SA-MRC/Wits Agincourt Unit (Research Outputs/Publications)

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Digital delivery of Behavioural Activation therapy to overcome depression and facilitate social and economic transitions of adolescents in South Africa
(2021-04-19) Prof. Michelle Craske; Prof. Sarah-Jayne Blakemore; Prof. Heather O’Mahen; Prof. Alastair Van Heerden; Prof. Stephen Tollman; Prof. Crick Lund; Prof. Tholene Sodi; Dr Kate Orkin; Dr Mahreen Mahmud; Dr Emma Kilford; Ms Julia Ruiz Pozuelo; Dr Bianca Moffett; Dr Xavier Gómez-Olivé; Dr Rhian Twine; Prof. Kathleen Kahn; Prof. Alan Stein
Adolescence is a critical period in life when young people negotiate independence and increased responsibility and make important decisions. The incidence of depression peaks during adolescence, coinciding with the development of multiple cognitive functions in the brain. Adolescent depression is a key public health concern, with high prevalence rates reported among rural and low resource communities in South Africa. Depression impacts young people’s ability to make decisions and manage stressful situations in life.2 It has also been linked to poor social, economic, and health outcomes including early pregnancy, HIV, lower educational attainment and poverty in adulthood. Evidence is urgently needed for cost-effective and scalable interventions targeting adolescent depression. Behavioural activation (BA) is a psychological therapy which focuses on making links between mood and behaviour. It does this by identifying activities that are meaningful and positively reinforcing for the individual (activation), and addressing processes that inhibit activation (e.g. avoidance). BA has been shown to be effective in treating adolescent depression, and can be adapted to diverse sociocultural contexts. In addition to improving depressive symptoms, studies suggest that BA targets cognitive functions involved in depression, including executive function and social cognition. These functions develop substantially during adolescence and are associated with a range of future socioeconomic outcomes. Further, BA has been successfully delivered online and through trained peer mentors with limited specialist intervention, offering a scalable solution to overcome the lack of access to psychological therapies. The proposed trial will be a pilot randomised controlled trial to evaluate digital delivery of Behavioural Activation therapy for adolescents with depression in rural South Africa (DoBAt study). Central to the study is an iterative process to co-design the Kuamsha app (meaning “activate” in Swahili) through extensive formative work with adolescents from the study site. We will assess the feasibility, acceptability and determine the preliminary effectiveness of the intervention (primary objective). As a secondary objective, we will locally adapt and pilot outcome measures of mental health, cognition, risky behaviours, socioeconomic measures, and collect descriptive data to inform the development of a further larger trial. has context menu
Changing Knowledge and Attitudes Towards HIV Treatment‑as‑Prevention and “Undetectable=Untransmittable”: A Systematic Review
(2021-04-30) Jacob Bor; Charlie Fischer; Mirva Modi; Bruce Richman; Cameron Kinker; Rachel King; Sarah K. Calabrese; Idah Mokhele; Tembeka Sineke; Thembelihle Zuma; Sydney Rosen; Till Bärnighausen; Kenneth H. Mayer; Dorina Onoya2
People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable=Untransmittable, U=U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could beneft from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U=U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identifed 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests benefcial impacts on knowledge, stigma, HIV testing, and viral suppression. Review was pre-registered at PROSPERO: CRD42020153725
Prevalence and socio-demographic associations of diet and physical activity risk-factors for cardiovascular disease in Bo, Sierra Leone
(2021-10-10) Tahir Bockarie; Maria Lisa Odland; Haja Wurie; Rashid Ansumana; Joseph Lamin; Miles Witham; Oyinlola Oyebode; Justine Davies
Background: Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone. Methods: Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics. Results: 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04-1.15)), add salt at the Table (OR 1.88 (1.82-1.94)), eat salty snacks (OR 2.00 (1.94-2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12-1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20-1.27)) or consume salty snacks (OR 1.35 (1.31-1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles. Conclusion: Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation.
