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ObjectivesEvidence regarding interventions to engage men and boys to improve sexual and reproductive health and rights (SRHR) has grown rapidly across subtopics such as HIV, family planning and gender-based violence (GBV). We conducted a review of the effectiveness of interventions to engage men and boys across SRHR domains, lessons learnt about successful programming, and about harms/unintended consequences, in low- and middle-income countries (LMIC).DesignSystematic review of reviews following Cochrane guidelines.Data sourcesPubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane were searched (18 October–9 November 2022; 9 September 2024).Eligibility criteriaEligible reviews were published since 2015, covered WHO-defined SRHR domain(s) and focused mostly on LMIC.Data extraction and synthesisData extraction by multiple reviewers focused on intervention effectiveness, implementation best practices, unintended consequences, and quality/risk of bias.ResultsThirty-five systematic reviews were included, comprising ~960 primary studies. Reviews focused on HIV prevention/care, reproductive health, maternal and newborn health, and GBV. Reviews consistently concluded that men were successfully engaged, yielding benefits to both women and men’s SRHR outcomes; no adverse intervention impacts on prevalence of SRHR outcomes were reported. We summarised the interventions most consistently found to be effective across reviews, in a programmer-friendly visual mapped onto a framework of men as clients, partners and agents of change. Person-centred, gender-transformative, multilevel approaches were most effective. Remaining evidence gaps include engaging men as contraceptive users, sexually transmitted infections other than HIV, preventing unsafe abortion and SGBV as experienced by men and boys.ConclusionsThere is substantial evidence supporting a range of successful interventions to engage men and boys to improve SRHR, with markedly similar principles and approaches emerging across SRHR domains. It is time to scale up and integrate these strategies, monitoring for any potential harms and tailoring as needed to socio-cultural contexts and for specific vulnerable subpopulations.

Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa. A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16-55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex. About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1-4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5-6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex. Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.

Background HIV education targeting children and adolescents is a key component of HIV prevention. This is especially important in the context of increasing HIV prevalence rates among adolescents and young people. The authors sought to examine the role and effectiveness of an extra-curricular school based programme, Soul Buddyz Clubs (SBC) on HIV knowledge, attitudes, behaviours and biomedical outcomes. Methods This paper employs a mixed methods approach drawing on data from independent qualitative and quantitative sources. Secondary data analysis was performed using survey data from a nationally representative sample that was restricted to 10-14 year-old males and females living in South Africa. Ten focus group discussions and ten in-depth interviews conducted with SBC members and facilitators from 5 provinces, as part of a process evaluation are used to triangulate the effectiveness of SBC intervention. Results The analysis of survey data from 2 198 children indicated that 12% of respondents were exposed to SBC with 4% reporting that they had ever belonged to a club. Children exposed to SBC were more likely to be medically circumcised (AOR 2.38; 95%CI 1.29 -4.40, p=0.006), had correct HIV knowledge (AOR 2.21; 95%CI 1.36 – 3.57, p<0.001) and had less HIV stigmatising attitudes (AOR 0.54; 95%CI 0.31-0.93, p=0.025), adjusting for age, sex, province and exposure to other media – in comparison to those not exposed. Propensity Score Matching findings were consistent with the regression findings. Qualitative findings also supported some of the quantitative results. SBC members reported having learnt about HIV prevention life skills, including condom use, positive attitudes towards people living with HIV, and alcohol abuse. Conclusions Participation in SBC is associated with accessing biomedical HIV prevention services, specifically MMC, correct HIV prevention knowledge and less HIV stigmatizing attitudes. This paper demonstrates the effectiveness of a school-based extracurricular intervention using a club approach targeting boys and girls ages 10-14 years on some of the key HIV prevention biomarkers as well as knowledge and attitudes. The article suggests that extra-curricular interventions can form an effective component of school-based comprehensive sexuality education in preventing HIV and promoting medical male circumcision.

