Academic Wits University Research Outputs (Main submissions)
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Item Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa(2022-10-05) Michel GarenneThe study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issuesItem All-cause mortality of hospitalised patients with suspected COVID-19 in Sierra Leone: a prospective cohort study(2023-02-05) Olivia Farrant; Mamadu Baldeh; Joseph Baio Kamara; Emma Bailey; Stephen Sevalie; Gibrilla Deen; James Baligeh Walter Russell; Daniel Youkee; Andy JM Leather; Justine Davies; Sulaiman LakohObjectives To study the mortality of patients with COVID-19 in Sierra Leone, to explore the factors associated with mortality during the COVID-19 pandemic and to highlight the complexities of treating patients with a novel epidemic disease in a fragile health system. Study design A prospective single-centre cohort study. Data were extracted from paper medical records and transferred onto an electronic database. Specific indicators were compared between survivors and non-survivors, using descriptive statistics in Stata V.17. Study setting The infectious diseases unit (IDU) at Connaught Hospital in Freetown, Sierra Leone Participants Participants were all patients admitted to the IDU between March and July 2020. Aims of study The primary outcome of the study was to examine the all-cause mortality of hospitalised patients with suspected COVID-19 in Sierra Leone and the secondary outcome measures were to examine factors associated with mortality in patients positive for COVID-19. Results 261 participants were included in the study. Overall, 41.3% of those admitted to the IDU died, compared with prepandemic in-hospital mortality of 23.8%. Factors contributing to the higher mortality were COVID-19 infection (aOR 5.61, 95% CI 1.19 to 26.30, p=0.02) and hypertension (aOR 9.30, 95% CI 1.18 to 73.27, p=0.03) Conclusions This study explores the multiple factors underpinning a doubling in facility mortality rate during the COVID-19 pandemic in Sierra Leone . It provides an insight into the realities of providing front-line healthcare during a pandemic in a fragile health system.Item Assessing risk for HIV infection among adolescent girls in SouthAfrica: an evaluation of the VOICE risk score (HPTN 068)(2019-07) Danielle Giovenco; Audrey Pettifor; Catherine MacPhail; Kathleen Kahn; Ryan Wagner; Estelle Piwowar-Manning; Jing Wang; James P HughesAbstractIntroduction:To maximize impact and minimize costs, antiretroviral pre-exposure prophylaxis (PrEP) interventions should beoffered to those at highest risk for HIV infection. The risk score derived from the VOICE trial is one tool currently being uti-lized to determine eligibility in adolescent PrEP trials in sub-Saharan Africa. This study is aimed at evaluating the utility of therisk score in predicting HIV incidence among a cohort of adolescent girls in rural South Africa.Methods:We utilized data from HIV Prevention Trials Network (HPTN) 068, a phase III randomized controlled trial con-ducted in rural Mpumalanga province, South Africa. School-attending young women aged 13 to 20 years were enrolled intothe trial from 2011 to 2012 and followed for up to three years. A risk score based on individual-level risk factors measuredat enrolment was calculated for HPTN 068 participants who completed a one-year follow-up visit and were HIV seronegativeat enrolment. Possible scores ranged from 0 to 10. A proportional hazards model was then used to determine if risk score atenrolment was predictive of incident HIV infection at follow-up and an area under the curve analysis was used to examine thepredictive ability of the score.Results and Discussion:The risk score had limited variability in the HPTN 068 sample. Scores≥5 identified 85% of incidentinfections from 94% of the sample, compared to the VOICE sample in which scores≥5 identified 91% of incident infectionsfrom only 64% of participants. The risk score did not predict HIV incidence after one year of follow-up (hazardratio=1.029; 95% confidence interval (CI): 0.704, 1.503,p=.884) and showed poor predictive ability (area under thecurve=0.55; 95% CI: 0.44, 0.65). Certain individual risk factors that comprise the risk score may be context specific or notrelevant for adolescent populations. Additional factors should be considered when assessing risk for the purposes of deter-mining PrEP eligibility.Conclusions:The VOICE risk score demonstrated low utility to predict HIV incidence in the HPTN 068 sample. Findings high-light the need for an age and developmentally appropriate tool for assessing risk for HIV infection among adolescents. Use ofthe VOICE risk score for determining PrEP eligibility in younger populations should be carefully considered.Item Associations Between Key Psychosocial Stressors and Viral Suppression and Retention in Care Among Youth with HIV in Rural South