3. Electronic Theses and Dissertations (ETDs)
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Item Psychological Wellbeing Among South African Women with Endometriosis: A Quantitative Study(University of the Witwatersrand, Johannesburg, 2025-01) Ismail, Raeesah; Rogers, ShawnEndometriosis is a chronic illness that significantly impacts the physical, emotional, and psychological wellbeing (PW) of women. Despite its prevalence, the psychological toll of endometriosis remains under-researched, particularly in South Africa, where healthcare disparities and limited resources exacerbate challenges. The aim of this study addresses a critical gap in exploring the associative and predictive relationships between delayed diagnosis, psychosocial factors (participation in support groups and perceived medical support), and demographics (age and socioeconomic impact and access) on the experiences of PW in a sample of South African women diagnosed with endometriosis. Using a cross-sectional, correlational design, the study analysed 248 South African women aged 18–55 diagnosed with endometriosis. Participants were recruited via social media, support groups, and university students, employing non-probability sampling. Data was collected using the Ryff Psychological Wellbeing Scale, the Stellenbosch Endometriosis Quality of Life Scale (SEQOL), the Endometriosis Impact Questionnaire (EIQ), and a contextual questionnaire. Descriptive and inferential statistics, including Pearson correlations and regression analyses, were conducted. The simple regression results revealed that perceived medical support, EIQ Social Impact, SEQOL Support, socioeconomic status contextual burden, SEQOL Income, EIQ Employment & Financial and Education impact, and EIQ Psychological Impact and SEQOL PW were all significantly negative predictors of PW. However, delayed diagnosis, age, and support group participation were not found to be significant predictors. Additionally, the overall multiple regression model was significant (F(9, 238) = 8.81, p < .001) and accounted for approximately 25.0% of the variance in PW with socioeconomic contextual burden emerging as the only significant predictor of PW (p = .028). Socioeconomic Impact and Access factors accounted for the largest variance in PW, showing the role of healthcare access and financial strain. The two psychological factor measures also emerged as a key area affecting overall PW. The results emphasise the need for endometriosis awareness, integrating mental health support into treatment plans and addressing systemic barriers to healthcare. This research provides a foundation for future studies to leverage in studying South African women with endometriosis.Item Strengthening understanding of effective adherence strategies for first-line and second-line antiretroviral therapy (ART) in selected rural and urban communities in South Africa(University of the Witwatersrand, Johannesburg, 2024) Gumede, Siphamandla Bonga ZiphozonkeSouth Africa accounts for approximately 20% (4.8 million) of the worldwide population of individuals who are HIV-positive and receiving antiretroviral medication (ART). In 2019, approximately 15%-20% of individuals receiving first-line antiretroviral therapy (ART) and up to 30% of individuals receiving second-line ART in the HIV treatment program in South Africa encountered virological failure. In addition, over 40% of individuals receiving first-line antiretroviral therapy (ART) and up to 20% of individuals receiving second-line ART experienced loss to follow-up (LTFU). While there is a significant amount of research on adherence to antiretroviral therapy (ART), there is still a lack of studies examining the various elements at different levels that influence adherence to treatment and the processes that shape adherence behaviour, specifically in South Africa. Furthermore, there exists a dearth of documented information regarding the efficacy and consequences of the measures presently utilized to enhance adherence among individuals living with HIV (PLHIV) who are undergoing antiretroviral therapy (ART). This thesis employed a multilevel socio-ecological framework to elucidate the risk factors that influence treatment adherence across various levels. Additionally, it conducted a comprehensive evaluation of existing research that examined the impact or impacts of intervention techniques on enhancing treatment adherence. The studies presented in this thesis identified the barriers to and facilitators of adherence for people living with HIV on ART and assessed the impact of different adherence intervention strategies that aimed to promote treatment adherence. This was achieved by examining the five research questions: 1. What is the uptake rate of ART, and the individual-level predictors of virological failure and being lost to follow-up (LTFU) in PLHIV taking ART in urban communities? 2. What are the individual-level factors that predict virological failure, low CD4 count, and retention in care for patients on second-line ART in urban communities? 3. What are the individual, relationship or interpersonal, and community-level factors associated with self-reported adherence, pill count, and virological failure to ART in rural communities? 