Background The global mining industry has an opportunity to mobilize resources to advance progress against the Sustainable Development Goals (SDGs). In 2018, the Anglo-American Group outlined aspirations for mining host communities to meet the SDG3 health targets. To progress from aspiration to action we designed and implemented a mixed-methods approach to attain a deeper understanding of the health and wellbeing priorities within the local context of host communities of fifteen mines in South Africa. Methods To identify local needs and priorities relating to SDG3 targets in host communities, stakeholder workshops and key informant interviews were conducted between June and August 2019. A baseline assessment of health data, related to each of the SDG3 targets and indicators and to each host community location, was also conducted. Findings emerging from the qualitative and quantitative baseline assessments were compared to identify the extent to which health issues aligned and health and wellbeing priority areas for action. Results A total of 407 people participated in the workshops, and 85 key informants were interviewed. Quantitative data were available at sub-national level for seven of the nine SDG3 targets and eleven of the 21 indicators. Key priority areas for action identified through alignment of the qualitative and quantitative data were maternal mortality (SDG3.1), HIV (SDG3.3.1), tuberculosis (SDG3.3.2), substance abuse (SDG3.5), and road traffic accidents (SDG3.6) We found consistency in the individual, interpersonal, community, societal, and structural factors underlying these priority areas. At a structural level, poor access to quality healthcare was raised at every workshop as a key factor underlying the achievement of all SDG3 targets. Of the five priority areas identified, HIV, TB and substance abuse were found to overlap in the study communities in terms of risk, burden, and underlying factors. Conclusions We demonstrate a mixed method approach for identifying local health needs and prioritised SDG3 targets in mining host communities. Consistency in reporting suggests the need for effective, efficient and feasible interventions to address five priority areas. Given the prominent economic role of the mining sector in South Africa, it can play a critical role in implementing programmatic activities that further progress towards achieving the SDG3 targets.

Healthcare utilization surveys contextualize facility-based surveillance data for burden estimates. We describe healthcare utilization in the catchment areas for sentinel site healthcare facilities during the first year of the COVID-19 pandemic. We conducted a cross-sectional healthcare utilization survey in households in three communities from three provinces (KwaZulu-Natal, Western Cape and North West). Field workers administered structured questionnaires electronically with the household members reporting influenza-like illness (ILI) in the past 30 days or severe respiratory illness (SRI) since March 2020. Multivariable logistic regression was used to identify factors associated with healthcare utilization among individuals that reported illness. From November 2020 through April 2021, we enrolled 5804 households and 23,003 individuals. Any respiratory illness was reported by 1.6% of individuals; 0.7% reported ILI only, 0.8% reported SRI only, and 0.1% reported both ILI and SRI. Any form of medical care was sought by 40.8% (95% CI 32.9% - 49.6%) and 71.3% (95% CI 63.2% - 78.6%) of individuals with ILI and SRI, respectively. On multivariable analysis, respiratory illness was more likely to be medically attended for individuals at the Pietermaritzburg site (aOR 3.2, 95% CI 1.1–9.5, compared to Klerksdorp), that were underweight (aOR 11.5, 95% CI 1.5–90.2, compared to normal weight), with underlying illness (aOR 3.2, 95%CI 1.2–8.5), that experienced severe illness (aOR 4.8, 95% CI 1.6–14.3) and those with symptom duration of ≥10 days (aOR 7.9, 95% CI 2.1–30.2, compared to <5 days). Less than half of ILI episodes and only 71% of SRI episodes were medically attended during the first two COVID-19 waves in South Africa. Facility-based data may underestimate disease burden during the COVID-19 pandemic.

Background The Avahan India AIDS Initiative was implemented to provide HIV prevention services to key populations including female sex workers (FSWs) who carry the burden of India’s concentrated HIV epidemic. Established in 2003 and handed over to the Indian government in 2009, the Initiative included peer-led outreach education, condom promotion and distribution and STI treatment. This study aimed to determine if HIV prevention cascades could be generated using routine monitoring and evaluation data from the Avahan program and to assess their value in identifying and responding to program gaps for FSWs. Methods Two data sources were used namely the Integrated Behavioural and Biological Assessment reports and the Centralized Management Information System dataset. Indicators selected for the cascades were: FSWs at risk, belief that HIV can be prevented, condom access and consistent condom use with an occasional partner. Six districts were selected and stratified by HIV prevalence at baseline and two cascades were generated per district reflecting changes over time. Results Consistent condom use with occasional partners in this population increased in all six districts during program implementation, with statistically significant increases in four of the six. No patterns in the cascades were detected according to HIV prevalence either at baseline (2005) or at follow-up (2009). Cascades were able to identify key programmatic bottlenecks at baseline that could assist with focusing program efforts and direct resources at district levels. In some districts the belief that HIV could not be prevented contributed to inconsistent condom use, while in others, low levels of condom access were a more important barrier to consistent condom use. Conclusion This HIV prevention cascade analysis among FSWs in India suggests that cascades could assist in identifying program gaps, focus intervention efforts and monitor their effect. However, cascades cannot replace a detailed understanding of the multiple factors at individual, community and structural levels that lead to consistent condom use in this key population. Careful indicator selection coupled with innovative data collection methods will be required. Pilot projects are proposed to formally evaluate the value of HIV prevention cascades at district level.