Africa(2021-02-24) Lindsey M; Filiatreau; Audrey Pettifor; Jessie K; Edwards; Nkosinathi Masilela; Rhian Twine; F. Xavier Gómez-Olivé; Nicole Haberland; Chodziwadziwa Whiteson Kabudula; Sheri A; Lippman; Kathleen KahnDespite improvements in access to antiretroviral treatment over the past decade, sub-optimal HIV care outcomes persist among youth with HIV (YWH) in rural South Africa. Psychosocial stressors could impede improved HIV treatment outcomes within this population. We linked self-reported psychosocial health and demographic data from a cross-sectional survey conducted among YWH aged 12–24 in rural South Africa to individual medical record data, including facility visit history and viral load measurements. Poisson regression with robust standard errors was used to estimate the associations between five psychosocial stressors- heightened depressive symptoms (Center for Epidemiological Studies-Depression scale scores ≥ 16), lower social support (Medical Outcomes Social Support Scale scores ≤ 38), lower resilience (Conner-Davidson Resilience Scale scores ≤ 73), lower self-esteem (Rosenberg Self-Esteem Scale scores ≤ 21), and higher perceived stress (Sheldon Cohen Perceived Stress Scale scores ≥ 10)- and viral non-suppression (viral load ≥ 400 copies/mL) and loss to care (no documented clinic visits within the 90 days prior to survey), separately. A total of 359 YWH were included in this analysis. The median age of study participants was 21 (interquartile range: 16–23), and most were female (70.2%), single (82.4%), and attending school (54.7%). Over a quarter of participants (28.1%) had heightened depressive symptoms. Just 16.2% of all participants (n = 58) were lost to care at the time of survey, while 32.4% (n = 73) of the 225 participants with viral load data were non-suppressed. The prevalence of non-suppression in individuals with lower self-esteem was 1.71 (95% confidence interval: 1.12, 2.61) times the prevalence of non-suppression in those with higher self-esteem after adjustment. No meaningful association was observed between heightened depressive symptoms, lower social support, lower resilience, and higher perceived stress and viral non-suppression or loss to care in adjusted analyses. Retention in care and viral suppression among YWH in rural South Africa are below global targets. Interventions aimed at improving viral suppression among YWH should incorporate modules to improve participant’s self-esteem as low self-esteem is associated with viral non-suppression in this setting. Future studies should longitudinally explore the joint effects of co-occurring psychosocial stressors on HIV care outcomes in YWH and assess meaningful differences in these effects by age, gender, and route of transmission.Item Associations of father and adult male presence with first pregnancy and HIV infection: Longitudinal evidence from adolescent girls and young women in rural South Africa (HPTN068)(2021-01-08) Lisa Marie Albert; Jess Edwards; Brian Pence; Ilene S; Speizer; Susan Hillis; Kathleen Kahn; F Xavier Gómez-Olivé; Ryan G. Wagner; Rhian Twine; Audrey PettiforThis study, a secondary analysis of the HPTN 068 randomized control trial, aimed to quantify the association of father and male presence with HIV incidence and first pregnancy among 2533 school-going adolescent girls and young women (AGYW) in rural South Africa participating in the trial between March 2011 and April 2017. Participants' ages ranged from 13-20 years at study enrollment and 17-25 at the post-intervention visit. HIV and pregnancy incidence rates were calculated for each level of the exposure variables using Poisson regression, adjusted for age using restricted quadratic spline variables, and, in the case of pregnancy, also adjusted for whether the household received a social grant. Our study found that AGYW whose fathers were deceased and adult males were absent from the household were most at risk for incidence of first pregnancy and HIV (pregnancy: aIRR = 1.30, Wald 95% CI 1.05, 1.61, Wald chi-square p = 0.016; HIV: aIRR = 1.27, Wald 95% CI 0.84, 1.91, Wald chi-square p = 0.263) as compared to AGYW whose biological fathers resided with them. For AGYW whose fathers were deceased, having other adult males present as household members seemed to attenuate the incidence (pregnancy: aIRR = 0.92, Wald 95% CI 0.74, 1.15, Wald chi-square p = 0.462; HIV: aIRR = 0.90, Wald 95% CI 0.58, 1.39, Wald chi-square p = 0.623) such that it was similar, and therefore not statistically significantly different, to AGYW whose fathers were present in the household.Item Cardiometabolic disease risk factors in pre- and postmenopausal women from four sub-Saharan African countries: A cross-sectional study(2023-06) Raylton P. Chikwati; Nasrin Goolam Mahyoodeen; Nicole G. Jaff; Michele Ramsay; Lisa K. Micklesfield; Alisha N. Wade; Godfred Agongo; Gershim Asik; Solomon S.R. Choma; Palwende R. Boua; Jaya