4. What are the different treatment-taking behaviours and perspectives on adherence to ART between virally suppressed and unsuppressed patients on second-line ART in urban communities? 5. What treatment adherence strategies and interventions have been implemented and evaluated in sub-Saharan Africa for ART, hypertension, and Diabetes Mellitus? vii Chapter 2, a protocol paper, detailed the rationale, study aims, research designs, and methods employed in the studies reported on in this thesis. By adapting a multi-level socio-ecological framework to identify factors existing at various levels (including individual, relationship/interpersonal, and community level factors) and describing their interplay chapter 2 demonstrated how an existing socio-ecological conceptual framework can be used as a tool to provide guidance regarding facilitators and barriers to ART adherence. In the study reported in chapter 3, we described the ART uptake and the individual level predictors of virological failure and being LTFU in PLHIV taking ART in Johannesburg. In this retrospective cohort study, we presented analyses based on the TIER.Net database for a large cohort of HIV- infected adult patients who are taking first-line and second-line ART in Johannesburg, South Africa. TIER.Net is the ART monitoring and evaluation system used by the South African National Department of Health for recording ART patient-level information. Records were reviewed for patients on ART from seven high-volume public health facilities in Johannesburg. Study data included medical records of people with HIV who started ART between 01 April 2004 (the inception of the South African national HIV treatment program in the public health system setting) and 29 February 2020. This cut-off period was chosen to give the cohort patients a minimum of one year to receive their annual standard-of-care viral load test. In this study, factors such as age at ART start, current age, sex, duration on ART, baseline CD4 cell count, and retention in care were analyzed as covariates of outcomes (viral load and LTFU). Of the total study cohort, 95% (n=117 260/123 002) were on a first-line regimen and 5% (n=5 742/123 002) were on a second-line regimen. Most patients (59%, n=72 430/123 002) were initiated on an efavirenz-based, tenofovir disoproxil fumarate-based and emtricitabine-based regimen (fixed-dose combination). 91% (n=76 737/84 252) achieved viral suppression at least once since initiating ART and 59% (n=57 981/98 071) remained in care as at the end of February 2020. Findings from the univariate, multivariable logistic regression analysis and fixed effect model showed that younger patients, male patients, patients with low CD4 cell counts, and patients who were initiated on ART between 2004 and 2010 all had poorer clinical, treatment and retention outcomes, particularly those on second-line ART. While national ART guidelines and efforts to initiate PLHIV on treatment have contributed to a higher uptake of ART over time, much still needs to be done to improve retention in care. Although slight efforts have been made to address similar findings in sub-Saharan Africa, these demographic and clinical characteristics must be considered when designing/implementing treatment support strategies and models to improve treatment outcomes, retention in care, and subsequently treatment failures which lead to switching to more complex ART regimens. viii In the study reported in chapter 4, we aimed to identify individual-level factors that predict virological failure, low CD4 count, and retention in care for patients on second-line ART in Johannesburg. In this retrospective cohort study, we conducted analyses of secondary data that was exported from the TIER.Net database. Variables extracted included ART start dates, ART switch dates, treatment retention, viral load, and CD4 cell count results. This retrospective study of 825 PLHIV on second-line ART reported viral load suppression of 83% (n=570/686) among patients on second-line ART, demonstrating lower suppression rates compared to historic first- line treatment (92% suppression rate) in Johannesburg. Just under three-quarters (72%, n=597/825) of the patients remained in care over the reported period, slightly lower than the reported retention rate of 78% in a first-line treatment cohort from Johannesburg. Results from the multivariable logistic regression analysis reported that being <25 years of age, male sex, and geographical transfer (started initial treatment in a different region) independently predicted low CD4+ cell counts and virological failure on second-line treatment. Being younger than 25 years of age, male sex, and transferred-in patients, are easily identifiable factors that may trigger the need for added adherence and support interventions, which include targeted adherence and retention support programs, using mobile health solutions for patient communication, education, and appointment reminders. The study presented in chapter 5 investigated individual, relationship or interpersonal, and community-level factors associated with self-reported adherence, pill count, and virological failure to ART of patients accessing care at the Ndlovu Medical Centre, Limpopo