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We conducted a mixed-methods study to understand current drug use practices and access to healthcare services for people who use injection drugs in KwaZulu-Natal, South Africa. We used respondent-driven sampling to recruit 45 people who used injection drugs within the past 6 months from KwaZulu-Natal, South Africa. We found high rates of practices that increase HIV/viral hepatitis risk including the use of shared needles (43%) and direct blood injections (bluetoothing) (18%). Despite 35% living with HIV, only 40% accessed antiretroviral therapy within the past year, and one accessed PrEP. None of the participants ever tested for Hepatitis C.

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

Introduction In 2023, one‐fourth of new HIV acquisitions in children globally resulted from vertical transmission following incident HIV during pregnancy or breastfeeding. Oral pre‐exposure prophylaxis (PrEP) with tenofovir disoproxil and emtricitabine is safe and effective in pregnancy and postpartum, with long‐acting options emerging. Integrating PrEP into antenatal and postnatal care (ANC/PNC) is a crucial person‐centred approach to prevent maternal HIV acquisition and vertical transmission. This review summarizes oral PrEP initiation, continuation and adherence among pregnant and postpartum women receiving ANC/PNC. Methods We systematically searched three databases for English‐language quantitative studies published between 1 January 2015 and 28 March 2024. Eligible studies focused on pregnant and/or postpartum women accessing PrEP through ANC/PNC, and reported on initiation (receipt of prescription or self‐reported use), continuation (persistent use over time) and/or adherence (self‐reported and/or objective). Results We identified 481 articles; 12 studies from Kenya, Lesotho, Malawi and South Africa met our inclusion criteria. Study heterogeneity (e.g. definitions used, population included, follow‐up time) precluded meta‐analysis. All studies enrolled pregnant women; three also enrolled postpartum women. Median gestational age at enrolment ranged from 20 to 26 weeks, and follow‐up periods from 1 month post‐enrolment to 12 months postpartum. Oral PrEP initiation ranged from 14% to 84%. Continuation at 3 months ranged from 22% to 90% and declined postpartum in all studies. Self‐reported adherence (daily use) ranged from 11% to 81% in the past 7 or 30 days at 1 month (four studies) and from 54% to 81% at 3 months (two studies). Objectively measured adherence ranged from 34% to 62% for detectable tenofovir or tenofovir diphosphate levels at 1 month (three studies). One Kenyan trial demonstrated that universal versus risk‐based offers of oral PrEP resulted in similar PrEP use and HIV incidence. Two‐way SMS communication (Kenya) and real‐time adherence biofeedback counselling using urine tenofovir testing (South Africa) enhanced PrEP continuation/adherence compared to standard‐of‐care. Discussion Integrating oral PrEP into ANC/PNC showed high initiation among pregnant/postpartum women; however, continuation and adherence were suboptimal. Conclusions Oral PrEP integration into ANC/PNC can reach pregnant/postpartum women. Maximizing its impact will require offering long‐acting PrEP, person‐centred interventions to support adherence/continued use and differentiated delivery responsive to women's needs. PROSPERO Number CRD42024513442

Background People who inject drugs (PWID) are at risk of HIV acquisition. The number of PWID in South African cities is increasing, and in spite of an advanced HIV prevention and treatment programme, there are PWID who experience challenges accessing sexual and reproductive health (SRH) and HIV related services. Access to and acceptability of SRH and harm reduction services by PWID needs to be further understood and explored. Methods In-depth interviews (IDIs) were conducted with 10 key stakeholders and 11 PWID, in Durban, South Africa. Interviews were transcribed and translated. Data were thematically analysed using Dedoose software. Results Participants described stigma/discrimination from healthcare workers and other clients accessing services as barriers to accessing healthcare services. They were concerned about long waiting times at healthcare facilities because of possibilities of withdrawal, as well as lost opportunities to “hustle”. Targeted, non-discriminatory services, as well as mobile clinics existed in the city. Non-governmental organisations reportedly worked together with the public sector, facilitating access to HIV and TB prevention and treatment services. There were also needle exchange programmes and a harm reduction clinic in the city. However, there was limited access to contraceptive and STI services. Although there was reportedly good access to HIV and TB and harm reduction services in the city of Durban, uptake was low. Conclusions The integration of services to enable PWID to access different services under one roof is critical. There is also a need to strengthen linkages between public and private healthcare, and ensure services are provided in a non-discriminatory environment. This will facilitate uptake and access to more comprehensive SRH and harm reduction services for PWID in Durban, South Africa.