A. George; Nigel J. CrowtherObjective: To compare the risk factors for cardiometabolic disease between pre- and postmenopausal women from four sub-Saharan African countries. Study design: This cross-sectional study included 3609 women (1740 premenopausal and 1869 postmenopausal) from sites in Ghana (Navrongo), Burkina Faso (Nanoro), Kenya (Nairobi), and South Africa (Soweto and Dikgale). Demographic, anthropometric and cardiometabolic variables were compared between pre- and postmenopausal women, within and across sites using multivariable regression analyses. The sites represent populations at different stages of the health transition, with those in Ghana and Burkina Faso being rural, whilst those in Kenya and South Africa are more urbanised. Main outcome measures: Anthropometric and cardiometabolic variables. Results: The prevalence rates of risk factors for cardiometabolic disease were higher in South (Soweto and Dikgale) and East (Nairobi) Africa than in West Africa (Nanoro and Navrongo), irrespective of menopausal status. Regression models in combined West African populations demonstrated that postmenopausal women had a larger waist circumference (β = 1.28 (95 % CI: 0.58; 1.98) cm), log subcutaneous fat (β =0.15 (0.10; 0.19)) diastolic (β = 3.04 (1.47; 4.62) mm Hg) and log systolic (β = 0.04 (0.02; 0.06)) blood pressure, log carotid intima media thickness (β = 0.03 (0.01; 0.06)), low-density lipoprotein cholesterol (β = 0.14 (0.04; 0.23) mmol/L) and log triglyceride (β= 0.10 (0.04; 0.16)) levels than premenopausal women. No such differences were observed in the South and East African women. Conclusions: Menopause-related differences in risk factors for cardiometabolic disease were prominent in West but not East or South African study sites. These novel findings should inform cardiometabolic disease prevention strategies in midlife women specific to rural and urban and peri-urban locations in sub-Saharan Africa.Item Cash transfers for HIV prevention: what do young women spend it on? Mixed methods findings from HPTN 068(2018) Catherine MacPhail; Nomhle Khoza; Amanda Selin; Aimée Julien; Rhian Twine; Ryan G. Wagner; Xavier Goméz-Olivé; Kathy Kahn; Jing Wang; Audrey PettiforBackground Social grants have been found to have an impact on health and wellbeing in multiple settings. Who receives the grant, however, has been the subject of discussion with regards to how the money is spent and who benefits from the grant. Methods Using survey data from 1214 young women who were in the intervention arm and completed at least one annual visit in the HPTN 068 trial, and qualitative interview data from a subset of 38 participants, we examined spending of a cash transfer provided to young women conditioned on school attendance. Results We found that spending was largely determined and controlled by young women themselves and that the cash transfer was predominately spent on toiletries, clothing and school supplies. In interview data, young women discussed the significant role of cash transfers for adolescent identity, specifically with regard to independence from family and status within the peer network. There were almost no negative consequences from receiving the cash transfer. Conclusions We established that providing adolescents access to cash was not reported to be associated with social harms or negative consequences. Rather, spending of the cash facilitated appropriate adolescent developmental behaviors. The findings are encouraging at a time in which there is global interest in addressing the structural drivers of HIV risk, such as poverty, for young women.Item Changing relationships between HIV prevalence and circumcision in Lesotho(2023-04-04) Michel GarenneThe study investigates the complex relationships between circumcision and HIV prevalence in Lesotho, using Demographic and Health surveys (DHS) conducted in 2004, 2009 and 2014. Before the HIV epidemic, about half of the male adult population was circumcised as part of a traditional custom, and this proportion increased markedly after 2008 with the campaigns of Voluntary Medical Male Circumcision (VMMC), while HIV prevalence stayed at the same level. In 2004, HIV prevalence was higher in circumcised groups than in intact groups (RR=1.49, 95% CI=1.20-1.86). This relationship changed over time, and was inversed in 2014 (RR=0.86; 95% CI=0.70-1.06). The changing relationship seems to be due to an interaction with education, with more educated men being more circumcised and having less HIV over time. A multivariate analysis showed no net effect of circumcision on HIV, after controlling for wealth, education, and indicators of marriage and sexual behaviour. A small net effect of VMMC was found, probably due to condom use. In couple studies, the effect of circumcision and VMMC on HIV was not significant, with similar transmission from female to male and male to female. The study questions the amount of effort and money spent on VMMC in Lesotho.Item Cohort Profile: Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI).(2018) F Xavier Go´ mez-Olive´; Livia Montana; Ryan G Wagner; Chodziwadziwa W Kabudula; Julia K Rohr; Kathleen Kahn; Till Ba¨rnighausen; Mark Collinson; David Canning; Thomas Gaziano; Joshua A Salomon; Collin F Payne; Alisha Wad; Stephen M Tollman; Lisa BerkmanItem Community Health Worker Use of Smart Devices for Health Promotion: Scoping Review(2023-02-25) Merlin Greuel1 , BA, MGH, MD; Frithjof Sy1 , BSc, MD; Till Bärnighausen1,2,3 , MSc, MD, SCD; Maya Adam1,4 , BA, MD; Alain Vandormael1 , MSc, PhD; Jennifer Gates5 , BA; Guy Harling2,6,7,8,9 , BSc, MA, MPH, SCDBackground: Community health workers (CHWs) have become essential to the promotion of healthy behaviors, yet their work is complicated by challenges both within and beyond their control. These challenges include resistance to the change of existing behaviors, disbelief of health messages, limited community health literacy, insufficient CHW communication skills and knowledge, lack of community interest and respect for CHWs, and CHWs’ lack of adequate supplies. The rising penetration of “smart” technology (eg, smartphones and tablets) in low- and middle-income countries facilitates the use of portable electronic devices in the field. Objective: This scoping review examines to what extent mobile health in the form of smart devices may enhance the delivery of public health messages in CHW-client interactions, thereby addressing the aforementioned challenges and inducing client behavior change. Methods: We conducted a structured search of the PubMed and LILACS databases using subject heading terms in 4 categories: technology user, technology device, use of technology, and outcome. Eligibility criteria included publication since January 2007, CHWs delivering a health message aided by a smart device, and face-to-face communication between CHWs and clients. Eligible studies were analyzed qualitatively using a modified version of the Partners in Health conceptual framework. Results: We identified 12 eligible studies, 10 (83%) of which used qualitative or mixed methods approaches. We found that smart devices mitigate challenges encountered by CHWs by improving their knowledge, motivation, and creativity (eg, through self-made videos); their status within the community; and the credibility of their health messages. The technology stimulated interest in both CHWs and clients—and sometimes even in bystanders and neighbors. Media content produced locally or reflecting local customs was strongly embraced. Yet, the effect of smart devices on the quality of CHW-client interactions was inconclusive. Interactions suffered as CHWs were tempted to replace educational conversations with clients by passively watching video content. Furthermore, a series of technical difficulties experienced especially by older and less educated CHWs compromised some of the advantages brought about by mobile devices. Adequate CHW training ameliorated these difficulties. Only 1 study (8%) considered client health behavior change as an end point, thus revealing a major research gap. Conclusions: Smart mobile devices may augment CHWs’field performance and enhance face-to-face interactions with clients, yet they also generate new challenges. The available evidence is scarce, mostly qualitative, and focused on a limited range of health outcomes. Future research should include larger-scale interventions across a wide range of health outcomes and feature client health behavior change as an end point.Item Consensus study on factors influencing the academic entrepreneur in a middle-income country’s university enterprise(2023-05-20) Alfred Austin Farrell; James Ashton; WitnessMapanga; Maureen Joffe; Nombulelo Chitha; Mags Beksinska; Wezile Chitha; Ashraf Coovadia; Clare L. Cutland; RobinL. Drennan; Kathleen Kahn; Lizette L. Koekemoer; Lisa K.Micklesfield; JacquiMiot; Julian Naidoo; Maria Papathanasopoulos; Warrick Sive; Jenni Smit; StephenM. Tollman; Martin G. Veller; Lisa J.Ware; Jeffrey Wing; Shane A. NorrisPurpose – This study aims to ascertain the personal characteristics of a group of successful academic entrepreneurs in a South African university enterprise and the prevalent barriers and enablers to their entrepreneurial endeavour. Design/methodology/approach – The authors used a Delphi process to identify and rank the characteristics, enablers, barriers and behaviours of entrepreneurial academics, with a Nominal Group Technique applied to establish challenges they encounter managing their enterprise and to propose solutions. Findings – Perseverance, resilience and innovation are critical personal characteristics, while collaborative networks, efficient research infrastructure and established research competence are essential for success. The university’s support for entrepreneurship