Background: The relationship between in-utero antiretroviral (ARV) drug exposure and child growth... more Background: The relationship between in-utero antiretroviral (ARV) drug exposure and child growth needs further study as current data provide mixed messages. We compared postnatal growth in the first 18-months of life between children who are HIV-exposed uninfected (CHEU) with fetal exposure to ARV drugs (prophylaxis or triple-drug therapy (ART)) and CHEU not exposed to ARVs. We also examined other independent predictors of postnatal growth. Methods: We analysed data from a national prospective cohort study of 2526 CHEU enrolled at 6-weeks and followed up 3-monthly till 18-months postpartum, between October 2012 and September 2014. Infant anthropometry was measured, and weight-forage (WAZ) and length-forage (LAZ) Z-scores calculated. Generalized estimation equation models were used to compare Z-scores between groups. Results: Among 2526 CHEU, 617 (24.4%) were exposed to ART since-pregnancy (pre-conception ART), 782 (31.0%) to ART commencing post-conception, 879 (34.8%) to maternal ARV prophylaxis (Azidothymidine (AZT)), and 248 (9.8%) had no ARV exposure. In unadjusted analyses, preterm birth rates were higher among CHEU with no ARV exposure than in other groups. Adjusting for infant age, the mean WAZ profile was lower among CHEU exposed to preconception ART [-0.13 (95% confidence interval − 0.26; − 0.01)] than the referent AZT prophylaxis group; no differences in mean WAZ profiles were observed for the post-conception ART (− 0.05 (− 0.16; 0.07)), None (− 0.05 (− 0.26; 0.16)) and newly-infected (− 0.18 (− 0.48; 0.13)) groups. Mean LAZ profiles were similar across all groups. In multivariable analyses, mean WAZ and LAZ profiles for the ARV exposure groups were completely aligned. Several non-ARV factors including child, maternal, and socio-demographic factors independently predicted mean WAZ. These include child male (0.45 (0.35; 0.56)) versus female, higher maternal education grade 7-12 (0.28 (0.14; 0.42) and 12 + (0.36 (0.06; 0.66)) versus ≤ grade7, employment (0.16 (0.04; 0.28) versus unemployment, and household food security (0.17 (0.03; 0.31). Similar predictors were observed for mean LAZ.
Objectives We aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and... more Objectives We aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and assess associated factors, to evaluate progress towards United Nations-AIDS (UNAIDS) targets. Design Cross-sectional study. Setting The eight largest community health centres of Ehlanzeni, a rural district in northeast South Africa. Participants Pregnant women living with HIV (WLHIV) in their third trimester and postpartum WLHIV and their biological infants, recruited equally across all stages of the first 24 months post partum, were included. A sample of 612 mothers participated from a target of 1000. Primary outcome measures The primary outcome was maternal VL (mVL) non-suppression (defined here as mVL >1000 copies/mL). We collected information on antiretroviral use, healthcare visits and sociodemographics through interviews and measured plasma mVL. Descriptive statistics, χ 2 tests and multivariable logistic regression analysis were conducted. Results All mothers (median age: 30 years) were on antiretroviral therapy (ART) and 24.9% were on ART ≤12 months. The prevalence of mVL non-suppression was 14.7% (95% CI: 11.3% to 19.0%), while 13.8% had low-level viraemia (50-1000 copies/mL). Most (68.9%) women had initiated breast feeding and 37.6% were currently breast feeding their infants. Being younger than 25 years (adjusted odds ratio (AOR): 2.6 (95% CI: 1.1 to 6.4)), on first-line ART (AOR: 2.3 (95% CI: 1.1 to 4.6)) and married/cohabiting (AOR: 1.9 (95% CI: 1.0 to 3.7)) were significantly associated with increased odds of mVL nonsuppression. Conclusions The prevalence of mVL ≤1000 copies/mL of 85.3% among pregnant and postpartum WLHIV and attending public healthcare centres in this rural district is below the 2020 90-90-90 and 2030 95-95-95 UNAIDS targets. Given that low-level viraemia may also increase the risk of vertical HIV transmission, we recommend strengthened implementation of the new guidelines which include better ART options, improved ART regimen switching and mVL monitoring schedules, and intensified psychosocial support for younger women, while exploring district-level complementary interventions, to sustain VLs below 50 copies/mL among all women. ► This study provides maternal viral load (mVL) nonsuppression data from a rural setting where research of this kind is limited. ► The mVL measurements were conducted using the gold standard whole blood plasma rather than dried blood spots despite the challenging remote settings. ► The postpartum inclusion criterion targeted mothers attending clinics with their biological children and hence could present a sample biased towards biological mothers with better clinic attendance and less representative of mothers who mostly assign child healthcare visits to other caregivers. ► The sample sizes achieved were lower than planned and much lower for the postpartum stages which did not overlap with routine child vaccination schedules, but there was no statistically significant difference in the proportion of mVL non-suppression between the postpartum stages.
Objective Between 1998 and 2009 reported exclusive breastfeeding (EBF) rates in South African inf... more Objective Between 1998 and 2009 reported exclusive breastfeeding (EBF) rates in South African infants, aged 0-6 months, ranged from 6.2% to 25.7%.
Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient ep... more Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient epidemic tracking, programme planning and resource allocation. HIV sentinel surveillance usually employs unlinked anonymous HIV testing which raises ethical, epidemiological and public health challenges in the current era of universal test and treat. The World Health Organization (WHO) recommends that countries should consider using routine prevention of mother-to-child transmission of HIV (PMTCT) data for surveillance. We audited antenatal care clinics to assess the quality of HIV rapid testing practices as the first step to assess whether South Africa is ready to utilize PMTCT programme data for antenatal HIV surveillance. In 2017, we conducted a cross-sectional survey in 360 randomly sampled antenatal care clinics using the adapted WHO Stepwise-Process-for-Improving-the-Quality-of-HIV-Rapid-Testing (SPI-RT) checklist. We calculated median percentage scores within a domain (domain-specif...
The International Journal of Cardiovascular Imaging
HIV associated cardiomyopathy (HIVAC) is a poorly understood entity that may progress along a con... more HIV associated cardiomyopathy (HIVAC) is a poorly understood entity that may progress along a continuum. We evaluated a group of persons newly diagnosed with HIV and studied the evolution of cardiac abnormalities after ART initiation. We recruited a group of newly diagnosed, ART naïve persons with HIV and a healthy, HIV uninfected group. Participants underwent comprehensive cardiovascular evaluation, including cardiovascular magnetic resonance imaging. The HIV group was started on ART and re-evaluated 9 months later. The cardiovascular parameters of the study groups were compared at diagnosis and after 9 months. The ART naïve group’s (n = 66) left- and right end diastolic volume indexed for height were larger compared with controls (n = 22) (p < 0.03). The left ventricular mass indexed for height was larger in the naïve group compared with controls (p = 0.04). The ART naïve group had decreased left- and right ventricular ejection fraction (p < 0.03) and negative, non-linear as...
Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be ... more Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be used to control HIV incidence especially among people who are at increased risk for HIV such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). In South Africa, various approaches of delivering PrEP have been adopted at different service delivery points (facility-based only, school-based only, community-based only and hybrid school-facility and community-facility models) to overcome challenges associated with individual, structural, and health systems related barriers that may hinder access to and uptake of PrEP among these populations. However, little is known about how to optimize PrEP implementation and operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. This study aims to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation, and adherence among AGYW and ABYM. Metho...
IntroductionIn South Africa, HIV prevalence among adolescent girls and young women (AGYW) was 5.8... more IntroductionIn South Africa, HIV prevalence among adolescent girls and young women (AGYW) was 5.8% (15-19 years) and 15.6% (20-24 years) respectively in 2017. Amongst South African males, HIV prevalence in 2017 was 4.7% (15-19 years), 4.8% (20-24 years), 12.4% (25-29 years) and 18.4% (30-34 years). The National Department of Health adopted the universal test and treat (UTT) strategy in 2016, resulting in increases in same-day antiretroviral therapy initiations and linkage to care. Monitoring progress towards attainment of South Africa’s 95-95-95 targets amongst AGYW and adolescent boys and young men (ABYM) relies on high quality data to identify and address gaps in linkage to care. The purpose of this study is to provide evidence to guide efforts to improve linkage to, and retention in, HIV care among AGYW and ABYM in KwaZulu-Natal, in the context of the UTT strategy.Methods and analysisThis is a mixed methods study, which will be conducted in uMgungundlovu district of KwaZulu-Natal...
Background: Little is known about women who have experienced a recent rape, and how they differ f... more Background: Little is known about women who have experienced a recent rape, and how they differ from women without this exposure. Identifying factors linked to rape is important for preventing rape and developing effective responses in countries like South Africa with high levels of sexual violence. Objective: To describe the socio-demographic and health profile of women recently exposed to rape and to compare them with a non-rape-exposed group. Methods: The Rape Impact Cohort Evaluation Study (RICE) enrolled 852 women age 16-40 years exposed to rape from post-rape care centres in Durban (South Africa) and a control group of 853 women of the same age range who have never been exposed to rape recruited from public health services. Descriptive analyses include logistic regression modelling of socio-demographic characteristics associated with recent rape exposure. Results: Women with recent rape reported poorer health and more intimate partner violence than those who were not raped. They had a lower likelihood of having completed school (Odds Ratio [OR] 0.46 95% Confidence Interval (CI): 0.24-0.87) and dependence on a government grant as a main source of income (OR 0.61: 95%CI 0.49-0.77). They were more likely to live in informal housing (OR 1.88 95%CI: 1.43-2.46) or rural areas (OR 2.24: 95% CI 1.61-3.07) than formal housing areas-however they were also more likely to report fulltime employment (OR 4.24: 95%CI 2.73-6.57). Conclusion: The study shows that structural factors, such as lower levels of education, poverty, and living in areas of poor infrastructure are associated with women's vulnerability to rape. It also shows possible protection from rape afforded by the national financial safety net. It highlights the importance of safe transportation in commuting to work. Preventing rape is critical for enabling women's full social and economic development, and structural interventions are key for reducing women's vulnerability.
Introduction: HIV care, linkage, and retention are key weaknesses in South Africa’s national anti... more Introduction: HIV care, linkage, and retention are key weaknesses in South Africa’s national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. Very few studies have investigated the proportion of people newly diagnosed with HIV linked-to and retained-in-care in the ‘Universal Test-and-Treat’ era. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. Methods: We conducted an observational prospective cohort study from December 2017 to August 2019 to investigate LTRIC rates for adults with a new HIV diagnosis in uThukela district, South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess a...