Estimated effect of increased diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among low-income and middle-income countries: a microsimulation model
(2021-09-22) Sanjay Basu; David Flood; Pascal Geldsetzer; Michaela Theilmann; Maja E Marcus; Cara Ebert; Mary Mayige; Roy Wong-McClure; Farshad Farzadfar; Sahar Saeedi Moghaddam; Kokou Agoudavi; Bolormaa Norov; Corine Houehanou; Glennis Andall-Brereton; Mongal Gurung; Garry Brian; Pascal Bovet; Joao Martins; Rifat Atun; Till Bärnighausen; Sebastian Vollmer; Jen Manne-Goehler; Justine Davies
Background Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs. Methods We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and healthcare costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data—specifically from the subset of people who were defined as having any type of diabetes by WHO standards—from nationally representative, cross-sectional surveys (2006–18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1∙73 m² or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5∙07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate. Findings We obtained data from 23 678 people with diabetes from 67 countries. The median estimated 10-year risk was 10∙0% (IQR 4∙0–18∙0) for cardiovascular events, 7∙8% (5∙1–11∙8) for neuropathy with pressure sensation loss, 7∙2% (5∙6–9∙4) for end-stage renal disease, 6∙0% (4∙2–8∙6) for retinopathy with severe vision loss, and 2∙6% (1∙2–5∙3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051–1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304–1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental costeffectiveness ratio of $1362 per DALY averted (IQR 1304–1409). Interpretation Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes.
Community surveillance and response to maternal and child deaths in low- and middleincome countries: A scoping review
(2021-03-16) Tariro J. BaseraID; Kathrin Schmitz; Jessica PriceID; Merlin Willcox; Edna N. Bosire; Ademola Ajuwon; Marjorie Mbule; Agnes Ronan; Fiona Burtt; Esca Scheepers; Jude Igumbor
Background Civil registration and vital statistics (CRVS) systems do not produce comprehensive data on maternal and child deaths in most low- and middle-income countries (LMICs), with most births and deaths which occur outside the formal health system going unreported. Community-based death reporting, investigation and review processes are being used in these settings to augment official registration of maternal and child deaths and to identify deathspecific factors and associated barriers to maternal and childcare. This study aims to review how community-based maternal and child death reporting, investigation and review processes are carried out in LMICs. Methods We conducted a scoping review of the literature published in English from January 2013 to November 2020, searching PubMed, EMBASE, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews, Scopus, and Web of Science databases. We used descriptive analysis to outline the scope, design, and distribution of literature included in the study and to present the content extracted from each article. The scoping review is reported following the PRISMA reporting guideline for systematic reviews. Results Of 3162 screened articles, 43 articles that described community-based maternal and child death review processes across ten countries in Africa and Asia were included. A variety of approaches were used to report and investigate deaths in the community, including identification of deaths by community health workers (CHWs) and other community informants, reproductive age mortality surveys, verbal autopsy, and social autopsy. Community notification of deaths by CHWs complements registration of maternal and child deaths missed by routinely collected sources of information, including the CRVS systems which mostly capture deaths occurring in health facilities. However, the accuracy and completeness of data reported by CHWs are sub-optimal. Conclusions Community-based death reporting complements formal registration of maternal and child deaths in LMICs. While research shows that community-based maternal and child death reporting was feasible, the accuracy and completeness of data reported by CHWs are suboptimal but amenable to targeted support and supervision. Studies to further improve the process of engaging communities in the review, as well as collection and investigation of deaths in LMICs, could empower communities to respond more effectively and have a greater impact on reducing maternal and child mortality.