Province. This study was performed as a sub-study of the Intensified Treatment Monitoring Strategy to Prevent Accumulation of Drug Resistance (ITREMA) randomized clinical trial, a well-characterized cohort of 501 participants on antiretroviral treatment, that received prospective long-term follow-up for 96 weeks. In this study, markers of adherence and virological suppression status were periodically assessed. A comprehensive assessment of multilevel risk factors at the baseline of this trial enabled us to characterize their association with study outcomes (viral load, self-reported adherence, and pill count). The multilevel factors included demographic information, employment status, income composition, household composition, partnership status, food security, adherence, actual support from household members, actual family support, coping abilities, clinician trust, health literacy, mental health, and stigmatization. We found that over half (53%, n=243/458)) of the participants reported difficulties with adherence, and over one-third (35%, n=162/458) had suboptimal adherence measured through pill count (pill count<95%) at any point during follow-up. Virological failure appeared infrequently and occurred in 16% (n=68/436) of participants. Using tests of association and multivariable logistic regression analysis (stratified by sex), we found that being male was an independent risk factor for self-reported difficulties with adherence, suboptimal adherence measured through pill ix count, and virological failure. PLHIV who experienced moderate or severe depressive symptoms or had low household income were at increased risk of poor adherence and/or virological failure and may benefit from additional ART adherence support. In the stratified analysis, we found that the risk of virological failure was higher among male participants with food insecurity. We also found that while the prevalence of depressive symptoms was similar between males and females, the association was significant among female participants only. Task-oriented coping was associated with suboptimal adherence as indicated by pill count<95%. Our findings reported in chapter 5 contribute to the available knowledge on risk factors for adverse outcomes of ART in rural populations. The study findings may also contribute to the ongoing development of ‘rural proof’ healthcare policies currently being introduced in South Africa, such as the National Health Insurance and the new 2030 Human Resources for Health Strategy. These strategies seek to promote comprehensive access to healthcare services and also highlight the need for the government to take decisive steps to improve access to care for all individuals seeking healthcare services. Chapter 6 reports a cross-sectional study that sought to describe the different treatment-taking behaviours and perspectives of adherence to ART between virally suppressed and unsuppressed patients using second-line ART in Johannesburg. This study was conducted between July 2018 and August 2018, in five public health facilities (two hospitals, one community health center, and two primary healthcare clinics). We randomly sampled 10% of the population of 1 500 eligible patients and they were invited to participate in this study in one of two ways; telephonically or in facility recruitment where researchers met them at the facility during their scheduled clinic visit. The study sample comprised 149 participants; of which 48% (n=71/149) were virally unsuppressed. The majority of participants (63%, n=94/149) had disclosed their HIV status to their relatives and/or partners within one week of diagnosis. However, 28% (n=42/149) took longer than four weeks to disclose to their relatives and/or partners. Using multivariable logistic regression analysis, we found that single and unmarried people living with their partners were more likely to experience virological failure compared to those who were married. The more toxic second-line multi-pill, which is taken multiple times a day, was seen as significantly harder to take than a single tablet daily, well-tolerated first-line regimen. Participants experiencing medication- related difficulties in taking second-line ART and experiencing side effects were also subjective predictors of virological failure. We also found that participants with virological failure were more likely to have treatment-related side effects. Those participants with side effects were more likely to be unemployed. In general, employed individuals are linked to improved access to healthcare and better health outcomes as compared to their unemployed counterparts. However, while the correlation between improved health outcomes and employment exists, the causal relationship is x complicated as the relationship can be bi-directional. Our study results suggest the importance of improving patients’ knowledge about treatment and adherence, and motivation to continue ART use despite the persistence of side effects. Participants interviewed in the study reported in chapter 6 had firm recommendations around improving adherence to second-line ART, largely focused on reduced dosing and pill burden. These included a second-line fixed-dose combination, a dosage taken