Background : South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods : The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa’s HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results : The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa’s 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces’ greater MMC scale-up. Conclusions : MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa’s HIV epidemic in the coming years.

Background Improving health in Africa is a high priority internationally. Inadequate research capacity to produce local, relevant research has been identified as a limitation to improved population health. Increasing attention is being paid to the higher education sector in Africa as a method of addressing this; evidence that such investment is having the desired impact is required. A 1998 3-year investment by the Special Programme for Research and Training in Tropical Diseases (TDR) in research training at the School of Public Health, University of the Witwatersrand, South Africa was reviewed to assess its' impact. Methods A descriptive cross-sectional survey of the 70 students registered for the masters programme in epidemiology & biostatistics from 2000-2005 was conducted. Data were collected from self-administered questionnaires. Results Sixty percent (42/70) of students responded. At the time of the survey 19% of respondents changed their country of residence after completion of the masters course, 14% migrated within Africa and 5% migrated out of Africa. Approximately half (47%) were employed as researchers and 38% worked in research institutions. Sixty percent reported research output, and four graduates were pursuing PhD studies. Government subsidy to higher education institutions, investments of the University of the Witwatersrand in successful programmes and ongoing bursaries for students to cover tuition fees were important for sustainability. Conclusions Investing in African institutions to improve research training capacity resulted in the retention of graduates in Africa in research positions and produced research output. Training programmes can be sustained when national governments invest in higher education and where that funding is judiciously applied. Challenges remain if funding for students bursaries is not available.

Background Studies on migration often ignore the health and social impact of migrants returning to their rural communities. Several studies have shown migrants to be particularly susceptible to HIV infection. This paper investigates whether migrants to rural households have a higher risk of dying, especially from HIV, than non-migrants. Methods Using data from a large and ongoing Demographic Surveillance System, 41,517 adults, enumerated in bi-annual rounds between 2001 and 2005, and aged 18 to 60 years were categorized into four groups: external in-migrants, internal migrants, out-migrants and residents. The risk of dying by migration status was quantified by Cox proportional hazard regression. In a sub-group analysis of 1212 deaths which occurred in 2000 – 2001 and for which cause of death information was available, the relationship between migration status and dying from AIDS was examined in logistic regression. Results In all, 618 deaths were recorded among 7,867 external in-migrants, 255 among 4,403 internal migrants, 310 among 11,476 out-migrants and 1900 deaths were registered among 17,771 residents. External in-migrants were 28% more likely to die than residents [adjusted Hazard Ratio (aHR) = 1.28, P < 0.001, 95% Confidence Interval (CI) (1.16, 1.41)]. In the sub-group analysis, the odds of dying from AIDS was 1.79 [adjusted Odd ratio (aOR) = 1.79, P = 0.009, 95% CI (1.15, 2.78)] for external in-migrants compared to residents; there was no statistically significant difference in AIDS mortality between residents and out-migrants, [aOR = 1.25, P = 0.533, 95% CI (0.62–2.53)]. Independently, females were more likely to die from AIDS than males [aOR = 2.35, P < 0.001, 95% CI (1.79, 3.08)]. Conclusion External in-migrants have a higher risk of dying, especially from HIV related causes, than residents, and in areas with substantial migration this needs to be taken into account in evaluating mortality statistics and planning health care services.

South Africa has high rates of HIV prevalence and incidence and very high binge drinking rates amongst youth. GIS mapping of alcohol outlets and participatory research methods were used to explore and understand youth’s perception of alcohol availability and marketing, and their associated risks for HIV and sexual violence. Twenty seven youth 18–24 years from an urban and rural area participated in the study. There was high density of alcohol outlets at both sites with 97% within 500 m radius to a school; 76% of outlets had alcohol advertising signage on the exterior. Youth reported that alcohol is easily accessible to them. Alcohol advertising and marketing are appealing and entice them to consume alcohol, including binge drinking. Young women reported exposure to unsafe and transactional sex, and sexual violence at alcohol outlets. Effective policies are needed to regulate alcohol availability and marketing to youth.