9 /l) decreased from 0.70 in the randomized trial, and 0.61 in the whole-school study, to well wi... more 9 /l) decreased from 0.70 in the randomized trial, and 0.61 in the whole-school study, to well within the normal paediatric range of 0.05-0.45 (P < 0.05). The prevalence of eosinophilia declined from 57% to 37% in the randomized trial (mean for 400, 800 and 1200 mg albendazole doses); and from 47% to 24% in the whole-school study (500 mg stat mebendazole). Benzimidazole anthelminthics were highly effective against Ascaris but less so against Trichuris. Activated eosinophils are effector and immuno- regulatory leucocytes of the T-helper cell type 2 (Th2) immune re- sponse to parasitic helminths and atopic disorders. Under conditions of poverty where soil-transmitted helminths are hyperendemic, Th2 polarization of the immune profile is character- istic. Regular anthelminthic treatment should reduce contact with worm antigens, and this may contribute to re-balancing of the immune profile. Suppression of eosinophil recruitment and activa- tion, together with related cellular and mole...
Introduction New HIV infection during pre-conception and pregnancy is a significant contributor o... more Introduction New HIV infection during pre-conception and pregnancy is a significant contributor of mother–to–child transmission of HIV in South Africa. This study estimated HIV incidence (defined as new infection within the last one year from the time of the survey which included both new infections occurred during pregnancy or just before pregnancy) among pregnant women and described the characteristics of recently infected pregnant women at national level. Methods Between 1 October and 15 November 2017, we conducted a national cross–sectional survey among pregnant women aged 15–49 years old attending antenatal care at 1,595 public facilities. Blood specimens were collected from pregnant women and tested for HIV in a centralised laboratory. Plasma viral load and Limiting Antigen Avidity Enzyme Immunosorbent Assay (LAg) tests were further performed on HIV positive specimens to differentiate between recent and long–term infections. Recent infection was defined as infection that occur...
We compared first sex experiences and wellbeing of adolescent girls and young women (AGYW) who ha... more We compared first sex experiences and wellbeing of adolescent girls and young women (AGYW) who had an early sexual debut (age < 15) with those who had later sexual debut. We conducted a representative household survey among AGYW aged 15-24 years in six districts in South Africa. Of 3009 AGYW who had ever had sex, 8.9% reported early sexual debut. Early sexual debut was associated with coercion at first sex and a lower average well-being score compared with a later debut. Interventions which aim to delay early sexual debut may positively affect well-being.
Background:Long-acting reversible contraceptives (LARCs), which include the subdermal contracepti... more Background:Long-acting reversible contraceptives (LARCs), which include the subdermal contraceptive implant and intrauterine contraception, offer women safe, highly effective, long-term pregnancy prevention, and have expanded contraceptive options. The implant greatly expands LARC options for South African women as it is available free of charge at public health facilities, but little is known about factors associated with its uptake. This study describes factors associated with the intention to use the implant, including knowledge and beliefs about the implant and perceived outcome expectancies of implant use among women in Cape Town, South Africa.Methods:Between 2015 and 2016, the authors conducted a quantitative, cross-sectional survey among adult women attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, they measured knowledge, awareness, and attitudes, perceived outcome expectancy, and the intention to use the contraceptive im...
Aim South African adults with hypertension often have comorbid physical and mental health problem... more Aim South African adults with hypertension often have comorbid physical and mental health problems and disabilities, which can influence each other in complex ways. We modelled potential causal pathways connecting multimorbidity, depression, stress, disability and cardiovascular risks. Methods The study analysed observational data on 1043 adults with treated hypertension and with symptoms of depression (Patient Health Questionnaire-9 score > 9) who participated in a randomised trial in 20 primary health care clinics. A structural equation path model using cross-sectional baseline data estimated direct and indirect effects of sociodemographic variables and comorbidities on depression, stress and disability scores, and their further direct and indirect effects on smoking, body mass index and blood pressure. A cross-lagged structural equation model using longitudinal data estimated effects of depression symptoms, disability and blood pressure on each other over time. Results At base...
Southern African Journal of Infectious Diseases, 2020
The national human immunodeficiency virus (HIV) mother-to-child transmission rate at 6-10 weeks p... more The national human immunodeficiency virus (HIV) mother-to-child transmission rate at 6-10 weeks post-partum was 0.9% in 2016. There is a paucity of data about the intrapartum transmission rate after lifelong antiretroviral therapy was implemented in 2015. We assessed all pregnant women living with HIV who delivered at Tygerberg Hospital in 2017. Positive polymerase chain reactions (PCRs) at birth indicated an in utero transmission rate of 0.8%. One infant with a negative PCR at birth tested positive at 6-10 weeks. The intrapartum transmission rate was low (0.08%). About 25% of infants were lost to follow-up after birth.