once a day, and a reduction in the pill size. Furthermore, the participants suggested that education on the benefits of taking ART could improve adherence, whilst a few participants also suggested the implementation of injectable second-line ART. In chapter 7, we report a systematic review that assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions (ART, hypertension, diabetes mellitus). We systematically searched the PubMed, Web of Science, Scopus, Google Scholar, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases to identify relevant publications. Data were extracted from eligible studies for study characteristics and description of interventions for the study populations of interest. We found a relatively large body of evidence on interventions to improve adherence among adults living with chronic conditions in sub-Saharan Africa. Of the 25 473 total studies/records screened, a total of 77 studies were subsequently included, describing a total of 49,364 patients. Of the total included studies, 70% (n=54/77) were related to ART for HIV, 8% (n=6) were anti-hypertensive medication related, 16% (n=12/77) were anti- diabetic medication related and 6% (n=5/77) focused on medication for more than one condition. Of the total 77 studies, 60% (n=46/77) reported improved adherence based on the described study outcomes while 21% (n=16/77) reported no significant difference between studied groups. There is expanded evidence that community-and home-based, digital or mobile health (mhealth) and adherence counselling interventions can improve adherence to treatment for chronic conditions. Our findings underscore the need to develop a gold standard (or uniform measures) for measuring adherence. In the general discussion in chapter 8, the main findings were summarized, collated, and discussed. Chapter 8 provided context to the findings about the research questions and discussed its implications for future research along with recommendations. Thereafter, the strengths, limitations of this thesis, and directions for future research were also discussed. Combining multi-level models, the evidence from the studies presented in this thesis enabled us to identify the barriers to and facilitators of adherence for PLHIV on first-line and second-line ART and make recommendations for comprehensive, acceptable, and appropriate intervention strategies to improve treatment adherence. Our research found that many factors influence the xi ability to successfully engage individuals in HIV care. These factors include being male, being younger, experiencing ART-related side effects, having a low household income, presence of food insecurity, and experiencing moderate or severe depressive symptoms. With a large total sample size of 173 842 people included across all studies, our research ensured that a strong body of evidence was created regarding barriers to and facilitators of adherence to ART and adherence intervention strategies implemented to improve treatment adherence. However, all the research studies included in this thesis were conducted in a total of eight health facilities (seven of over 120 health facilities in one South African metropolitan municipality (urban setting) and one facility in a rural setting). While this ensured that study participants had comparable demographic profiles throughout the different studies in this thesis, these findings may not be generalizable to other regions or municipalities in South Africa, or other country settings. However, the research included in this thesis have sufficient sample sizes to enhance the impact of the findings. Furthermore, the magnitude and direction of the impact remained consistent throughout all chapters, indicating that the study results may be strong despite constraints associated with the study's conditions. Utilizing our study findings to enhance adherence intervention tactics is expected to enhance health outcomes and reduce the rate of patients transitioning to more intricate treatment alternatives, such as second-line and third-line ART regimens.Item Pelvic floor dysfunction in female patients at two academic hospitals in Johannesburg, three months post-pelvic fracture(University of the Witwatersrand, Johannesburg, 2024) Chopdat, Nazreen; Brandt, CorliaBackground: Research is sparse on PFD* in females who sustained a pelvic fracture in South Africa. This study aimed to determine PFD symptoms and associated factors among females aged 18 years three months post-pelvic fracture Method: A three-month quantitative longitudinal study was conducted over 19 months, at two South African teaching hospitals. History obtained from medical records and patient questioning; APFQ* used for PFD symptoms. Correlation tests and linear regression analysis were used. Results: Of 44 participants recruited, 37 completed the three-month follow-up. Median age was 37 (interquartile range 30.5-58) years. PVA* accounted for 87.50% of multiple fractures (P=0.040). Bladder and bowel dysfunction were most common, with sexual avoidance a significant outcome following pelvic trauma. The injury directly or indirectly limited sexual activity in 45.45% participants. Significant changes were noted in Total (p=0.0216), Bladder (p=0.0062) and