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Background Antenatal care (ANC) provides healthcare services to pregnant women in an attempt to ensure, the best possible pregnancy outcome for women and their babies. Healthcare providers’ understanding of their patient’s behaviour and reasons for engagement in care and their response to this insight can influence patient-provider interactions and patient demand for ANC early in pregnancy. We examined the insight of healthcare providers into women’s reasons for starting ANC later than the South African National Department of Health’s recommended 20 weeks gestation. We also looked at the impact of late ANC presentation on overall healthcare providers’ work experiences and their response in their interactions with patients. Methods In-depth interviews were conducted with 10 healthcare providers at Maternal Obstetrics Units (MOU) and Primary Healthcare Centres (PHC) in Gauteng, South Africa. Healthcare providers were selected with the assistance of the facility managers. Data analysis was conducted using the qualitative analysis software NVivo 11, using a thematic approach of pinpointing, examining, and recording patterns within the data. Results Healthcare providers were aware of patients need for secrecy in the early stages of pregnancy because of fears of miscarriage and women’s preference for traditional care. Women with prior pregnancies presumed to know about stages of pregnancy and neglected to initiate ANC early. Barriers to early ANC initiation also include, women’s need to balance income generating activities; travel cost to the clinic and refusal of care for coming after the daily patient limit has been reached. Healthcare providers encounter negative attitudes from un-booked patients. This has a reciprocal effect whereby this experience impacts on whether healthcare providers will react with empathy or frustration. Conclusions Timing of ANC is influenced by the complex decisions women make during pregnancy, starting from accepting the pregnancy itself to acknowledging the need for ANC. To positively influence this decision making for the benefit of early ANC, barriers such as lack of knowledge should be addressed prior to pregnancy through awareness programmes. The relationship between healthcare providers and women should be emphasized when training healthcare providers and considered as an important factor that can affect the timing of ANC.

Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD4<500 cells/μl antiretroviral therapy (ART) eligibility threshold and universal test and treat (UTT) policies in the Gauteng province of South Africa. We conducted a retrospective cohort study of 692 HIV positive adult (>18 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3-9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression. Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4-2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4-3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1-1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001). These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring.

Timing of engagement in HIV care in relation to pregnancy impacts maternal outcomes and the risk of vertical transmission of HIV. Option B+, a policy that mandates offering all pregnant women living with HIV (PWLH) lifelong antiretroviral therapy (ART) irrespective of their CD4 count, has been adopted across sub-Saharan Africa, including South Africa since 2015. This study aimed to assess the impact of expanded access to ART on engagement in HIV care and viral suppression among pregnant women in South Africa. This observational study used data from pregnant women living with HIV who delivered at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa from 2013-2017. Linkage to a national HIV laboratory cohort (the NHLS National HIV cohort) was used to ascertain engagement in HIV care prior to antenatal care (ANC) entry and viral load outcomes. Analyses were stratified by the pre-Option B+ (2013-2014), Option B+ (2015-31 Aug 2016) and Universal Test and Treat (post-01 Sept 2016) eras. We compared engagement rates before and during the Option B+ era and assessed factors associated with HIV care engagement and viral suppression. Risk ratios were estimated using log-binomial regression. Among 4,865 PWLH, 65% had evidence of prior engagement in HIV care. Prior engagement in care was higher during the Option B+ (64%) and UTT (71%) eras compared to the pre-Option B+ era (55%). Younger women (18-24 years) were less likely to engage in HIV care than those aged 25-34 years (aRR 0.8, 95% CI: 0.6-0.9). Women with CD4 counts <200 cells/mm³ were less likely to have been engaged in care prior to pregnancy compared to those with CD4 ≥ 500 (aRR 0.6, 95% CI: 0.6-0.7). Primigravid women had a 30% lower likelihood of earlier HIV care engagement compared to those with 2-3 pregnancies (aRR 0.7, 95% CI: 0.5-0.8). Overall viral suppression was higher in women reporting ART use prior to pregnancy compared to those with no prior HIV care (33% vs. 19%, p < 0.001). During the four-year study period, the proportion of PWLH who had a viral load recorded but were not virally suppressed ranged from 22-36%. We observed increased engagement in HIV care prior to pregnancy after implementation of policies that expanded access to ART. However, high prevalence of unsuppressed viral load across all policy eras highlights the need for continued monitoring and support to sustain the benefits of this policy. Pregnancy and antenatal care services remain an essential portal of entry to HIV care among PWLH in South Africa. Interventions to improve early ANC attendance and maternal engagement in HIV care prior to pregnancy are critical to eliminate vertical HIV transmission.