Introduction Knowledge of HIV status in South Africa (SA) is reported to be 90% among people livi... more Introduction Knowledge of HIV status in South Africa (SA) is reported to be 90% among people living with HIV. National level estimates could mask population-specific levels, which are critical to monitor program coverage and potential impact. Using data from the 2017 national antenatal sentinel survey, we assessed knowledge of HIV-positive status, initiation of antiretroviral therapy (ART), and socio-demographic characteristics associated with knowledge of HIVpositive status prior to the current pregnancy among women attending antenatal care. Methods Between 1 October and 15 November 2017, a nationally representative sample of 32,716 pregnant women were enrolled from 1,595 public health facilities selected from all districts of SA. Data on age, gravidity, knowledge of HIV-positive status and ART initiation prior to pregnancy were extracted from medical records. A blood sample was collected from each woman regardless of prior knowledge of HIV status or ART history, and tested for HIV in the laboratory. All HIV-positive pregnant women enrolled in the survey were eligible for inclusion in the analysis. Multivariable survey logistic regression was used to examine factors associated with knowledge of HIV-positive status prior to the current pregnancy. Results Of 10,065 eligible HIV-positive women, 60.8% (95% confidence interval (CI):59.9%-61.7%) knew their HIV status prior to the current pregnancy, of whom 91.1% (95% CI: 90.4%-91.7%) initiated ART prior to the current pregnancy. Knowledge of HIV-positive status was lower
Objective: To describe viral load levels among pregnant women and factors associated with failure... more Objective: To describe viral load levels among pregnant women and factors associated with failure to achieve viral suppression (viral load ≤50 copies/ml) during pregnancy. Design: Between 1 October and 15 November 2017, a cross-sectional survey was conducted among 15–49-year-old pregnant women attending antenatal care (ANC) at 1595 nationally representative public facilities. Methods: Blood specimens were taken from each pregnant woman and tested for HIV. Viral load testing was done on all HIV-positive specimens. Demographic and clinical data were extracted from medical records or self-reported. Survey logistic regression examined factors associated with failure to achieve viral suppression. Result: Of 10 052 HIV-positive participants with viral load data, 56.2% were virally suppressed. Participants initiating antiretroviral therapy (ART) prior to pregnancy had higher viral suppression (71.0%) by their third trimester compared with participants initiating ART during pregnancy (59.3%...
International Journal of Infectious Diseases, 2019
South Africa has used antenatal HIV surveys for HIV surveillance in pregnant women since 1990. We... more South Africa has used antenatal HIV surveys for HIV surveillance in pregnant women since 1990. We assessed South Africa's readiness to transition to programme data based antenatal HIV surveillance with respect to PMTCT uptake, accuracy of point-of-care rapid testing (RT) and selection bias with using programme data in the context of the 2017 antenatal HIV survey. Methods: Between 1 October and 15 November 2017, the national survey was conducted in 1,595 public antenatal facilities selected using stratified multistage cluster sampling method. Results of point-of-care RT were obtained from medical records. Blood samples were taken from eligible pregnant women and tested for HIV using immunoassays (IA) in the laboratory. Descriptive statistics were used to report on: PMTCT uptake; agreement between HIV point-of-care RT and laboratory-based HIV-1 IA; and selection bias associated with using programme data for surveillance. Results: PMTCT HIV testing uptake was high (99.8%). The positive percent agreement (PPA) between RT and IA was lower than the World Health Organization (WHO) benchmark (97.6%) at 96.3% (95% confidence interval (CI): 95.9%-96.6%). The negative percent agreement was above the WHO benchmark (99.5%), at 99.7% (95% CI: 99.6%-99.7%) nationally. PPA markedly varied by province (92.9%-98.3%). Selection bias due to exclusion of participants with no RT results was within the recommended threshold at 0.3%. Conclusion: For the three components assessed, South Africa was close to meeting the WHO standard for transitioning to routine RT data for antenatal HIV surveillance. The wide variations in PPA across provinces should be addressed.
We evaluated the effectiveness of the Skhokho interventions (enhanced teaching materials and a pa... more We evaluated the effectiveness of the Skhokho interventions (enhanced teaching materials and a parenting programme) in reducing dating and sexual violence. This pragmatic, threearm cluster randomised controlled trial was conducted in 24 State schools in Grade 8 classes, with all learners invited to participate. The interventions were: i) a schools' package: A Life Orientation (LO) curriculum workbook for the Grade 8 national curriculum and teacher training; ii) a workshop for caregivers and teenagers, supported by clubs in the second year. Arms were: a no intervention control, the schools' package, and the combined schools' and families' package. Learners were followed up for 18 months. The primary outcomes were the incidence of physical and/or sexual IPV, severe IPV and non-partner rape. At baseline, 3756 (61.8% of total) learners (aged 12-15) were interviewed and 3411 (90.8%) provided end line data. A third of caregivers and learners attended all four families' intervention workshop sessions. At baseline, 47% of girls and 29% boys were dating and 18% of boys and 2% of girls had had sex. Differences in the primary outcomes between study arms were not statistically significant, however all effects were in the direction of protection from violence and several secondary outcomes were significantly changed. For girls, the incidence of any IPV experience was aIRR 0.84 (95%CI 0.66, 1.07 p = 0.159) for the school's arm and the incidence of non-partner rape was aIRR 0.84 (95%CI 0.62, 1.14 p = 0.255) for the combined schools and families arm v. control arm. This under-powered pragmatic study's findings suggest a generally beneficial impact of the Skhokho interventions on a number of outcome measures, when viewed by both adolescents, caregivers and their teachers. These include measures of adolescents' exposure to violence, improved sexual health and reductions in several IPV risk factors. The intervention warrants further research. Trial registration ClinicalTrials.gov NCT02349321.