Sexual (p=0.0087) domain APFQ scores from preinjury to three months post-injury; and between subacute and three months post-injury, APFQ* Total (p=0.0361), Bladder (p=0.0002) and Bowel (p<0.0001) domain scores. Prolonged urinary catheter use, increased risk for higher scores of bladder PFD* (n=37, r=0.1585). Factors associated with less PFD at three months included number of vaginal deliveries preinjury (p-value 0.026, coeff -2.77, (95%CI: - 5.17 to -0.36), and bedrest with non-weightbearing choice of treatment (p-value 0.046, coeff -4.00, 95% CI: -7.92 to -0.08). Conclusion: PFD is present prior to and at three months post pelvic fracture with an increase in frequency and severity at three months. Symptoms are most prevalent in the subacute phase. The results of this study support the relevance of screening for PFD* within the early period and at three months for females following orthopaedic trauma. Clinical implications: Screening for PFD should become standard practice for females’ post-pelvic fracture in hospital and during outpatient follow-ups. Duration of catheterisation should be justifiable. Screening for bladder dysfunction is pertinent in patients requiring prolonged catheterisation, and patients requiring less conservative management. Guidance on safety to return to sexual activity is important to include as vi part of routine follow-up orthopaedic sessions. Integrating PFD screening and management into standard orthopaedic practice can improve outcomes and quality of life of affected individuals.Item The association between poor sleep quality and cardiometabolic risk in HIV+ individuals and the general population living in a rural area of South Africa(University of the Witwatersrand, Johannesburg, 2024) Reddy, Tracy; Scheuermaier, Karine; Karstaedt, AlanStudies show that both poor sleep quality and HIV infection independently increase cardiometabolic risk (CMR). Additionally, poor sleep quality is common with HIV infection. Our study investigated whether HIV infection interacts with poor sleep quality to affect CMR in people living with HIV (PLWH) in a rural area of South Africa. We recruited 200 HIV+ participants and 200 controls from Qwa Qwa in Free State in South Africa and assessed their CMR, sleep quality, daytime sleepiness, risk of obstructive sleep apnoea and degree of depressive symptoms. Sleep quality (p = 0.15), daytime sleepiness (p = 0.31) and the cardiometabolic risk score (MetScore) (p = 0.93) were similar between HIV+ and control participants. Fewer HIV+ participants had a high risk of sleep apnoea (p = 0.019) but more HIV+ participants had symptoms of clinical depression (p = 0.0007). Poorer sleep quality in the HIV+ participants was associated with pain (p = 0.0006), more severe depressive symptoms (p<0.0001) and longer HIV duration (p = 0.011). However, HIV infection was not associated with a higher MetScore (p = 0.18) once age, sex and sleep and depression markers were adjusted for. Additionally, HIV infection increased the risk of hypertension (p = 0.016). HIV status did not interact with sleep quality (p = 0.32) to affect CMR. Our findings indicate that healthcare facilities should consider monitoring CMR factors in HIV+ individuals.Item Investigating Knowledge, Attitudes, and Perceptions of SARS-CoV-2 Vaccine Hesitancy among Pregnant Women in Soweto, South Africa(University of the Witwatersrand, Johannesburg, 2024) Maccarthy, Samuel Oluwasegun; Myburgh, NelliePregnant women face heightened risks of severe COVID-19 consequences, making vaccination vital for their protection. In South Africa, despite government initiatives, vaccine hesitancy persists among pregnant women, hindering widespread coverage. This study delves into the knowledge, attitudes, and perceptions of COVID-19 vaccines among 60 unvaccinated pregnant women in Soweto, South Africa. It aims to identify influencers shaping their vaccine decisions, addressing a critical gap in understanding hesitancy in this vulnerable group. Data from a validated questionnaire reveal diverse information sources, with media being primary. Safety concerns emerge as the foremost hesitancy factor, and "personal decision" is a key influencer. Applying the 3C Model, the study unveils crucial factors guiding pregnant women's COVID-19 vaccination choices, providing insights for targeted public health strategies to address hesitancy in this susceptible population.Item The Clinical Genomics of African Oesophageal Cancer(University of the Witwatersrand, Johannesburg, 2024) Ngundu, Nerija Lamantha; Mathew, Christopher; Penny, ClementIn South Africa, oesophageal cancer is responsible for the 6th highest cancer-related deaths, with oesophageal squamous cell carcinoma (OSCC) being the most prevalent type at an incidence rate of 8.6/cases/100,000 for males and 4.7/cases/100,000 for females. It is often diagnosed at a late stage due to its asymptomatic nature, making it too late for any form of therapeutic interventions to be introduced. Information regarding the genetics of this disease on the African continent is limited, even more so in South Africa. This makes the task of identifying molecular markers, development of diagnostic and monitoring tools quite difficult. Therefore, the aim