Developing and evaluating a frailty index for older South Africans—findings from the HAALSI study
(2021-06-09) Fred J. Barker; Justine I. Davies; F. Xavier Gomez-Olive; Kathleen Kahn; Fiona E. Matthews; Collin F. Payne; Joshua A. Salomon; Stephen M. Tollman; Alisha N.Wade; Richard W.Walker; Miles D.Witham
Background: despite rapid population ageing, few studies have investigated frailty in older people in sub-Saharan Africa. We tested a cumulative deficit frailty index in a population of older people from rural South Africa. Methods: analysis of cross-sectional data from the Health and Ageing in Africa: Longitudinal Studies of an INDEPTH Community (HAALSI) study. We used self-reported diagnoses, symptoms, activities of daily living, objective physiological indices and blood tests to calculate a 32-variable cumulative deficit frailty index. We fitted Cox proportional hazards models to test associations between frailty category and all-cause mortality. We tested the discriminant ability of the frailty index to predict one-year mortality alone and in addition to age and sex. Results: in total 3,989 participants were included in the analysis, mean age 61 years (standard deviation 13); 2,175 (54.5%) were women. The median frailty index was 0.13 (interquartile range 0.09–0.19); Using population-specific cutoffs, 557 (14.0%) had moderate frailty and 263 (6.6%) had severe frailty. All-cause mortality risk was related to frailty severity independent of age and sex (hazard ratio per 0.01 increase in frailty index: 1.06 [95% confidence interval 1.04–1.07]). The frailty index alone showed moderate discrimination for one-year mortality: c-statistic 0.68–0.76; combining the frailty index with age and sex improved performance (c-statistic 0.77–0.81). Conclusion: frailty measured by cumulative deficits is common and predicts mortality in a rural population of older South Africans. The number of measures needed may limit utility in resource-poor settings.
Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic
(2020-08-11) Travis P. Baggett; Justine A. Scott; Mylinh H. Le; Fatma M. Shebl; Christopher Panella; Elena Losina; Clare Flanagan; Jessie M. Gaeta; Anne Neilan; Emily P. Hyle; Amir Mohareb; Krishna P. Reddy; Mark J. Siedner; Guy Harling; Milton C. Weinstein; Andrea Ciaranello; Pooyan Kazemian; Kenneth A. Freedberg
Importance: Approximately 356,000 people stay in homeless shelters nightly in the US. They are at high risk for COVID-19. Objective: To assess clinical outcomes, costs, and cost-effectiveness of strategies for COVID-19 management among sheltered homeless adults. Design: We developed a dynamic microsimulation model of COVID-19 in sheltered homeless adults in Boston, Massachusetts. We used cohort characteristics and costs from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were from published literature and national databases. We examined surging, growing, and slowing epidemics (effective reproduction numbers [Re] 2.6, 1.3, and 0.9). Costs were from a health care sector perspective; time horizon was 4 months, from April to August 2020. Setting & Participants: Simulated cohort of 2,258 adults residing in homeless shelters in Boston. Interventions: We assessed daily symptom screening with polymerase chain reaction (PCR) testing of screen-positives, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternate care sites [ACSs] for mild/moderate COVID-19, and temporary housing, each compared to no intervention. Main Outcomes and Measures: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case prevented of COVID-19. Results: We simulated a population of 2,258 sheltered homeless adults with mean age of 42.6 years. Compared to no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild/moderate disease led to 37% fewer infections and 46% lower costs (Re=2.6), 75% fewer infections and 72% lower costs (Re=1.3), and 51% fewer infections and 51% lower costs (Re=0.9). Adding PCR testing every 2 weeks further decreased infections; incremental cost per case prevented was $1,000 (Re=2.6), $27,000 (Re=1.3), and $71,000 (Re=0.9). Temporary housing with PCR every 2 weeks was most effective but substantially more costly than other options. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions & Relevance: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer COVID-19 infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in COVID-19 infections at modest incremental cost and should be considered during future surges.