Background: The relationship between in-utero antiretroviral (ARV) drug exposure and child growth... more Background: The relationship between in-utero antiretroviral (ARV) drug exposure and child growth needs further study as current data provide mixed messages. We compared postnatal growth in the first 18-months of life between children who are HIV-exposed uninfected (CHEU) with fetal exposure to ARV drugs (prophylaxis or triple-drug therapy (ART)) and CHEU not exposed to ARVs. We also examined other independent predictors of postnatal growth. Methods: We analysed data from a national prospective cohort study of 2526 CHEU enrolled at 6-weeks and followed up 3-monthly till 18-months postpartum, between October 2012 and September 2014. Infant anthropometry was measured, and weight-forage (WAZ) and length-forage (LAZ) Z-scores calculated. Generalized estimation equation models were used to compare Z-scores between groups. Results: Among 2526 CHEU, 617 (24.4%) were exposed to ART since-pregnancy (pre-conception ART), 782 (31.0%) to ART commencing post-conception, 879 (34.8%) to maternal ARV prophylaxis (Azidothymidine (AZT)), and 248 (9.8%) had no ARV exposure. In unadjusted analyses, preterm birth rates were higher among CHEU with no ARV exposure than in other groups. Adjusting for infant age, the mean WAZ profile was lower among CHEU exposed to preconception ART [-0.13 (95% confidence interval − 0.26; − 0.01)] than the referent AZT prophylaxis group; no differences in mean WAZ profiles were observed for the post-conception ART (− 0.05 (− 0.16; 0.07)), None (− 0.05 (− 0.26; 0.16)) and newly-infected (− 0.18 (− 0.48; 0.13)) groups. Mean LAZ profiles were similar across all groups. In multivariable analyses, mean WAZ and LAZ profiles for the ARV exposure groups were completely aligned. Several non-ARV factors including child, maternal, and socio-demographic factors independently predicted mean WAZ. These include child male (0.45 (0.35; 0.56)) versus female, higher maternal education grade 7-12 (0.28 (0.14; 0.42) and 12 + (0.36 (0.06; 0.66)) versus ≤ grade7, employment (0.16 (0.04; 0.28) versus unemployment, and household food security (0.17 (0.03; 0.31). Similar predictors were observed for mean LAZ.
Objectives We aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and... more Objectives We aimed to measure the prevalence of maternal HIV viral load (VL) non-suppression and assess associated factors, to evaluate progress towards United Nations-AIDS (UNAIDS) targets. Design Cross-sectional study. Setting The eight largest community health centres of Ehlanzeni, a rural district in northeast South Africa. Participants Pregnant women living with HIV (WLHIV) in their third trimester and postpartum WLHIV and their biological infants, recruited equally across all stages of the first 24 months post partum, were included. A sample of 612 mothers participated from a target of 1000. Primary outcome measures The primary outcome was maternal VL (mVL) non-suppression (defined here as mVL >1000 copies/mL). We collected information on antiretroviral use, healthcare visits and sociodemographics through interviews and measured plasma mVL. Descriptive statistics, χ 2 tests and multivariable logistic regression analysis were conducted. Results All mothers (median age: 30 years) were on antiretroviral therapy (ART) and 24.9% were on ART ≤12 months. The prevalence of mVL non-suppression was 14.7% (95% CI: 11.3% to 19.0%), while 13.8% had low-level viraemia (50-1000 copies/mL). Most (68.9%) women had initiated breast feeding and 37.6% were currently breast feeding their infants. Being younger than 25 years (adjusted odds ratio (AOR): 2.6 (95% CI: 1.1 to 6.4)), on first-line ART (AOR: 2.3 (95% CI: 1.1 to 4.6)) and married/cohabiting (AOR: 1.9 (95% CI: 1.0 to 3.7)) were significantly associated with increased odds of mVL nonsuppression. Conclusions The prevalence of mVL ≤1000 copies/mL of 85.3% among pregnant and postpartum WLHIV and attending public healthcare centres in this rural district is below the 2020 90-90-90 and 2030 95-95-95 UNAIDS targets. Given that low-level viraemia may also increase the risk of vertical HIV transmission, we recommend strengthened implementation of the new guidelines which include better ART options, improved ART regimen switching and mVL monitoring schedules, and intensified psychosocial support for younger women, while exploring district-level complementary interventions, to sustain VLs below 50 copies/mL among all women. ► This study provides maternal viral load (mVL) nonsuppression data from a rural setting where research of this kind is limited. ► The mVL measurements were conducted using the gold standard whole blood plasma rather than dried blood spots despite the challenging remote settings. ► The postpartum inclusion criterion targeted mothers attending clinics with their biological children and hence could present a sample biased towards biological mothers with better clinic attendance and less representative of mothers who mostly assign child healthcare visits to other caregivers. ► The sample sizes achieved were lower than planned and much lower for the postpartum stages which did not overlap with routine child vaccination schedules, but there was no statistically significant difference in the proportion of mVL non-suppression between the postpartum stages.
Objective Between 1998 and 2009 reported exclusive breastfeeding (EBF) rates in South African inf... more Objective Between 1998 and 2009 reported exclusive breastfeeding (EBF) rates in South African infants, aged 0-6 months, ranged from 6.2% to 25.7%.
Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient ep... more Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient epidemic tracking, programme planning and resource allocation. HIV sentinel surveillance usually employs unlinked anonymous HIV testing which raises ethical, epidemiological and public health challenges in the current era of universal test and treat. The World Health Organization (WHO) recommends that countries should consider using routine prevention of mother-to-child transmission of HIV (PMTCT) data for surveillance. We audited antenatal care clinics to assess the quality of HIV rapid testing practices as the first step to assess whether South Africa is ready to utilize PMTCT programme data for antenatal HIV surveillance. In 2017, we conducted a cross-sectional survey in 360 randomly sampled antenatal care clinics using the adapted WHO Stepwise-Process-for-Improving-the-Quality-of-HIV-Rapid-Testing (SPI-RT) checklist. We calculated median percentage scores within a domain (domain-specif...
The International Journal of Cardiovascular Imaging
HIV associated cardiomyopathy (HIVAC) is a poorly understood entity that may progress along a con... more HIV associated cardiomyopathy (HIVAC) is a poorly understood entity that may progress along a continuum. We evaluated a group of persons newly diagnosed with HIV and studied the evolution of cardiac abnormalities after ART initiation. We recruited a group of newly diagnosed, ART naïve persons with HIV and a healthy, HIV uninfected group. Participants underwent comprehensive cardiovascular evaluation, including cardiovascular magnetic resonance imaging. The HIV group was started on ART and re-evaluated 9 months later. The cardiovascular parameters of the study groups were compared at diagnosis and after 9 months. The ART naïve group’s (n = 66) left- and right end diastolic volume indexed for height were larger compared with controls (n = 22) (p < 0.03). The left ventricular mass indexed for height was larger in the naïve group compared with controls (p = 0.04). The ART naïve group had decreased left- and right ventricular ejection fraction (p < 0.03) and negative, non-linear as...
Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be ... more Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be used to control HIV incidence especially among people who are at increased risk for HIV such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). In South Africa, various approaches of delivering PrEP have been adopted at different service delivery points (facility-based only, school-based only, community-based only and hybrid school-facility and community-facility models) to overcome challenges associated with individual, structural, and health systems related barriers that may hinder access to and uptake of PrEP among these populations. However, little is known about how to optimize PrEP implementation and operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. This study aims to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation, and adherence among AGYW and ABYM. Metho...
IntroductionIn South Africa, HIV prevalence among adolescent girls and young women (AGYW) was 5.8... more IntroductionIn South Africa, HIV prevalence among adolescent girls and young women (AGYW) was 5.8% (15-19 years) and 15.6% (20-24 years) respectively in 2017. Amongst South African males, HIV prevalence in 2017 was 4.7% (15-19 years), 4.8% (20-24 years), 12.4% (25-29 years) and 18.4% (30-34 years). The National Department of Health adopted the universal test and treat (UTT) strategy in 2016, resulting in increases in same-day antiretroviral therapy initiations and linkage to care. Monitoring progress towards attainment of South Africa’s 95-95-95 targets amongst AGYW and adolescent boys and young men (ABYM) relies on high quality data to identify and address gaps in linkage to care. The purpose of this study is to provide evidence to guide efforts to improve linkage to, and retention in, HIV care among AGYW and ABYM in KwaZulu-Natal, in the context of the UTT strategy.Methods and analysisThis is a mixed methods study, which will be conducted in uMgungundlovu district of KwaZulu-Natal...
Background: Little is known about women who have experienced a recent rape, and how they differ f... more Background: Little is known about women who have experienced a recent rape, and how they differ from women without this exposure. Identifying factors linked to rape is important for preventing rape and developing effective responses in countries like South Africa with high levels of sexual violence. Objective: To describe the socio-demographic and health profile of women recently exposed to rape and to compare them with a non-rape-exposed group. Methods: The Rape Impact Cohort Evaluation Study (RICE) enrolled 852 women age 16-40 years exposed to rape from post-rape care centres in Durban (South Africa) and a control group of 853 women of the same age range who have never been exposed to rape recruited from public health services. Descriptive analyses include logistic regression modelling of socio-demographic characteristics associated with recent rape exposure. Results: Women with recent rape reported poorer health and more intimate partner violence than those who were not raped. They had a lower likelihood of having completed school (Odds Ratio [OR] 0.46 95% Confidence Interval (CI): 0.24-0.87) and dependence on a government grant as a main source of income (OR 0.61: 95%CI 0.49-0.77). They were more likely to live in informal housing (OR 1.88 95%CI: 1.43-2.46) or rural areas (OR 2.24: 95% CI 1.61-3.07) than formal housing areas-however they were also more likely to report fulltime employment (OR 4.24: 95%CI 2.73-6.57). Conclusion: The study shows that structural factors, such as lower levels of education, poverty, and living in areas of poor infrastructure are associated with women's vulnerability to rape. It also shows possible protection from rape afforded by the national financial safety net. It highlights the importance of safe transportation in commuting to work. Preventing rape is critical for enabling women's full social and economic development, and structural interventions are key for reducing women's vulnerability.
Introduction: HIV care, linkage, and retention are key weaknesses in South Africa’s national anti... more Introduction: HIV care, linkage, and retention are key weaknesses in South Africa’s national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. Very few studies have investigated the proportion of people newly diagnosed with HIV linked-to and retained-in-care in the ‘Universal Test-and-Treat’ era. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. Methods: We conducted an observational prospective cohort study from December 2017 to August 2019 to investigate LTRIC rates for adults with a new HIV diagnosis in uThukela district, South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess a...