Background People with tuberculosis (TB) may face long-term physical and psycho-social-economic disability related to TB treatment. The Corona Virus Disease 2019 (COVID-19) pandemic and government restrictions disrupted health care services. We describe health-seeking behaviour, perceived financial impact, and the mental health of TB survivors one year after the COVID-19 pandemic. We further explore factors associated with the perceived impact of COVID-19 and government restrictions on health-seeking behaviour. Methods This is a cross-sectional study nested in an ongoing observational TB Sequel cohort study. Adults (≥ 18yrs) who had completed treatment for drug-susceptible pulmonary TB in South Africa, the Gambia, and Mozambique before the start of the COVID-19 pandemic, completed a COVID-19 questionnaire which included the WHO tool for Behavioural Insights on COVID-19, the Kessler Psychological Distress Scale (K10) and Medical Outcomes Short Form Survey (SF-36) for health-related quality of life. Questionnaires were administered during scheduled TB Sequel follow-up study visits between 04/2021 and 10/2021. We used publicly available data on the number of COVID-19 cases and the start and end date of each wave to define country-specific COVID-19 “in-wave” and “out-of-wave” phases. We compared psycho-social and economic measures reported during these phases. In addition, we explored factors associated with poor health-seeking behaviour (comprised of moderate or serious impact) using logistic regression. Results Four hundred eighty seven TB survivors (69% male, median age 33 years IQR 25–42, median time since TB treatment completion 16 months IQR 13–27) completed the COVID-19 questionnaire. About a quarter of TB survivors reported that their financial status ( n  = 117; 24%) or their health-seeking behaviour for any health condition ( n  = 128; 26%) had been seriously impacted by COVID-19 and the governments’ response. A third of patients (30.4%) reported using coping strategies. Logistic regression indicated that males, living with HIV and being on antiretroviral treatment (ART), being impacted financially during COVID-19, and experiencing social changes, were associated with poor health-seeking behaviour. Conclusion Governments’ response to COVID-19 affected TB survivors’ healthcare-seeking behaviour, financial status and mental health. The long-term adverse effects on health-seeking behaviour are important for TB survivors who are at increased risk for recurrent disease and long-term disability in the first two years after treatment completion. Trial registration Clinical trial number: not applicable.

Background Multi-drug resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) in pregnant women is a cause for concern globally; few data have described the safety of second-line anti-TB medications during pregnancy. We aim to describe TB treatment and pregnancy outcomes among pregnant women receiving second-line anti-tuberculosis treatment for MDR/RR-TB in Johannesburg, South Africa. Methods We conducted a retrospective record review of pregnant women (≥ 18 years) who received treatment for MDR/RR-TB between 01/2010–08/2016 at three outpatient treatment sites in Johannesburg, South Africa. Demographic, treatment and pregnancy outcome data were collected from available medical records. Preterm birth (< 37 weeks), and miscarriage were categorized as adverse pregnancy outcomes. Results Out of 720 women of child-bearing age who received MDR/RR-TB treatment at the three study sites, 35 (4.4%) pregnancies were identified. Overall, 68.7% (24/35) were HIV infected, 83.3% (20/24) were on antiretroviral therapy (ART). Most women, 88.6% (31/35), were pregnant at the time of MDR/RR-TB diagnosis and four women became pregnant during treatment. Pregnancy outcomes were available for 20/35 (57.1%) women, which included 15 live births (11 occurred prior to 37 weeks), 1 neonatal death, 1 miscarriage and 3 pregnancy terminations. Overall, 13/20 (65.0%) women with known pregnancy outcomes had an adverse pregnancy outcome. Of the 28 women with known TB treatment outcomes 17 (60.7%) completed treatment successfully (4 were cured and 13 completed treatment), 3 (10.7%) died and 8 (28.6%) were lost-to-follow-up. Conclusions Pregnant women with MDR/RR-TB suffer from high rates of adverse pregnancy outcomes and about 60% achieve a successful TB treatment outcome. These vulnerable patients require close monitoring and coordinated obstetric, HIV and TB care.

Postpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers. We set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa. We conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3-6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score <5), low to medium depression (CES-D 10 total score ≥5 and <10) and major depressive symptoms (CES-D 10 total score≥10). We used ordered logistic regression to identify predictors of postpartum depression and report adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Overall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9-1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3-0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0-0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2-0.8). Targeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services.

Background Tuberculosis (TB) affects people’s quality of life (QoL). We prospectively monitored physical and mental health-related QoL over time in people with TB in the Southern African region with a high HIV and TB burden. Methods Adults aged ≥ 15 years with pulmonary TB were enrolled in five cohorts in Malawi, Mozambique, South Africa, Zambia, and Zimbabwe from October 2022 to September 2024. We assessed six QoL outcomes using validated instruments at the start (baseline), end of treatment, and 6 months post-treatment: symptoms of depression (PHQ-9), mental and physical health (SF-12 mental, SF12-MC, SF-12 physical component, SF12-PC), physical fitness (6-Minute Walk Test, 6MWT; 1-min Sit-To-Stand Test, STST), and respiratory health (Saint-George-Respiratory-Questionnaire, SGRQ). Missing QoL scores were imputed with multivariate imputation by chained equations. We compared the proportion of participants with impaired QoL, defining impairment based on outcome-specific cut-off values. We also estimated changes in QoL scores and examined their associations with baseline characteristics using Bayesian multivariable regression models. Results We included 1438 participants with a median follow-up of 344 days (interquartile range [IQR] 183–373). The median age was 39 years (IQR 30–50); 67% were male, and 39% living with HIV. At baseline, 49% had symptoms of depression, 73% had impaired mental health and 92% impaired physical health-related QoL, 68–74% had reduced physical fitness (68%: 6MWT, 74%: STST), and 78% impaired respiratory health. All QoL outcomes improved by the end of treatment, notably depressive symptoms (48% to 5%), mental health-related QoL (73% to 28%), and respiratory health (78% to 11%). Most QoL impairments continued to decrease post-treatment, especially physical and respiratory health; depressive symptoms remained below 5%. Across QoL domains and study visits, better outcomes were associated with age < 30 (83% probability), and worse outcomes with female gender (86%) and a prior TB history (89%). Living with HIV and alcohol drinking were associated with worse QoL only at baseline (88% and 87%). Conclusions TB negatively impacts QoL across physical, mental, and social domains, including post-treatment. The study highlights the need for integrated mental and physical healthcare and rehabilitation during TB treatment and beyond, especially for high-risk populations, to address the long-term impact of TB on QoL.

BackgroundThe ideal clinic realisation and maintenance (ICRM) programme in South Africa aims to elevate primary healthcare clinic (PHC) service quality in preparation for the National Health Insurance rollout. This study investigated ICRM implementation from clinic workers’ and patients’ experiences in the Gauteng province.MethodsA mixed-methods cross-sectional survey was conducted across 45 Gauteng PHCs. Anonymous semistructured interviews with 335 clinic staff explored their knowledge and experiences with the ICRM programme. Facility assessments captured structural factors impacting ICRM implementation. Log-binomial regression was used to assess factors related to confidence in ICRM implementation and improvements in ICRM certification, and thematic analysis examined patient and staff experiences.ResultsWhile 86.9% of clinical/management staff (95% CI 75.1 to 93.6) reported understanding ICRM, only 41.9% (95% CI 32.6 to 53.0) could cite specific guidelines. Enablers included guideline training (reported by 47.9% of staff, 95% CI 39.6 to 56.3) and support from district teams (44.6%, 95% CI 36.6 to 52.8). Barriers included facility size (32.9%, 95% CI 25.7 to 40.9) and infrastructure challenges (28.4%, 95% CI 21.6 to 36.2). Staff confidence in ICRM implementation was moderate (63.1%, 95% CI 56.1 to 69.6), higher when ICRM champions were present (relative risk ratio (RRR) 2.3 vs not present, 95% CI 1.0 to 5.2), guidelines were clear to staff (RRR 2.3, 95% CI 1.1 to 5.0) and sufficient training was perceived (RRR 2.7, 95% CI 1.4 to 5.3). From 2018 to 2021, 60.3% of facilities (95% CI 43.8 to 74.8) improved in ICRM classification. Compared with facilities with no status change, staff from clinics with downgraded stats were less likely to report clear guidelines (RRR 0.5, 95% CI 0.2 to 1.0) to identify an ICRM champion (RRR 0.3, 95% CI 0.1 to 0.7) or have a knowledgeable manager (RRR 0.01, 95% CI 0.01 to 0.3).ConclusionChallenges in ICRM implementation persist. Staff knowledge, training and district support play significant roles, while clear guidelines, sufficient resources and effective leadership are essential for sustaining and enhancing ICRM performance.