of this study was to identify the somatic mutation profiles of African patients with OSCC, thereby assisting in the expansion of knowledge regarding the genomic landscape as well fostering the development of molecular markers that could be useful in the diagnosis and treatment of this cancer. This was done by isolating DNA from blood, saliva and tumour samples and conducting whole exome sequencing (WES) on 21 matched blood/OSCC tumour samples. Data analysis was performed using R. The WES from 21 matched blood/tumour pairs revealed that somatic single nucleotide variants (SNV) were much more prevalent in comparison to somatic insertions or deletions (indels). The tumour mutation burden (TMB) was ~2 mutations per Mb. Tumour Protein 53 (TP53) was the most commonly mutated gene with 11 of the 12 mutations occurring in the DNA binding domain of the protein. Mutations in TP53, Titin (TTN) and Mucin 19 (MUC19) suggested that these genes were involved in relatively early events in the development of the tumours. Analysis of copy number alterations revealed a high degree of complexity in the tumour genome, with frequent amplification detected on chromosomes 1p33, 11q23.3 and 21q22.2, and common regions of deletion on chromosomes 5q31.2 and 7q32.3. Three mutational signatures were identified and the molecular pathway analysis showed that the NOTCH, RTK-KAS, and TP53 pathways were the most significantly altered pathways. The alterations discovered in this study have contributed to the greater scheme of the molecular landscape of OSCC.Item Internal migration and sexual partnerships and practices: Findings from a South African Cohort(University of the Witwatersrand, Johannesburg, 2024) Nyanisa , Yandisa; Ginsburg, Carren; Levin, JonathanIntroduction There are high levels of geographic movement of people within South Africa’s borders, especially from rural to urban areas of the country. Such movements have an impact on sexual partnerships and practices. The aim of this study is to determine the relationship between internal migration and sexual partnerships and practices in a cohort of migrants and residents of the Agincourt study site (non-migrants) in South Africa’s rural northeast over two survey waves from 2018 to 2019. Methods This study used data from the Migrant Health Follow-Up Study (MHFUS) which commenced in 2017. The MHFUS is a 5-year cohort study that is nested within the Agincourt Health and Demographic Surveillance System (HDSS) longitudinal research platform. The cohort is based on a simple random sample of 3800 Agincourt HDSS residents and migrants aged 18 – 40. The Agincourt HDSS is located in a 420 square kilometre area of the Bushbuckridge district, Mpumalanga Province. Descriptive statistics, logistic and ordinal regression models were used to describe the characteristics of migrants and non-migrants in the cohort as well as sociodemographic factors associated with the number of sexual partners reported by participants, their type of recent sexual partners (whether a partner was regular or casual) and their calculated risk score (based on condom use and HIV testing). Results Sexual partnerships and practices differed by migration status and gender. A larger proportion of migrants than non-migrants had more than one partner in the last 12 months in both study waves. Of those migrants who had sexual partners in the last 12 months (n=1265), 11.2% had partners in both their place of origin and their current place of residence (migrant destination) in Wave 1. Nine or more total sexual life partners were reported more frequently by migrants (16.8%) compared to non-migrants (8.9%) in Wave 1. More males (31.6%) than females (5.3%) had two or more partners in Wave 1 and there were more males (15.6%) who reported having partners in iii both the origin and current locations compared to females (4.9%). Not using a condom was more common among non-migrants than migrants in both waves, with females being less likely to have used a condom in their last sexual intercourse compared to males. Ordinal logistic regression analysis indicated that the number of sexual partners in the last 12 months was associated with migration status, age, gender and employment status in Wave 1, while in Wave 2 it was also associated with level of education. Most recent partner (whether a partner was regular or casual) was associated with gender, education and employment in Wave 1 while associated with age, gender and employment in Wave 2. Risk score was associated with age and education in Wave 1 while associated with migration status, age, gender and education in Wave 2. Conclusion The study showed that sexual partnerships and practices differed by migration status and gender with non-migrants and females reporting more risky sexual practices compared to migrants and males. Internal migration can introduce risky behaviors that are related to sexual partnerships and practices. The study shows that the effect of migration can vary widely depending on factors such as gender dynamics, employment and education. A study of the relationship between internal migration and sexual relationships sheds light on this population's possible susceptibility to HIV/STIs. The evidence in this study also