9 /l) decreased from 0.70 in the randomized trial, and 0.61 in the whole-school study, to well wi... more 9 /l) decreased from 0.70 in the randomized trial, and 0.61 in the whole-school study, to well within the normal paediatric range of 0.05-0.45 (P < 0.05). The prevalence of eosinophilia declined from 57% to 37% in the randomized trial (mean for 400, 800 and 1200 mg albendazole doses); and from 47% to 24% in the whole-school study (500 mg stat mebendazole). Benzimidazole anthelminthics were highly effective against Ascaris but less so against Trichuris. Activated eosinophils are effector and immuno- regulatory leucocytes of the T-helper cell type 2 (Th2) immune re- sponse to parasitic helminths and atopic disorders. Under conditions of poverty where soil-transmitted helminths are hyperendemic, Th2 polarization of the immune profile is character- istic. Regular anthelminthic treatment should reduce contact with worm antigens, and this may contribute to re-balancing of the immune profile. Suppression of eosinophil recruitment and activa- tion, together with related cellular and mole...
Introduction New HIV infection during pre-conception and pregnancy is a significant contributor o... more Introduction New HIV infection during pre-conception and pregnancy is a significant contributor of mother–to–child transmission of HIV in South Africa. This study estimated HIV incidence (defined as new infection within the last one year from the time of the survey which included both new infections occurred during pregnancy or just before pregnancy) among pregnant women and described the characteristics of recently infected pregnant women at national level. Methods Between 1 October and 15 November 2017, we conducted a national cross–sectional survey among pregnant women aged 15–49 years old attending antenatal care at 1,595 public facilities. Blood specimens were collected from pregnant women and tested for HIV in a centralised laboratory. Plasma viral load and Limiting Antigen Avidity Enzyme Immunosorbent Assay (LAg) tests were further performed on HIV positive specimens to differentiate between recent and long–term infections. Recent infection was defined as infection that occur...
We compared first sex experiences and wellbeing of adolescent girls and young women (AGYW) who ha... more We compared first sex experiences and wellbeing of adolescent girls and young women (AGYW) who had an early sexual debut (age < 15) with those who had later sexual debut. We conducted a representative household survey among AGYW aged 15-24 years in six districts in South Africa. Of 3009 AGYW who had ever had sex, 8.9% reported early sexual debut. Early sexual debut was associated with coercion at first sex and a lower average well-being score compared with a later debut. Interventions which aim to delay early sexual debut may positively affect well-being.
Background:Long-acting reversible contraceptives (LARCs), which include the subdermal contracepti... more Background:Long-acting reversible contraceptives (LARCs), which include the subdermal contraceptive implant and intrauterine contraception, offer women safe, highly effective, long-term pregnancy prevention, and have expanded contraceptive options. The implant greatly expands LARC options for South African women as it is available free of charge at public health facilities, but little is known about factors associated with its uptake. This study describes factors associated with the intention to use the implant, including knowledge and beliefs about the implant and perceived outcome expectancies of implant use among women in Cape Town, South Africa.Methods:Between 2015 and 2016, the authors conducted a quantitative, cross-sectional survey among adult women attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, they measured knowledge, awareness, and attitudes, perceived outcome expectancy, and the intention to use the contraceptive im...
Aim South African adults with hypertension often have comorbid physical and mental health problem... more Aim South African adults with hypertension often have comorbid physical and mental health problems and disabilities, which can influence each other in complex ways. We modelled potential causal pathways connecting multimorbidity, depression, stress, disability and cardiovascular risks. Methods The study analysed observational data on 1043 adults with treated hypertension and with symptoms of depression (Patient Health Questionnaire-9 score > 9) who participated in a randomised trial in 20 primary health care clinics. A structural equation path model using cross-sectional baseline data estimated direct and indirect effects of sociodemographic variables and comorbidities on depression, stress and disability scores, and their further direct and indirect effects on smoking, body mass index and blood pressure. A cross-lagged structural equation model using longitudinal data estimated effects of depression symptoms, disability and blood pressure on each other over time. Results At base...
Southern African Journal of Infectious Diseases, 2020
The national human immunodeficiency virus (HIV) mother-to-child transmission rate at 6-10 weeks p... more The national human immunodeficiency virus (HIV) mother-to-child transmission rate at 6-10 weeks post-partum was 0.9% in 2016. There is a paucity of data about the intrapartum transmission rate after lifelong antiretroviral therapy was implemented in 2015. We assessed all pregnant women living with HIV who delivered at Tygerberg Hospital in 2017. Positive polymerase chain reactions (PCRs) at birth indicated an in utero transmission rate of 0.8%. One infant with a negative PCR at birth tested positive at 6-10 weeks. The intrapartum transmission rate was low (0.08%). About 25% of infants were lost to follow-up after birth.