Mortality in children aged <5 years with severe acute respiratory illness in a high HIVprevalence urban and rural areas of South Africa, 2009–2013
(2021-08-12) Oluwatosin A Ayeni; Sibongile Walaza; Stefano Tempia; Michelle Groome; Kathleen Kahn; Shabir A Madhi; Adam L Cohen; Jocelyn Moyes; Marietjie Venter; Marthi Pretorius; Florette Treurnicht; Orienka Hellferscee; Anne von Gottberg; Nicole Wolter; Cheryl Cohen
Background: Severe acute respiratory illness (SARI) is an important cause of mortality in young children, especially in children living with HIV infection. Disparities in SARI death in children aged <5 years exist in urban and rural areas. Objective: To compare the factors associated with in-hospital death among children aged <5 years hospitalized with SARI in an urban vs. a rural setting in South Africa from 2009-2013. Methods: Data were collected from hospitalized children with SARI in one urban and two rural sentinel surveillance hospitals. Nasopharyngeal aspirates were tested for ten respiratory viruses and blood for pneumococcal DNA using polymerase chain reaction. We used multivariable logistic regression to identify patient and clinical characteristics associated with in-hospital death. Results: From 2009 through 2013, 5,297 children aged <5 years with SARI-associated hospital admission were enrolled; 3,811 (72%) in the urban and 1,486 (28%) in the rural hospitals. In-hospital case-fatality proportion (CFP) was higher in the rural hospitals (6.9%) than the urban hospital (1.3%, p<0.001), and among HIV-infected than the HIV-uninfected children (9.6% vs. 1.6%, p<0.001). In the urban hospital, HIV infection (odds ratio (OR):11.4, 95% confidence interval (CI):5.4-24.1) and presence of any other underlying illness (OR: 3.0, 95% CI: 1.0-9.2) were the only factors independently associated with death. In the rural hospitals, HIV infection (OR: 4.1, 95% CI: 2.3-7.1) and age <1 year (OR: 3.7, 95% CI: 1.9-7.2) were independently associated with death, whereas duration of hospitalization ≥5 days (OR: 0.5, 95% CI: 0.3-0.8) and any respiratory virus detection (OR: 0.4, 95% CI: 0.3-0.8) were negatively associated with death. Conclusion: We found that the case-fatality proportion was substantially higher among children admitted to rural hospitals and HIV infected children with SARI in South Africa. While efforts to prevent and treat HIV infections in children may reduce SARI deaths, further efforts to address health care inequality in rural populations are needed.
Effect of a storytelling intervention on the retention of serodiscordant couples in ART/PrEP services at antenatal clinic in Namacurra province in Zambézia, Mozambique
(2021-06) Carolyn M Audet; Erin Graves; Almiro M Emílio; Ariano Matino; Paula Paulo; Arifo M Aboobacar; Carlota L Fonseca; Sara Van Rompaey; Caroline De Schacht
Background: Sub-Saharan Africa reported 550,000 new HIV infections among women in 2018. Pregnancy and the postpartum period are associated with an increased risk of HIV acquisition (adjusted risk ratio [RR]: 2.8 during pregnancy and 4.0 in postpartum period vs. non-pregnant or postpartum women, respectively). Acquisition of HIV during pregnancy and breastfeeding increases risk of mother to child transmission. We propose to test the impact of a peer-delivered oral storytelling intervention to increase retention in, and adherence to, pre-exposure prophylaxis (PrEP)/combination antiretroviral treatment (ART) among expectant couples. Design: We propose a randomized controlled trial (RCT) (35 intervention and 35 control couples) at a health facility where 11% of expectant couples were in serodiscordant relationships in 2018. Couples randomized to the storytelling arm will be visited by a two community volunteers and who successfully adhered to PrEP/ART during a recent pregnancy. This expert couple will orate to participating couples three stories (at 1, 3 and 5 weeks after study enrollment) designed to empower, educate, and establish "ideal" interpersonal communication strategies within couples/families, and support adherence practices among participants. The primary outcome among HIV-uninfected women will be adherence to PrEP at 3 months. Conclusions: PrEP among at-risk pregnant women must be implemented so that high levels of adherence and retention are achievable for them and their partners. We will test our storytelling intervention to identify an optimal strategy for PrEP education and family engagement in a region with high HIV prevalence. Our results will have an impact by effectively engaging serodiscordant couples in prevention/treatment during pregnancy and beyond.