adds to the knowledge base needed for guidance in areas of prevention of STI, while future South African research focused on sexual partnerships and practices should incorporate measures of migration. Understanding these factors is essential for researchers, policymakers and health organizations involved in managing and providing support to migrants.Item The association between substance use and HIV in two Sub-Saharan African countries, 2014 - 2016(University of the Witwatersrand, Johannesburg, 2024) Jack, Samantha Louise; Mall, SumayaBackground People Living With HIV/AIDS (PLWHA) are recognized to have an increased risk of substance abuse - alcohol heavy episodic drinking (HED), tobacco smoking, and illicit drugs. Substance use amongst PLWHA is associated with poorer antiretroviral treatment (ART) adherence, increased risk of cancers, and worse morbidity and mortality. Substance use is also associated with an increased risk of HIV infection amongst those who are HIV negative. The majority of this research is focused outside of the African continent and in high-income countries; thus, this study aims to contribute towards research in low-middle income African countries such as South Africa and Kenya. Aim This study aims to investigate the association between HIV and substance use in South Africa and Kenya, and the possible associated covariates. Methods The study population for this secondary data analysis included n=7919 men and women participants drawn between the ages of 40 and 60 recruited between August 2013 and August 2016. The Mann-Whitney test was used for continuous variables and all other categorical variables were analysed using a chi squared test or Fisher’s exact test. Predictive factors for the logistic regression models were informed by the literature review and conceptually modelled using a Direct Acyclic Graph. An overall logistic regression model was run which included both countries, and then separate logistic regression models were run for Kenya and South Africa. Results The prevalence of substance use in the overall sample was 54.30%. In Kenya it was 51.33% and in South Africa (SA) 55.60%. The prevalence of HIV in the overall sample was 20.94%. In Kenya HIV prevalence was 13.66%, and in SA 23.35%. PLWHA had a 1.22 greater odds of substance use than those who were HIV negative in the overall sample (p=0.012, 95%CI 1.04 - 1.43). In Kenya, PLWHA had a 1.49 higher odds of substance use (p=0.013, 95%CI 1.09 - 2.03). In SA, there was no significant association found between HIV status and substance use. In the Kenyan logistic model HIV status, sex, marital status and employment status were found to be associated with substance use. Full-time employment and marriage presented as protective factors against substance use in Kenya. In the SA logistic model age, sex, marital status and employment status were associated with substance use. Marriage was also a protective factor for the SA model. Self-employment and informal employment increased the odds of substance use by more than two-fold in the SA model (aOR=2.27, p<0.001, 95%CI 1.63-3.16; aOR= 1.50, p=0.0008, 95%CI 1.19-1.91 respectively). The factor with the largest odds for substance use across all three models was being male, with increased odds of 15.5 in the overall model (p<0.0001, 95%CI 13.4-17.9), 11.6 in Kenya (p<0.0001, 95%CI 8.65-15.5) and 17.7 in South Africa (p<0.0001, 95%CI 14.9-21.1). Conclusion Treatment of substance use disorders should become a staple in integrated routine ART care as the prevalence of substance use in PLWHA in this study and across the literature is high, especially in men The implementation of the substance use treatment should be tailored to the unique gendered and socioeconomic factors that are present in each country.Item HIV-exposure as a risk factor for mortality among neonates with culture- confirmed bloodstream infection and meningitis in South Africa, 2019- 2020(University of the Witwatersrand, Johannesburg, 2024) Marumo, Andani Ronel; Musenge , Eustasius; Mashau, RudzaniBackground: HIV-exposed but uninfected neonates (HEU) are a growing population. Exposure to HIV has been associated with increased mortality and morbidity. We aimed to determine the effect of HIV-exposure as a risk factor for mortality in neonates admitted with bloodstream infections (BSIs) and/or meningitis at non-academic hospitals in South Africa. Methods: We conducted a retrospective cohort study using data from the Baby GERMS-SA surveillance project of hospitalised neonates with culture-confirmed BSI and meningitis at six non-academic hospitals in South Africa from October 2019 to September 2020. A multivariable Cox proportional hazards regression was used to determine the effect of HIV- exposure regardless of HIV-status as a risk factor for mortality. We further examined the effect of HIV-exposure using a multivariable logistics regression. Results: Of 697 neonates with a known maternal HIV status and in-hospital outcome, 34% (239/697) were exposed to HIV and 1% (4/239) were HIV PCR-positive. The HEU neonates had significant low gestational age (77% (184/239) vs. 66% (296/458), p=0.001) and very low birth weight (48% (115/239) vs. 40% (184/458), p=0.016) compared to HIV-unexposed