Nelly Jinga, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Building C, First Floor, Sunnyside Office Park, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa, Email njinga@heroza.org; nelly.jinga@gmail.comBackground: Repeated monitoring of viral load (VL) among pregnant women living with HIV (WLWH) is critical in vertical transmission prevention. For women who are newly diagnosed with HIV during pregnancy, a subsequent VL is recommended three months after ART initiation, and for all women living with HIV, follow-up VL is required every six months throughout pregnancy and breastfeeding. Here, we describe the uptake and timing of VL testing and frequency and distribution of viraemic episodes during pregnancy.Methods: We linked prospective cohort data from WLWH whose infants were born at Rahima Moosa Mother and Child Hospital (RMMCH) in Johannesburg, South Africa (2013– 2018) to laboratory data from the National Health Laboratory Services national HIV cohort. We report the uptake and timing of VL testing, and frequency of viremia and viral suppression. We applied the log binomial regression, to explore factors associated with having at least one or more VL test. Crude relative risks (RR) and adjusted relative risks (aRR) with 95% confidence intervals (CI) relative risk were reported.Results: Data from 4064 women with known dates of entry into antenatal care and delivery during the study period were analysed. Overall, less than half (46%) completed VL testing during pregnancy. Most VLs were conducted during the third trimester (67%). Only 5% (n = 100) were during the first trimester and 11% within 7 days of delivery. Three-quarters of tests during pregnancy indicated viral suppression (VL < 400 copies/mL), 7% viraemic (VL 400– 1000 copies/mL), and 19% high-grade viraemia (VL > 1000 copies/mL). We found that being older (≥ 35) and being engaged in HIV care prior to pregnancy were significantly associated with VL testing during pregnancy.Conclusion: With less than half of pregnant women living with HIV in this study having a VL measure during their pregnancy, and VL testing occurring late in pregnancy, this study highlights critical gaps in providing quality HIV care to women and prevention of vertical transmission.

The best method to measure adherence to antiretroviral therapy (ART) in resource-limited settings has not yet been established, particularly among adolescents and young adults (AYAs). The use of mobile technology may address the need for standardized tools in measuring adherence in this often marginalized population. We conducted a cross-sectional validation study among AYAs (18-35 years) attending a South African HIV clinic between 07/2015-09/2017. We determine the diagnostic accuracy of two modes of delivering an adherence questionnaire (self-administered electronic vs interviewer-administered paper-adherence questionnaire) comprising two self-reported adherence tools (South African National Department of Health (NDoH) adherence questionnaire and the Simplified Medication Adherence Questionnaire (SMAQ)) to identify poor adherence compared to; 1) a detectable viral load (≥1000 copies/mL) and 2) a sub-optimal concentration of efavirenz (EFV) (EFV ≤1.00 µg/mL) measured by therapeutic drug monitoring (TDM). Of 278 included participants, 7.1% and 7.3% completing the electronic- and paper-questionnaires had a detectable viral load, while 14.7% and 16.5% had a sub-optimal concentration of EFV, respectively. According to viral load monitoring, the electronic-adherence questionnaire had a higher sensitivity (Se) in detecting poor adherence than the paper-based version across the NDoH adherence questionnaire (Se: 63.6% vs 33.3%) and SMAQ (Se: 90.9% vs 66.7%). In contrast, when using blood drug concentration (EFV ≤1.00 µg/mL), the paper-adherence questionnaire produced a higher sensitivity across both adherence tools; namely the NDoH adherence questionnaire (Se: 50.0% vs 38.1%) and SMAQ (Se: 75.0% vs 57.1%). When using more accurate real-time measures of poor adherence such as TDM in this young adult population, we observe a higher sensitivity of an interviewer-administered paper-adherence questionnaire than an identical set of self-administered adherence questions on an electronic tablet. An interviewer-administered questionnaire may elicit more accurate responses from participants through a sense of increased accountability when engaging with health care workers.