Throwing the bones to diagnose HIV: Views of rural South African traditional healers on undertaking HIV counselling and testing
(2022-10-10) Carolyn M. Audet; Elise M. Clemens; Sizzy Ngobeni; Mevian Mkansi; Daniel E. Sack; Ryan G. Wagner
In 2018, nearly 800,000 HIV positive individuals in South Africa were unaware of their status. Traditional healers see patients who avoid health clinics, including those who refuse HIV testing. This manuscript details the results of a qualitative study to understand traditional healer perspectives on performing healer-initiated HIV counseling and testing HIV in rural South Africa. We conducted 30 structured in-depth, in-person interviews between April and June 2019 to elicit traditional healer attitudes towards partnering with local health services to perform HIV counseling and testing with their patients. Healers reported that while some patients are open about their HIV status, others lie about it due to stigma around the disease. This creates challenges with concurrent treatment, which healers believe leads to allopathic and/or traditional medication treatment failure. Most healers expressed both an interest and a willingness to perform HIV counseling and testing. Healers felt that by performing testing in the community, it would overcome issues related to HIV stigma, as well as a lack of confidentiality and trust with health care workers at the clinic. Trained traditional healers may be able to bridge the testing gap between “non-testers” and the allopathic health system, essentially “opening” thousands of new testing locations with little financial investment.
Healer-led vs. clinician-led training to improve personal protective equipment use among traditional healers in South Africa: a randomized controlled trial protocol
(2021-03-01) Carolyn M. Audeta; Bryan E. Shepherdd; Muktar H. Aliyua; Mosa Moshabela; Mariah J. PettapiecePhillipsa; Ryan G. Wagner
There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional ‘injections’, in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer’s place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.
Has the relationship between wealth and HIV risk in Sub-Saharan Africa changed over time? A temporal, gendered and hierarchical analysis.
(2021-05-29) Emily Andrus; Sanyu A Mojola; Elizabeth Moran; Marisa Eisenberg; Jon Zelner
This study examines the relationship between wealth and HIV infection in Sub-Saharan Africa to determine whether and how this relationship has varied over time, within and across countries, by gender, and urban environment. The analysis draws on DHS and AIS data from 27 Sub-Saharan African countries, which spanned the 14 years between 2003 and 2016. We first use logistic regression analyses to assess the relationship between individual wealth, HIV infection and gender by country and year stratified on urban environment. We then use meta-regression analyses to assess the relationship between country level measures of wealth and the odds of HIV infection by gender and individual level wealth, stratified on urban environment. We find that there is a persistent and positive relationship between wealth and the odds of HIV infection across countries, but that the strength of this association has weakened over time. The rate of attenuation does not appear to differ between urban/rural strata. Likewise, we also find that these associations were most pronounced for women and that this relationship was persistent over the study period and across urban and rural strata. Overall, our findings suggest that the relationship between wealth and HIV infection is beginning to reverse and that in the coming years, the relationship between wealth and HIV infection in Sub-Saharan Africa may more clearly mirror the predominant global picture.