is a significant enabler, with unnecessary bureaucracy and poor access to project and general enterprise funding an impediment. Successful academic entrepreneurs have strong leadership, and effective management and communication skills. Research limitations/implications – The main limitation is the small study participant group drawn from a single university enterprise, which complicates generalisability. The study supported the use of Krueger’s (2009) entrepreneurial intentions model for low- and middle-income country (LMIC) academic entrepreneur investigation but proposed the inclusion of mitigators to entrepreneurial activation to recognize contextual deficiencies and challenges.Item Decision-making and cash spending patterns of adolescent girls and young women participating in a cash-transfer intervention in Tanzania: Implications for sexual health(2019-12-06) Joyce Wamoyi; Peter Balvanz; Margaret W; Gichane; Suzanne Maman; Samuel Mugunga; Esther Majani; Audrey PettiforAlthough cash transfers (CT) have been recommended as a strategy to address structural drivers of HIV, the evidence of the effects of CT on sexual risk and HIV outcomes is mixed. This could partly be due to CT implementation dynamics and beneficiary interpersonal factors. We conducted an assessment of CT component of the DREAMS programme in Tanzania. We explored how AGYW spent their CT over time, to whom they disclosed cash receipt, and where they sought advice on CT use. The study employed qualitative research methods including: 20 longitudinal in-depth interviews (IDIs) and 60 cross-sectional IDIs with AGYW in the CT programme. Data were analysed thematically. AGYW use of CT fell into five categories: business development, survival, self-care, helping family, and savings. The primary uses of CT funds were investment in businesses and livestock for savings. AGYW use of cash changed over instalments. AGYW consulted a variety of sources when deciding on how to use the cash, primarily mothers, programme personnel, and long-term partners/husbands. CT programmes that give cash directly to AGYW and have a strong entrepreneurial mentorship component could have implications for HIV prevention, SRH, and overall social and economic development.Item Dimensionality and differential item endorsement of depressive symptoms among aging Black populations in South Africa: Findings from the HAALSI study(2020-09-02) Leslie B; Adams a b; Meagan Farrell a; Sumaya Mall c; Nomsa Mahlalela d; Lisa Berkman aBackground The Center for Epidemiologic Studies-Depression (CES-D) scale is a widely used measure of depressive symptoms, but its construct validity has not been adequately assessed in sub-Saharan Africa. This study validates the CES-D among an aging Shangaan-speaking and predominantly Black African sample in rural South Africa, with a special emphasis on gender differences. Methods An 8-item CES-D scale was administered in Shangaan to 5059 respondents, aged 40+ years, residing in Agincourt, South Africa. We used Cronbach's alpha and exploratory and confirmatory factor analysis to examine and confirm dimensionality of the CES-D scale. Differential endorsement of CES-D items by gender were assessed using the Mantel-Haenszel (MH) odds ratio test. Results Reliability of the CES-D scale differed by gender with women reporting higher internal consistency on items than men. A two-factor solution was retained and confirmed representing two latent factors: (1) Negative Affect (six items) and (2) Diminished Positive Affect (two items). MH results showed that men exhibited significantly higher odds of putting an effort in everything that they did (OR: 1.33, 95% CI: 1.15–1.54) and lower odds of feeling depressed (OR: 0.71, 95% CI: 0.56–0.89) and having restless sleep (OR: 0.67, 95% CI:0.58–0.77) than women. Limitations Analyses were limited to a dichotomous, short form of the CES-D, a self-reported population-based measure. Conclusion Aging Black Africans differ in endorsing affective and somatic items on the CES-D scale by gender, which may lead to skewed population-level estimates of depression in key subpopulations. These findings highlight the importance of continued research disentangling cross-cultural and gendered nuances of depression measurements.Item Epidemiology of chronic multimorbidity and temporary migration in a rural South African community in health transition: A cross-sectional population-based analysis(2023-04-21) Armstrong Dzomba; Carren Ginsburg; Chodziwadziwa W. Kabudula; Rachel R. Yorlets; Pedzisai Ndagurwa; Sadson Harawa; Mark N. Lurie; Stephen T. McGarvey; Stephen Tollman; Mark A. Collinson; Michael J. White; Francesc X. Gomez-OliveIntroduction: In sub-Saharan African settings, the increasing non-communicable disease mortality is linked to migration, which disproportionately exposes subpopulations to risk factors for co-occurring HIV and NCDs. Methods: We examined the