Introduction Knowledge of HIV status in South Africa (SA) is reported to be 90% among people livi... more Introduction Knowledge of HIV status in South Africa (SA) is reported to be 90% among people living with HIV. National level estimates could mask population-specific levels, which are critical to monitor program coverage and potential impact. Using data from the 2017 national antenatal sentinel survey, we assessed knowledge of HIV-positive status, initiation of antiretroviral therapy (ART), and socio-demographic characteristics associated with knowledge of HIVpositive status prior to the current pregnancy among women attending antenatal care. Methods Between 1 October and 15 November 2017, a nationally representative sample of 32,716 pregnant women were enrolled from 1,595 public health facilities selected from all districts of SA. Data on age, gravidity, knowledge of HIV-positive status and ART initiation prior to pregnancy were extracted from medical records. A blood sample was collected from each woman regardless of prior knowledge of HIV status or ART history, and tested for HIV in the laboratory. All HIV-positive pregnant women enrolled in the survey were eligible for inclusion in the analysis. Multivariable survey logistic regression was used to examine factors associated with knowledge of HIV-positive status prior to the current pregnancy. Results Of 10,065 eligible HIV-positive women, 60.8% (95% confidence interval (CI):59.9%-61.7%) knew their HIV status prior to the current pregnancy, of whom 91.1% (95% CI: 90.4%-91.7%) initiated ART prior to the current pregnancy. Knowledge of HIV-positive status was lower
Objective: To describe viral load levels among pregnant women and factors associated with failure... more Objective: To describe viral load levels among pregnant women and factors associated with failure to achieve viral suppression (viral load ≤50 copies/ml) during pregnancy. Design: Between 1 October and 15 November 2017, a cross-sectional survey was conducted among 15–49-year-old pregnant women attending antenatal care (ANC) at 1595 nationally representative public facilities. Methods: Blood specimens were taken from each pregnant woman and tested for HIV. Viral load testing was done on all HIV-positive specimens. Demographic and clinical data were extracted from medical records or self-reported. Survey logistic regression examined factors associated with failure to achieve viral suppression. Result: Of 10 052 HIV-positive participants with viral load data, 56.2% were virally suppressed. Participants initiating antiretroviral therapy (ART) prior to pregnancy had higher viral suppression (71.0%) by their third trimester compared with participants initiating ART during pregnancy (59.3%...
International Journal of Infectious Diseases, 2019
South Africa has used antenatal HIV surveys for HIV surveillance in pregnant women since 1990. We... more South Africa has used antenatal HIV surveys for HIV surveillance in pregnant women since 1990. We assessed South Africa's readiness to transition to programme data based antenatal HIV surveillance with respect to PMTCT uptake, accuracy of point-of-care rapid testing (RT) and selection bias with using programme data in the context of the 2017 antenatal HIV survey. Methods: Between 1 October and 15 November 2017, the national survey was conducted in 1,595 public antenatal facilities selected using stratified multistage cluster sampling method. Results of point-of-care RT were obtained from medical records. Blood samples were taken from eligible pregnant women and tested for HIV using immunoassays (IA) in the laboratory. Descriptive statistics were used to report on: PMTCT uptake; agreement between HIV point-of-care RT and laboratory-based HIV-1 IA; and selection bias associated with using programme data for surveillance. Results: PMTCT HIV testing uptake was high (99.8%). The positive percent agreement (PPA) between RT and IA was lower than the World Health Organization (WHO) benchmark (97.6%) at 96.3% (95% confidence interval (CI): 95.9%-96.6%). The negative percent agreement was above the WHO benchmark (99.5%), at 99.7% (95% CI: 99.6%-99.7%) nationally. PPA markedly varied by province (92.9%-98.3%). Selection bias due to exclusion of participants with no RT results was within the recommended threshold at 0.3%. Conclusion: For the three components assessed, South Africa was close to meeting the WHO standard for transitioning to routine RT data for antenatal HIV surveillance. The wide variations in PPA across provinces should be addressed.
We evaluated the effectiveness of the Skhokho interventions (enhanced teaching materials and a pa... more We evaluated the effectiveness of the Skhokho interventions (enhanced teaching materials and a parenting programme) in reducing dating and sexual violence. This pragmatic, threearm cluster randomised controlled trial was conducted in 24 State schools in Grade 8 classes, with all learners invited to participate. The interventions were: i) a schools' package: A Life Orientation (LO) curriculum workbook for the Grade 8 national curriculum and teacher training; ii) a workshop for caregivers and teenagers, supported by clubs in the second year. Arms were: a no intervention control, the schools' package, and the combined schools' and families' package. Learners were followed up for 18 months. The primary outcomes were the incidence of physical and/or sexual IPV, severe IPV and non-partner rape. At baseline, 3756 (61.8% of total) learners (aged 12-15) were interviewed and 3411 (90.8%) provided end line data. A third of caregivers and learners attended all four families' intervention workshop sessions. At baseline, 47% of girls and 29% boys were dating and 18% of boys and 2% of girls had had sex. Differences in the primary outcomes between study arms were not statistically significant, however all effects were in the direction of protection from violence and several secondary outcomes were significantly changed. For girls, the incidence of any IPV experience was aIRR 0.84 (95%CI 0.66, 1.07 p = 0.159) for the school's arm and the incidence of non-partner rape was aIRR 0.84 (95%CI 0.62, 1.14 p = 0.255) for the combined schools and families arm v. control arm. This under-powered pragmatic study's findings suggest a generally beneficial impact of the Skhokho interventions on a number of outcome measures, when viewed by both adolescents, caregivers and their teachers. These include measures of adolescents' exposure to violence, improved sexual health and reductions in several IPV risk factors. The intervention warrants further research. Trial registration ClinicalTrials.gov NCT02349321.
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Papers by Carl Lombard