Large age shifts in HIV-1 incidence patterns in KwaZulu-Natal, South Africa
(2021-07-13) Adam Akullian; Alain Vandormael; Joel C Miller; Anna Bershteyn; Edward Wenger; Diego Cuadros; Dickman Gareta; Till Bärnighausen; Kobus Herbst; Frank Tanser
Recent declines in adult HIV-1 incidence have followed the large-scale expansion of antiretroviral therapy and primary HIV prevention across high-burden communities of sub-Saharan Africa. Mathematical modeling suggests that HIV risk will decline disproportionately in younger adult age-groups as interventions scale, concentrating new HIV infections in those >age 25 over time. Yet, no empirical data exist to support these projections. We conducted a population-based cohort study over a 16-y period (2004 to 2019), spanning the early scale-up of antiretroviral therapy and voluntary medical male circumcision, to estimate changes in the age distribution of HIV incidence in a hyperepidemic region of KwaZulu-Natal, South Africa, where adult HIV incidence has recently declined. Median age of HIV seroconversion increased by 5.5 y in men and 3.0 y in women, and the age of peak HIV incidence increased by 5.0 y in men and 2.0 y in women. Incidence declined disproportionately among young men (64% in men 15 to 19, 68% in men 20 to 24, and 46% in men 25 to 29) and young women (44% in women 15 to 19, 24% in women 20 to 24) comparing periods pre- versus post-universal test and treat. Incidence was stable (<20% change) in women aged 30 to 39 and men aged 30 to 34. Age shifts in incidence occurred after 2012 and were observed earlier in men than in women. These results provide direct epidemiological evidence of the changing demographics of HIV risk in sub-Saharan Africa in the era of large-scale treatment and prevention. More attention is needed to address lagging incidence decline among older individuals.
Poor retention and care-related sex disparities among youth living with HIV in rural Mozambique
(2021-05-21) Aima A Ahonkhai; Muktar H Aliyu; Carolyn M Audet; Magdalena Bravo; Melynda Simmons; Gael Claquin; Peter Memiah; Anibal N Fernando; James G Carlucci; Bryan E Shepherd; Sara Van Rompaey; Zhihong Yu; Wu Gong; Sten H Vermund; C William Wester
Background: There are few studies that characterize sex-related differences in HIV outcomes among adolescents and young adults (AYA) 15-24 years of age. Methods: We conducted a retrospective cohort study among AYA who enrolled in a comprehensive HIV program in Mozambique between 2012-2016. We assessed patients by sex and pregnancy/lactation status, comparing time to combination antiretroviral therapy (ART) initiation using Cox proportional hazard models. We employed multivariable logistic regression to investigate pre- and post-ART retention. Patients were defined as 'retained pre-ART' if they attended at least 3 of 4 required visits or started ART in the 6 months after enrollment, and 'retained post-ART' if they had any ART pickup or clinical visit during the last 90 days of the one-year follow-up period. Results: Of 47,702 patients in the cohort, 81% (n = 38,511) were female and 19% (n = 9,191) were male. Of the females, 57% (n = 21,770) were non-pregnant and non-lactating (NPNL) and 43% (n = 16,741) were pregnant or lactating (PL). PL (aHR 2.64, 95%CI:2.47-2.81) and NPNL females (aHR 1.36, 95%CI:1.30-1.42) were more likely to initiate ART than males. PL females had higher odds of pre-ART retention in care (aOR 3.56, 95%CI: 3.30-3.84), as did NPNL females (aOR 1.71, 95%CI: 1.62-1.81), compared to males. This was also true for retention post-ART initiation, with higher odds for both PL (aOR 1.78, 95%CI:1.63-1.94) and NPNL females (aOR 1.50, 95%CI:1.35-1.65) compared to males. Conclusions: PL females were most likely to initiate ART and remain in care post-ART in this AYA cohort, likely reflecting expansion of Option B+. Despite pregnancy and policy driven factors, we observed important sex-related disparities in this cohort. NPNL females were more likely to initiate ART and be retained in care before and after ART initiation than males. These data suggest that young males need targeted interventions to improve these important care continuum outcomes.