prevalence, patterns, and factors associated with two or more concurrent diagnoses of chronic diseases (i.e., multimorbidity) among temporary within-country migrants. Employing a cross-sectional design, our study sample comprised 2144 residents and non-residents 18–40 years interviewed and with measured biomarkers in 2018 in Wave 1 of the Migrant Health Follow-up Study (MHFUS), drawn from the Agincourt Health and Demographic Surveillance System (AHDSS) in rural north-eastern South Africa. We used modified Poisson regression models to estimate the association between migration status and prevalent chronic multimorbidity conditional on age, sex, education, and healthcare utilisation. Results: Overall, 301 participants (14%; 95% CI 12.6–15.6), median age 31 years had chronic multimorbidity. Multimorbidity was more prevalent among non-migrants (14.6%; 95% CI 12.8–16.4) compared to migrants (12.8%; 95% CI 10.3–15.7). Nonmigrants also had the greatest burden of dual-overlapping chronic morbidities, such as HIV-obesity 5.7%. Multimorbidity was 2.6 times as prevalent (PR 2.65. 95% CI 2.07– 3.39) among women compared to men. Among migrants, men, and individuals with secondary or tertiary education manifested lower prevalence of two or more conditions. Discussion: In a rural community with colliding epidemics, we found low but significant multimorbidity driven by a trio of conditions: HIV, hypertension, and obesity. Understanding the multimorbidity burden associated with early adulthood exposures, including potential protective factors (i.e., migration coupled with education), is a critical first step towards improving secondary and tertiary prevention for chronic disease among highly mobile marginalised sub-populations.Item Estimating population level 24-h sodium excretion using spot urine samples in older adults in rural South Africa(2023-02-01) Jacques D. Du Toita; David Kapaonb; Nigel J. Crowtherc; Shafika Abrahams-Gessele; June Fabian; Chodziwadziwa W. Kabudula; Alisha N. Wade; Stephen Tollman; Thomas A. GazianoBackground: South Africa has introduced regulations to reduce sodium in processed foods. Assessing salt consumption with 24-h urine collection is logistically challenging and expensive. We assess the accuracy of using spot urine samples to estimate 24-h urine sodium (24hrUNa) excretion at the population level in a cohort of older adults in rural South Africa. Methods: 24hrUNa excretion was measured and compared to that estimated from matched spot urine samples in 399 individuals, aged 40–75 years, from rural Mpumalanga, South Africa.We used the Tanaka, Kawasaki, International Study of Sodium, Potassium, and Blood Pressure (INTERSALT), and Population Mean Volume (PMV) method to predict 24hrUNa at the individual and population level. Results: The population median 24hrUNa excretion from our samples collected in 2017 was 2.6 g (interquartile range: 1.53–4.21) equal to an average daily salt intake of 6.6 g, whereas 65.4% of participants had a salt excretion above the WHO recommended 5 g/day. Estimated population median 24hrUNa derived from the INTERSALT, both with and without potassium, showed a nonsignificant difference of 0.25 g (P = 0.59) and 0.21 g (P = 0.67), respectively. In contrast, the Tanaka, Kawasaki, and PMV formulas were markedly higher than the measured 24hrUNa, with a median difference of 0.51 g (P = 0.004), 0.99 g (P = 0.00), and 1.05 g (P = 0.00) respectively. All formulas however performed poorly when predicting an individual’s 24hrUNa, Conclusion: In this population, the INTERSALT formulas are a well suited and cost-effective alternative to 24-h urine collection for the evaluation of population median 24hrUNa excretion. This could play an important role for governments and public health agencies in evaluating local salt regulations and identifying at-risk populations.Item Estimating the contribution of HIV-infected adults to household pneumococcal transmission in South Africa, 2016–2018: A hidden Markov modelling study(2021-12-23) Deus Thindwa; Nicole Wolter; Amy Pinsent; Maimuna CarrimI; John Ojal; Stefano Tempia; Jocelyn Moyes; Meredith McMorrow; Jackie Kleynhans; Anne von Gottberg; Neil French; PHIRST group; Cheryl Cohen; Stefan FlascheHuman immunodeficiency virus (HIV) infected adults are at a higher risk of pneumococcal colonisation and disease, even while receiving antiretroviral therapy (ART). To help evaluate potential indirect effects of vaccination of HIV-infected adults, we assessed whether HIV-infected adults disproportionately contribute to household transmission of pneumococci. We constructed a hidden Markov model to capture the dynamics of pneumococcal carriage acquisition and clearance observed during a longitudinal household-based nasopharyngeal swabbing study, while accounting for sample misclassifications. Households were followed-up twice weekly for approximately 10 months each year during a