black South African population with a high prevalence of obesity.DesignCross-sectional study.SettingRural South African population-based cohort.Participants765 black individuals aged 40–70 years and with no history of diabetes.Primary and secondary outcome measuresThe primary outcome measure was concordance between HbA1c-defined diabetes and FPG-defined diabetes. Secondary outcome measures were differences in anthropometric characteristics, fat distribution and insulin resistance (measured using Homoeostatic Model Assessment of Insulin Resistance (HOMA-IR)) between those with concordant and discordant HbA1c/FPG classifications and predictors of HbA1c variance.ResultsThe prevalence of HbA1c-defined diabetes was four times the prevalence of FPG-defined diabetes (17.5% vs 4.2%). Classification was discordant in 15.7% of participants, with 111 individuals (14.5%) having HbA1c-only diabetes (kappa 0.23; 95% CI 0.14 to 0.31). Median body mass index, waist and hip circumference, waist-to-hip ratio, subcutaneous adipose tissue and HOMA-IR in participants with HbA1c-only diabetes were similar to those in participants who were normoglycaemic by both biomarkers and significantly lower than in participants with diabetes by both biomarkers (p1c variance beyond glucose and age only in women.ConclusionsConcordance was poor between HbA1c and FPG in diagnosis of diabetes in black South Africans, and participants with HbA1c-only diabetes phenotypically resembled normoglycaemic participants. Further work is necessary to determine which of these parameters better predicts diabetes-related morbidities in this population and whether a population-specific HbA1c threshold is necessary.

Objectives: Our study investigates measurement, correlates, and functional associations of vision impairment (VI) in an aging population in rural South Africa. Methods: 1582 participants aged 40–69 reported on near (NVI) and distance vision impairment (DVI) and completed objective vision tests. Logistic and linear regression were used to evaluate sociodemographic, health, and psychosocial correlates of VI and assess relationships between VI and cognitive and physical function. Results: VI prevalence was considerably higher according to objective testing (56%) versus self-reports (18%). Older adults were especially likely to underreport impairment. Objective VI was associated with age, education, cardiometabolic disease, and female sex. Conversely, self-reported VI was associated with psychosocial factors. Objective NVI and both types of DVI were associated with worse visual cognition and slower gait speed, respectively. Discussion: Self-reported and objective VI measures should not be used interchangeably in this context. Our findings highlight extensive burden of untreated VI in this region.

BackgroundThe relationship between subjective social position (SSP) and cognitive ageing unclear, especially in low-income settings. We aimed to investigate the relationship between SSP and cognitive function over time among older adults in rural South Africa.MethodsData were from 3771 adults aged ≥40 in the population-representative ‘Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa’ from 2014/2015 (baseline) to 2018/2019 (follow-up). SSP was assessed at baseline with the 10-rung MacArthur Network social position ladder. Outcomes were composite orientation and episodic memory scores at baseline and follow-up (range: 0–24). Mortality- and attrition-weighted linear regression estimated the associations between baseline SSP with cognitive scores at each of the baseline and follow-up. Models were adjusted for age, age2, sex, country of birth, father’s occupation, education, employment, household assets, literacy, marital status and health-related covariates.ResultsSSP responses ranged from 0 (bottom ladder rung/lowest social position) to 10 (top ladder rung/highest social position), with a mean of 6.6 (SD: 2.3). SSP was positively associated with baseline cognitive score (adjusted β=0.198 points per ladder rung increase; 95% CI 0.145 to 0.253) and follow-up cognitive score (adjusted β=0.078 points per ladder rung increase; 95% CI 0.021 to 0.136).ConclusionIndependent of objective socioeconomic position measures, SSP is associated with orientation and episodic memory scores over two time points approximately 3 years apart among older rural South Africans. Future research is needed to establish the causality of the observed relationships, whether they persist over longer follow-up periods and their consistency in other populations.

There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional ‘injections’, in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer’s place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.

This review aimed to determine: whether EF is affected in children and adolescents (2–24-years-old) with perinatal HIV infection, perinatal HIV exposure without infection, and behaviourally acquired HIV. A systematic review (PROSPERO number: CRD42017067813) was conducted using 11 electronic databases (01.01.1981–09.07.2019) and 8 conference websites. Primary quantitative studies with EF scores on cognitive tasks and/or behavioural report measures were included. Meta-analyses were performed by EF subtype and subpopulations compared. 1789 records were found. Sixty-one studies were included in the narrative synthesis; 32 (N = 7884 participants) were included in meta-analyses. There was a distinct pattern of reduced EF in those with perinatal HIV infection on antiretroviral therapy compared to controls: pooled effect sizes were largest for verbal and visuospatial working memory, with smaller effects on planning, inhibitory control and set-shifting. Data were limited for other HIV-affected subpopulations. Perinatal HIV infection is associated with reduced EF with varying effect sizes for the different EF subtypes.

PurposeThe PHIRST study (Prospective Household cohort study of Influenza, Respiratory Syncytial virus, and other respiratory pathogens community burden and Transmission dynamics in South Africa) aimed to estimate the community burden of influenza and respiratory syncytial virus (RSV) including the incidence of infection, symptomatic fraction, and disease severity, and to assess household transmission. We further aimed to estimate the impact of HIV infection and age on disease burden and transmission, and to assess the burden of Bordetella pertussis and Streptococcus pneumoniae.ParticipantsWe enrolled 1684 individuals in 327 randomly selected households in two sites (rural Agincourt subdistrict, Mpumalanga Province and urban Jouberton Township, North West Province) over 3 consecutive influenza and RSV seasons. A new cohort of households was enrolled each year. Eligible households included those with >2 household members where ≥80% of household members provided consent (and assent for children aged 7-17 years). Enrolled household members were sampled with nasopharyngeal swabs twice weekly during the RSV and influenza seasons of the year of enrolment. Serology samples were collected at enrolment and before and after the influenza season annually.Findings to dateThere were 122,113 potential individual follow-up visits over the 3 years, and participants were interviewed for 105,783 (87%) of these. Out of 105,683 nasopharyngeal swabs from follow-up visits, 1,258 (1%), 1,026 (1%), 273 (Future plansFuture planned analyses include analysis of influenza serology results and RSV burden and transmission. Households enrolled in the PHIRST study during 2016-2018 were eligible for inclusion in a study of SARS-CoV-2 transmission initiated in July 2020. This study uses similar testing frequency and household selection methods to assess the community burden of SARS-CoV-2 infection and the role of asymptomatic infection in virus transmission.RegistrationClinical trials.gov NCT02519803Article summaryStrengths and limitations of this studyPHIRST was conducted in urban and rural African settings with high HIV prevalence, allowing assessment of the effect of HIV on community burden and transmission dynamics of respiratory pathogens.Households were selected randomly to provide a representative sample of the community. Twice weekly sampling from each cohort of individuals for 6-10 months irrespective of symptoms allows estimation of community burden, household secondary infection risk, and serial interval including asymptomatic or paucisymptomatic episodes.Polymerase chain reaction testing of >100,000 nasopharyngeal swab samples for multiple pathogens (influenza, respiratory syncytial virus, pertussis and Streptoccocus pneumonia) allows detailed examination of disease burden and transmission and pathogen interactionsPHIRST was not powered to assess severe outcomes (i.e. hospitalisation and death).We only examined four pathogens, but other micro-organisms may be important. Samples have been stored which could allow us to implement broader multi-pathogen testing in the future.