uninfected (HUU) neonates. Exclusive breastfeeding was more common in HUU neonates (44% (202/458) vs. 32% (77/239)). We did not observe significant differences in age at the time of infection (median age 6 vs. 6 days p=0.14), and duration of hospitalisation (median length of 17 vs. 15 days p=0.12) between the HEU and HUU neonates. The crude in-hospital mortality among HIV-exposed neonates and HUU neonates was 26% (63/239) and 23% (104/458), respectively. After adjusting for relevant confounders such as birth weight, timing of infection, use of invasive devices, breastfeeding, and maternal age, there was no difference in the risk for mortality between HEU neonates and those who were HUU (HR 1.12, 95% CI: 0.76-1.67, p=0.549) at 28-days. The odds of mortality were 1.21 (95% CI 0.72–2.05, v p=0.467) times more among HEU neonates than among HUU neonates in the exploratory analysis. Conclusions: We did not find a difference in mortality between HEU and HUU neonates with culture-confirmed invasive infections in our study. Regardless of their HIV exposure status, approximately a quarter of these neonates died in hospital.Item Factors Associated with Uptake of HIV Testing Services among Men in South Africa(University of the Witwatersrand, Johannesburg, 2024) Khoza, Samson S.; Christofides, NicolaBackground: In 2016, the overall Human immunodeficiency virus (HIV) prevalence rate was estimated at 12,7% and the total number of people living with HIV was estimated at approximately 7,03 million in the South African population in 2016. The World Health Organization recommends that people know their HIV status by getting tested and those who are found to be HIV positive get initiated on treatment early. However, HIV testing rates are below the 90% target and reportedly lower among males in South Africa. Aim: The study aimed to investigate factors associated with HIV Counselling and Testing (HCT) among men aged 18-34 years in South Africa. Methods: The study is a cross-sectional study using secondary data from Testa Boy study conducted by the Centre for Communication Impact in collaboration with Genesis Analytics between April and May 2017. The primary study employed a three multistage sampling approach, where at the first, the country was stratified into nine provinces, with sample size proportional to the population size of each province. After that an initial sub-place (district) was selected randomly from each province. Households were then randomly selected from the enumeration area (EA) or Primary Sampling Unit (PSU) in each sub-place (township/village). Finally, following the household selection, one eligible respondent from each household was selected randomly to participate in the study using a KISH grid that was used to draw a sample of PSUs. Data was collected using a self-administered questionnaire. The primary study constituted of a total of 3,000 male and female participants across all provinces in South Africa. We restricted our study to 1, 388 male participants. The outcome variable of this study was “uptake of HIV Counselling and Testing in the past 12 months”. The data was analysed using Stata SE version 14. Both univariable and multivariable analyses were employed. Results: About 52% of total of 1,388 men had HCT uptake in the past 12 months. Rates of HCT uptake at the provincial level ranged from 41% and 60% with Western Cape recording the high levels and North-west recording the lowest levels. In the multivariable analyses, men residing in provinces outside of the Western Cape demonstrated significantly lower odds of HCT uptake. The odds of HCT uptake was significantly lower among men in the Eastern Cape (AOR0.33, 95%CI 0.33-0.94), Limpopo (AOR0.54, 95%CI 0.30-0.99) and North-west (AOR 0.43, 95%CI 0.22-0.83) compared to the men in Western Cape. Employed men were 1.34 times significantly more likely to receive HCT compared to unemployed men (AOR1.34, 95% CI 1.01-1.77, p=0.039). Middle income (AOR 1.51, 95% CI 1.01-2.27) and low-income men (OR 1.60, 95% CI 1.16-2.21) had significantly increased odds of HCT uptake than rich-income men. With regards to sexual history, men who did not report condom use at first (AOR 0.71, 95% CI 0.53-0.93) and at last sex (AOR 0.68, 95% CI 0.52-0.90) exhibited significantly reduced odds of HCT uptake compared to those who reported condom use. Knowing someone who is HIV positive (AOR 1.40, 95% CI 1.09-1.82) was significantly associated with increased HCT uptake among men. iii Conclusion: The study provides important insights into the patterns and determinants of HCT uptake among men in South Africa. Geographic residence emerged as a key factor, with men from most provinces outside Western Cape exhibiting substantially lower odds of HCT uptake compared to those in Western Cape. Risky sexual behaviours such as not using condoms during sexual intercourse were correlated with low HCT uptake. Targeted interventions, such as expanding community-based HCT initiatives, strengthening health system infrastructure in underserved areas and tailor-made combinations of prevention interventions such as HCT and condom prevention strategies could contribute to increased HCT uptake and better control of the HIV epidemic in the country.