three-year study period for nasopharyngeal carriage detection via real-time PCR. We estimated the effect of participant’s age, HIV status, presence of a HIV-infected adult within the household and other covariates on pneumococcal acquisition and clearance probabilities. Of 1,684 individuals enrolled, 279 (16.6%) were younger children (<5 years-old) of whom 4 (1.5%) were HIV-infected and 726 (43.1%) were adults (�18 years-old) of whom 214 (30.4%) were HIV-infected, most (173, 81.2%) with high CD4+ count. The observed range of pneumococcal carriage prevalence across visits was substantially higher in younger children (56.9– 80.5%) than older children (5–17 years-old) (31.7–50.0%) or adults (11.5–23.5%). We estimate that 14.4% (95% Confidence Interval [CI]: 13.7–15.0) of pneumococcal-negative swabs were false negatives. Daily carriage acquisition probabilities among HIV-uninfected younger children were similar in households with and without HIV-infected adults (hazard ratio: 0.95, 95%CI: 0.91–1.01). Longer average carriage duration (11.4 days, 95%CI: 10.2– 12.8 vs 6.0 days, 95%CI: 5.6–6.3) and higher median carriage density (622 genome equivalents per millilitre, 95%CI: 507–714 vs 389, 95%CI: 311.1–435.5) were estimated in HIVinfected vs HIV-uninfected adults. The use of ART and antibiotics substantially reduced carriage duration in all age groups, and acquisition rates increased with household size. Although South African HIV-infected adults on ART have longer carriage duration and density than their HIV-uninfected counterparts, they show similar patterns of pneumococcal acquisition and onward transmission.Item Executive function and pre-academic skills in preschoolers from South Africa(2023-08-25) Caylee J. Cook; Steven Howard; Gaia Scerif; Rhian Twine; Kathleen Kahn; Shane Norris; Catherine DraperBackground: While there is now considerable evidence in support of a relationship between executive function (EF) and academic success, these findings almost uniformly derive from Western and high-income countries. Yet, recent findings from low- to middle- income countries have suggested that patterns of EF and academic skills differ in these contexts, but there is little clarity on the extent, direction and nature of their association. Aim: This study aimed to investigate the contribution of EF to pre-academic skills in a sample of preschool children (N = 124; Mage = 50.91 months; 45% female). Setting: Two preschools were recruited from an urban setting in a community with both formal and informal housing, overcrowding, high levels of crime and violence, and poor service delivery. Three preschools were recruited from rural communities with household plots, a slow rate of infrastructure development, reliance on open fires for cooking, limited access to running water and rudimentary sanitation. Methods: Pre-academic skills were assessed using the Herbst Early Childhood Development Criteria test, and EF was assessed using the Early Years Toolbox. Results: Although EF scores appeared high and pre-academic skills were low (in norm comparisons), EF inhibition (ß = 0.23, p = 0.001) and working memory (ß = 0.25, p < 0.001) nevertheless showed strong prediction of pre-academic skills while shifting was not significant. Conclusion: While EF is an important predictor of pre-academic skills even in this low- and middle-income country context, factors in addition to EF may be equally important targets to foster school readiness in these settings. Contribution: The current study represents a first step towards an understanding of the current strengths that can be leveraged, and opportunities for additional development, in the service of preparing all children for the demands of school.Item Executive function associated with sexual risk in young South African women: Findings from the HPTN 068 cohort(2018-04-02) Molly Rosenberg; Audrey Pettifor; Mihaela Duta; Nele Demeyere; Ryan G. Wagner; Amanda Selin; Catherine MacPhail; Oliver Laeyendecker; James P. Hughes; Alan Stein; Stephen Tollman; Kathleen KahnPurpose Heightened sexual risk in adolescence and young adulthood may be partially explained by deficits in executive functioning, the set of cognitive processes used to make reasoned decisions. However, the association between executive function and sexual risk is understudied among adolescent girls and young women, particularly in low- and middle-income countries. Methods In a cohort of 853 young women age 18–25 in rural Mpumalanga province, South Africa, we evaluated executive function with three non-verbal cognitive tests: I. a rule-finding test, II. a trail-making test, and III. a figure drawing test. Using log-binomial regression models, we estimated the association between lower executive function test scores and indicators of sexual risk (unprotected sex acts, concurrent partnerships, transactional sex, and recent HSV-2 infection). Results In general, young