The impact of retirement on inpatient healthcare utilization in Guangzhou, China: a regression discontinuity analysis of 189,031 health insurance claims
(2022-04-29) Xintong Zhao; Yuehua Liu; Xin Zhang; Till Bärnighausen; Simiao Chen BMC Geriatrics
Background Previous studies suggest that retirement, a major life event, affects overall healthcare utilization. We examine, the effects of retirement on inpatient healthcare utilization, including effect heterogeneity by gender, disease category, and type of health service. Methods We used routine health insurance claims data (N = 87,087) spanning the period 2021 - September 2013 from the Urban Employee Basic Medical Insurance (UEBMI), a mandatory social health insurance for working and retired employees in urban China. We applied a non-parametric fuzzy regression discontinuity design using the statutory retirement age in urban China as an exogenous instrument to measure the causal effect of retirement on six measures of inpatient healthcare utilization. Results Retirement reduced total hospital costs (-84.71 Chinese Yuan (CNY), 95% confidence interval (CI) -172.03 – 2.61), shortened length of hospital stays (-44.59, 95% CI -70.50 – -18.68), and increased hospital readmissions (0.06, 95% CI 0.00 – 0.12) and primary hospital visits (0.06, 95% CI 0.02 – 0.09) among women. Retirement did not significantly change inpatient healthcare utilization among men. The retirement effects among women varied by disease category. Specifically, retirement substantially increased hospitalizations for non-communicable diseases (NCDs), yet had only modest or no effect on hospitalizations for communicable diseases or injuries. Retirement effects among women also varied by the type of services. For relatively inexpensive services, such as nonoperative treatment, there were surges in the extensive margin (hospital readmission). For relatively expensive and invasive services, such as surgeries, retirement reduced the intensive margin (out-of-pocket expenditures and length of stay). Conclusions Retirement decreases overall use of inpatient healthcare for women. The examination on the disease-related heterogeneous effects helps with the introduction and implementation of integrated healthcare delivery and appropriate incentive schemes to encourage better use of healthcare resources among older adults.
There are no equal opportunity infectors: Epidemiological modelers must rethink our approach to inequality in infection risk
(2022-02-09) Jon Zelner; Nina B Masters; Ramya Naraharisetti; Sanyu A Mojola; Merlin Chowkwanyun; Ryan Malosh
Mathematical models have come to play a key role in global pandemic preparedness and outbreak response: helping to plan for disease burden, hospital capacity, and inform nonpharmaceutical interventions. Such models have played a pivotal role in the COVID-19 pandemic, with transmission models-and, by consequence, modelers-guiding global, national, and local responses to SARS-CoV-2. However, these models have largely not accounted for the social and structural factors, which lead to socioeconomic, racial, and geographic health disparities. In this piece, we raise and attempt to clarify several questions relating to this important gap in the research and practice of infectious disease modeling: Why do epidemiologic models of emerging infections typically ignore known structural drivers of disparate health outcomes? What have been the consequences of a framework focused primarily on aggregate outcomes on infection equity? What should be done to develop a more holistic approach to modeling-based decision-making during pandemics? In this review, we evaluate potential historical and political explanations for the exclusion of drivers of disparity in infectious disease models for emerging infections, which have often been characterized as "equal opportunity infectors" despite ample evidence to the contrary. We look to examples from other disease systems (HIV, STIs) and successes in including social inequity in models of acute infection transmission as a blueprint for how social connections, environmental, and structural factors can be integrated into a coherent, rigorous, and interpretable modeling framework. We conclude by outlining principles to guide modeling of emerging infections in ways that represent the causes of inequity in infection as central rather than peripheral mechanisms.