Background Sexually transmitted infection (STI) partner notification is key to fostering STI cure and preventing onward STI transmission; this is critical among people planning for pregnancy given the high STI morbidity and mortality among neonates. This qualitative study explores how women planning for pregnancy and considering HIV pre-exposure prophylaxis approach STI partner notification in Durban, South Africa to inform future interventions. Methods We conducted a cohort study evaluating pre-exposure prophylaxis use as a part of safer conception care among adult women (≥ 18 years) without HIV, partnered with a man living with HIV or unknown HIV-serostatus, and planning for pregnancy. As part of an STI-focused sub-study, 25 women who completed etiologic STI screening also completed qualitative interviews exploring participant STI partner notification practices, preferences, and interaction with pregnancy. We used an inductive and deductive approach to generate a codebook, organized our findings according to the Disclosure Processes Model, and identified preliminary themes using content analysis. Results The median age of sub-study participants was 25 (range 19–33) years, five (20%) were diagnosed with an STI during the study, and 2 (8%) became pregnant during the study. Preliminary themes included 1) Participants’ perceptions of their own and their partner’s additional partnerships affected STI partner notification perceptions and practices; 2) Participants’ asymptomatic presentation and etiologic, laboratory diagnosis supported partner notification; 3) Participants reported male reluctance to engage with healthcare services and a reliance on female participant testing and subsequent partner notification; 4) Participants endorsed provider-assisted STI partner notification; 5) STI diagnoses and partner notification led participants to mistrust their partners and subsequently impacted their condom use during pregnancy planning. Conclusions We found a lack of partner concurrency and asymptomatic infection to influence STI partner notification with partner notification affecting pregnancy planning and condom use. Since women report having high STI testing and care engagement, they bear a high burden of partner notification and potential subsequent blame and often appreciated provider assistance. Interventions are needed to engage men in STI testing and care and to mitigate the potential harms of STI partner notification.

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

IntroductionTuberculosis (TB) remains the leading cause of infectious disease deaths, particularly among people living with HIV (PWH). Despite being preventable, TB preventive therapy (TPT) uptake is low in high-burden regions like South Africa, where new guidelines have expanded TPT eligibility and introduced shorter, more effective regimens like 3 months of weekly rifapentine and isoniazid (3HP). As differentiated service delivery models for HIV care have proven effective, there is increasing recognition that decentralising TPT delivery may improve coverage and completion. This study explores whether a community-based TPT delivery strategy can enhance uptake and completion of TPT compared with traditional clinic-based services.Method and analysisWe will conduct a household-randomised, non-blinded, controlled trial. Persons eligible for TPT will be recruited from the TB TRIAGE+Trial study, a community-based household TB screening study. Households containing at least one person eligible for TPT will be randomised 1:1 to either community-based TPT or standard-of-care clinic referral for TPT. At enrolment, all participants will be provided with a 2-week supply of TPT in the community. Participants randomised to the community arm will receive the entire course of TPT in a single dispense (12 weeks of 3HP or 6 months of isoniazid, if 3HP is contraindicated). Clinic-arm participants will be referred to their local clinic for the remainder of their course of TPT and will collect TPT refills on the clinic-determined schedule. Our primary outcome is the proportion of participants who complete a course of TPT. Secondary outcomes include overall adherence to TPT, predictors of adherence with TPT, participant satisfaction with the assigned TPT delivery method and adverse events.Ethics and disseminationThe study and its tools were approved by the Human Sciences Research Councils Research Ethics Committee (approval number: 2/25/10/23), based in Pretoria, Gauteng, South Africa, as well as the University of Washington Institutional Review Board (Study 00018448). Study findings will be shared through the community advisory group and local stakeholder meetings, relevant international and local meetings/conferences and peer-reviewed publications.Trial registration numberNCT06214910. Date and version: 3.0, 30 July 2024.

Implanon NXT was introduced in South Africa (SA) in 2014 to expand the contraceptive method mix. While studies have explored patterns of implant use, data on contraceptive choice following implant removal is limited. Here, we describe contraceptive choice among 120 women requesting Implanon NXT removal, between 2017 and 2018, at an urban reproductive health clinic in Durban, SA. Among women who used the implant for three years (n=91), >50% chose to reinsert Implanon NXT. Reasons for choosing to reinsert included satisfaction with the implant, the desire for a long-acting method and having had no side effects. A third of women chose not to reinsert Implanon NXT after three years due to side effects such as problematic bleeding. Most women requesting early removal of the implant switched to male condoms, injectables or oral contraceptives. Contraceptive services should provide women with contraceptive options and allow women to make informed decisions regarding contraceptive choice, in addition to providing support and managing side effects among Implanon NXT users.(Afr J Reprod Health 2021; 25[1]: 41-48. Implanon NXT a été introduit en Afrique du Sud (SA) en 2014 pour élargir la gamme de méthodes contraceptives. Alors que les études ont exploré les modèles d'utilisation des implants, les données sur le choix de la contraception après le retrait de l'implant sont limitées. Ici, nous décrivons le choix de la contraception parmi 120 femmes demandant le retrait d'Implanon NXT, entre 2017 et 2018, dans une clinique de santé reproductive urbaine à Durban, SA. Parmi les femmes ayant utilisé l'implant pendant trois ans (n = 91),> 50% ont choisi de réinsérer Implanon NXT. Les raisons du choix de la réinsertion comprenaient la satisfaction à l'égard de l'implant, le désir d'une méthode à action prolongée et l'absence d'effets secondaires. Un tiers des femmes ont choisi de ne pas réinsérer Implanon NXT après trois ans en raison d'effets secondaires tels que des saignements problématiques. La plupart des femmes demandant le retrait précoce de l'implant sont passées aux préservatifs masculins, aux injectables ou aux contraceptifs oraux. Les services de contraception devraient offrir aux femmes des options contraceptives et leur permettre de prendre des décisions éclairées concernant le choix de la contraception, en plus de fournir un soutien et de gérer les effets secondaires parmi les utilisatrices d'Implanon NXT.(Afr J Reprod Health 2021; 25[1]: 41-48.