women with lower executive function scores reported higher frequencies of sexual risk outcomes, though associations tended to be small with wide confidence intervals. Testing in the lowest quintile of Test I was associated with more unprotected sex [aPR (95% CI): 1.4 (1.0, 1.8)]. Testing in the lowest quintile of Test II was associated with more concurrent relationships and transactional sex [aPR (95% CI): 1.6 (1.1, 2.5) and 1.7 (1.3, 2.4), respectively], and testing in the lowest four quintiles of Test III was associated with more concurrent relationships [aPR (95% CI): 1.7 (1.0, 2.7)]. Conclusions These results demonstrate an association between low executive function and sexual risk in South African young women. Future work should seek to understand the nature of this association and whether there is promise in developing interventions to enhance executive function to reduce sexual risk.Item Feasibility of an online consensus approach for the diagnosis of cognitive impairment and dementia in rural South Africa(2023-03-04) Darina T. Bassil; Meagan T. Farrell; AlbertWeerman; Muqi Guo; Ryan G.Wagner; AdamM. Brickman; M. Maria Glymour; Kenneth M. Langa; Jennifer J. Manly; Brent Tipping; India Butler; Stephen Tollman; Lisa F. BerkmanINTRODUCTION:We describe the development and feasibility of using an online consensus approach for diagnosing cognitive impairment and dementia in rural South Africa. METHODS: Cognitive assessments, clinical evaluations, and informant interviews from Cognition and Dementia in the Health and Aging in Africa Longitudinal Study (HAALSI Dementia) were reviewed by an expert panel using a web-based platform to assign a diagnosis of cognitively normal, mild cognitive impairment (MCI), or dementia. RESULTS: Six hundred thirty-five participants were assigned a final diagnostic category, with 298 requiring adjudication conference calls. Overall agreement between each rater’s independent diagnosis and final diagnosis (via the portal or consensus conference) was 78.3%. A moderate level of agreement between raters’ individual ratings and the final diagnostic outcomes was observed (average κ coefficient = 0.50).DISCUSSION: Findings show initial feasibility in using an online consensus approach for the diagnosis of cognitive impairment and dementia in remote, rural, and lowresource settings.Item Forgotten but not gone in rural South Africa: Urinary schistosomiasis and implications for chronic kidney disease screening in endemic countries [version 1; peer review: awaiting peer review](2023-02-10) Alison Craik; Mwawi Gondwe; Nokthula Mayindi; Shingirai Chipungu; Bongekile Khoza; Xavier Gómez-Olivé; Stephen Tollman; John Frean; Laurie A. Tomlinson; June FabianBackground: Urinary schistosomiasis caused by infection with Schistosoma haematobium (S. haematobium) remains endemic in Africa and is associated with haematuria and albuminuria/proteinuria. Kidney Disease Improving Global Outcomes clinical guidelines recommend evaluating proteinuria/albuminuria and glomerular filtration rate for chronic kidney disease (CKD) diagnosis. The guidelines are informed by population data outside of Africa but have been adopted in many African countries with little validation. Our study aimed to characterise the burden of urinary schistosomiasis in rural South Africa (SA) and evaluate its relationship with markers of kidney dysfunction with implications for CKD screening. Methods: In this population-based cohort study, we recruited 2021 adults aged 20 – 79 years in the Mpumalanga Province, SA. Sociodemographic data were recorded, urinalysis performed, and serum creatinine and urine albumin and creatinine measured. Kidney dysfunction was defined as an estimated glomerular filtration rate (eGFR) <60ml/min/1.73m2 and/or urine albumin-creatinine ratio>3.0mg/mmol. S. haematobium infection was determined by urine microscopy. Multivariable analyses were performed to determine relationships between S. haematobium and markers of kidney dysfunction. Results: Data were available for 1226 of 2021 participants. 717 (58.5%) were female and the median age was 35 years (IQR 27 – 47). Prevalence of kidney dysfunction and S. haematobium was 20.2% and 5.1% respectively. S. haematobium was strongly associated with kidney dysfunction (OR 8.66; 95% CI 4.10 – 18.3) and related to albuminuria alone (OR 8.69; 95% CI 4.11 – 18.8), with no evidence of an association with eGFR <90ml/min/1.73m2 (OR 0.43; 95% CI 0.05 – 3.59). Discussion: The strong association between urinary schistosomiasis and albuminuria requires careful consideration when screening for CKD. Screening for, and treatment of, schistosomiasis should be a routine part of initial work-up for CKD in S. haematobium endemic areas. Urinary schistosomiasis, a neglected tropical disease, remains a public health concern in the Mpumulanga province of SA.
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