Interventions addressing the adolescent HIV continuum of care in South Africa: a systematic review and modified Delphi analysis
(2022-04-29) Brian Zanoni; Moherndran Archary; Thobekile Sibaya; Tatiana Ramos; Geri Donenberg; Maryam Shahmanesh; Connie Celum; Audrey Pettifor; Linda Gail Bekker; Jessica Haberer
Introduction: Compared with adults, adolescents in South Africa have larger gaps at each step of the HIV continuum of care resulting in low levels of viral suppression. Methods: We conducted a systematic review and modified Delphi analysis of interventions addressing the HIV continuum of care for adolescents in South Africa. We searched PubMed, Science Direct, and Google Scholar and online conference proceedings from the International AIDS Society, the International AIDS Conference, and the Conference on Retrovirology and Opportunistic Infections from 1 January 2010 to 30 September 2020. We then conducted a modified Delphi analysis with 29 researchers involved in the National Institutes of Health's Fogarty International-supported Adolescent HIV Implementation Science Alliance-South Africa to evaluate interventions for efficacy, feasibility and potential for scale-up. Results: We identified nine initial published articles containing interventions addressing the adolescent HIV continuum of care in South Africa, including five interventions focused on HIV diagnosis, two on antiretroviral therapy adherence and two on retention in care. No studies addressed linkage to care or transition from paediatric to adult care. Two studies discussed intervention costs. In-home and HIV self-testing, community-based adherence support, and provision of adolescent-friendly services were the most impactful and scalable interventions addressing the adolescent HIV continuum of care. Conclusion: Future interventions should work comprehensively across the adolescent HIV continuum of care and be tailored to the specific needs of adolescents.
The double-edged role of accessed status on health and well-being among middle- and older-age adults in rural South Africa: The HAALSI study
(2022-09) Shao-Tzu Yu; Brian Houle; Lenore Manderson; Elyse A Jennings; Stephen M Tollman; Lisa F Berkman; Guy Harling
Background: Social capital theory conceptualizes accessed status (the socioeconomic status of social contacts) as interpersonal resources that generate positive health returns, while social cost theory suggests that accessed status can harm health due to the sociopsychological costs of generating and maintaining these relationships. Evidence for both hypotheses has been observed in higher-income countries, but not in more resource-constrained settings. We therefore investigated whether the dual functions of accessed status on health may be patterned by its interaction with network structure and functions among an older population in rural South Africa. Method: We used baseline survey data from the HAALSI study ("Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa") among 4,379 adults aged 40 and older. We examined the direct effect of accessed status (measured as network members' literacy), as well as its interaction with network size and instrumental support, on life satisfaction and self-rated health. Results: In models without interactions, accessed status was positively associated with life satisfaction but not self-rated health. Higher accessed status was positively associated with both outcomes for those with fewer personal contacts. Interaction effects were further patterned by gender, being most health-protective for women with a smaller network and most health-damaging for men with a larger network. Conclusions: Supporting social capital theory, we find that having higher accessed status is associated with better health and well-being for older adults in a setting with limited formal support resources. However, the explanatory power of both theories appears to depending on other key factors, such as gender and network size, highlighting the importance of contextualizing theories in practice.
CD4+ T-cell count at antiretroviral therapy initiation in the "Treat AII" era in South A: an interrupted time series analysis.
(2012-11-05) Yapa HM; Kim H-y; Post FA; Jiamsakul A; de Neve J-W; Tanser F; Iwuji C; Baisley K; Shamanesh M; Pillay D; Siedner MJ; Barnighausen T; Bot J
The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries
(2022-10-22) Yuanwei Xu; Pascal Geldsetzer; Jen Manne-Goehler; Michaela Theilmann; Maja-E Marcus; Zhaxybay Zhumadilov; Sarah Quesnel-Crooks; Omar Mwalim; Sahar Saeedi Moghaddam; Sogol Koolaji; Khem B Karki; Farshad Farzadfar; Narges Ebrahimi; Albertino Damasceno; Krishna K Aryal; Kokou Agoudavi; Rifat Atun; Till Bärnighausen; Justine Davies; Lindsay M Jaacks; Sebastian Vollmer; Charlotte Probst
Background: Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals' socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings. Methods: In this pooled analysis of individual-level data, we used available nationally representative surveys-mainly WHO Stepwise Approach to Surveillance surveys-conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers). Findings: Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7-51·2] and HED 63·3% [61·0-65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1-33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6-40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs. Interpretation: The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs. Funding: Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

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