Background People who inject drugs (PWID) are often excluded in research due to social circumstances and a lack of creativity when recruiting this community. Respondent driven sampling (RDS) is one method used to access marginalised and stigmatised communities such as PWID. This study piloted RDS with PWID in eThekwini District, South Africa, and also explored participants’ perspectives of the usefulness of this approach to recruit PWID. Methods In-depth interviews (IDIs) were conducted with 10 key stakeholders, followed by a cross-sectional survey among 45 PWID recruited via RDS. Further, 11 of these PWID participated in IDIs. Survey data were entered into REDCap and descriptively analysed. IDIs were transcribed, translated and thematically analysed using Dedoose software. Results Participants described barriers and facilitators accessing PWID for research. Access to PWID was viewed as challenging because of factors including stigma and concerns of criminalisation. However, making use of PWID networks and peers was felt to be important to facilitate recruitment. RDS was described as an acceptable recruitment strategy, and was rated as “not burdensome” by most (98%). RDS was successfully carried out in this pilot. Participation of PWID in research was viewed as important, but challenging. It was felt that participation of PWID could be impacted by concerns of opioid withdrawal, therefore timing (length and time) of participation was important to consider in study design. Reimbursement strategies for PWID participating in research were discussed. Incentives for participation, including cash reimbursement, were viewed favourably for PWID. Conclusions RDS is plausible for recruitment of PWID in eThekwini District, South Africa. It can be used to further understand PWID networks and to better serve them for future research and appropriate care. Trial registration N/A, not a clinical trial.

IntroductionTuberculosis (TB) remains a significant public health challenge in many African communities, where underreporting and underdiagnosis are prevalent due to barriers in accessing care and inadequate diagnostic tools. This is particularly concerning in hard-to-reach areas with a high burden of TB/HIV co-infection, where missed or delayed diagnoses exacerbate disease transmission, increase mortality and lead to severe economic and health consequences. To address these challenges, it is crucial to evaluate innovative, cost-effective, community-based screening strategies that can improve early detection and linkage to care.Methods and analysisWe conduct a prospective, community-based, diagnostic, pragmatic trial in communities of the Butha Buthe District in Lesotho and the Greater Edendale area of Msunduzi Municipality, KwaZulu-Natal in South Africa to compare two strategies for population-based TB screening: computer-aided detection (CAD) technology alone (CAD4TBv7 approach) versus CAD combined with point-of-care C reactive protein (CRP) testing (CAD4TBv7-CRP approach). Following a chest X-ray, CAD produces an abnormality score, which indicates the likelihood of TB. Score thresholds informing the screening logic for both approaches were determined based on the WHO’s target product profile for a TB screening test. CAD scores above a threshold prespecified for the CAD4TBv7 approach indicate confirmatory testing for TB (Xpert MTB/RIF Ultra). For the CAD4TBv7-CRP approach, a CAD score within a predefined window requires the conduct of the second screening test, CRP, while a score above the respective upper threshold is followed by Xpert MTB/RIF Ultra. A CRP result above the selected cut-off also requires a confirmatory TB test. Participants with CAD scores below the (lower) threshold and those with CRP levels below the cut-off are considered screen-negative. The trial aims to compare the yield of detected TB cases and cost-effectiveness between two screening approaches by applying a paired screen-positive design. 20 000 adult participants will be enrolled and will receive a posterior anterior digital chest X-ray which is analysed by CAD software.Ethics and disseminationThe protocol was approved by National Health Research Ethics Committee in Lesotho (NH-REC, ID52-2022), the Human Sciences Research Council Research Ethics Committee (HSRC REC, REC 2/23/09/20) and the Provincial Health Research Committee of the Department of Health of KwaZulu-Natal (KZ_202209_022) in South Africa and from the Swiss Ethics Committee Northwest and Central Switzerland (EKNZ, AO_2022–00044). This manuscript is based on protocol V.4.0, 19 January 2024. Trial findings will be disseminated through peer-reviewed publications, conference presentations and through communication offices of the consortium partners and the project’s website (https://tbtriage.com/).Trial registrationClinicalTrials.gov (NCT05526885), South African National Clinical Trials Register (SANCTR; DOH-27-092022-8096).