Implementing and scaling-up Stepping Stones in KwaZulu-Natal, South Africa: Lessons from working in informal settlements

KwaZulu-Natal (KZN), a major epicenter of the South African HIV epidemic, has large informal settlements where thousands of people live. The settlements are often underserved by municipal services and lack accessible health care. Given high rates of HIV, there is a critical need to assess the successes and challenges of implementing HIV prevention and treatment in this context. Stepping Stones is a widely used life-skills training intervention focused on curbing gender-based violence and reducing HIV risk. The program addresses issues such as communication about HIV, relationship skills, and assertiveness. The manual-based curriculum encourages participants to engage in critical reflection through role-playing and group dialogue. Previous evaluations of Stepping Stones in South Africa found significant reductions in intimate partner violence and herpes simplex virus-2, and improvements in couple communication and negotiation. Under Project SOAR, the Population Council and the MatCH Research Unit of the University of the Witwatersrand conducted program evaluations in 18 selected informal settlements in KZN. This brief focuses on the experiences, challenges, successes, and perceived effects of implementing (and scaling up) Stepping Stones in the informal settlement setting

Dual protection against sexually transmitted infections and pregnancy in South Africa

Promotion of simultaneous protection against sexually transmitted infections (STIs) and unintended pregnancy, referred to as dual protection, represents an important public health intervention. We investigated its prevalence and correlates in South Africa. A cross-sectional survey of 929 sexually active women, aged 15-49 years, was conducted in 89 public primary health care clinics, with dual method use and use of condom alone at last sexual intercourse as outcomes. At last intercourse, 12% of women were protected from both STIs and pregnancy. In multivariate analysis, higher education, being unmarried, and multiple sex partnership in the past year were predictors of dual method use, while younger age, higher education and awareness of the dual function of condoms were predictors of condom use alone. Dual protection is low in this population. The predominance of hormonal contraceptive use in South Africa means that increasing barrier method use among hormonal contraceptive users is an important strategy for increasing dual protectio

Ever and repeat HIV testing rates among male and female clients: Findings from a reproductive health services integration project in South Africa

Background. HIV testing rates have increased in recent years. Repeat testing is recommended to identify and treat new HIV infections timeously. However, there are limited data on repeat HIV testing, especially in South Africa (SA).Objectives. To provide data on repeat HIV testing rates in males and females in a district in SA.Methods. A sexual and reproductive health (SRH) service integration model was implemented in seven healthcare facilities in eThekwini District, KwaZulu-Natal Province, SA, between 2009 and 2011. HIV testing data were collected from male and female clients attending these facilities, prior to (baseline) and after the implementation (endline) of the 3-year health services integration intervention.Results. There were 230 clients at baseline (195 female, 35 male) and 200 at endline (169 female, 31 male). High ever-tested rates were reported at baseline (females 95.4%, males 74.3%) and endline (females 91.7%, males 87.1%), with large increases in male testing rates over time. In addition, high increases were seen between baseline and endline among those who had tested more than once and more than twice in their lifetime. Increases between baseline and endline testing rates were highest in HIV testing services (HTS) (37.0 - 93.3% for clients who had tested more than once, and 11.1 - 53.3% for those who had tested more than twice).Conclusions. HIV testing and repeat testing increased over time, especially in males and in HTS. Promotion and integration of SRH services are critical to facilitate improved health-seeking behaviour and HIV testing of both male and female clients. They are also important for continued access to HTS at multiple service delivery points

Acceptability of the female condom in different groups Of women in South Africa-A Multicentred study to inform the national female condom introductory strategy

Objectives. To assess the acceptability of the female condom to different groups of women and their partners in South Africa.Design. Descriptive, cross-sectional study.Setting. Multicentre study conducted in five sites.Subjects. The study recruited 678 women from five centres to an acceptability trial of the female condom. Acceptability and successful use varied between the centres. Outcome measures. Factors affecting successful use and willingness and intention to use the method again.Results. In total, 209 women used the condom at least once. Discontinuation rates were high, with partner reluctance to try the method as the main reason given for discontinuation at all sites. Women who had previous experience with the male condom or who received a more intensive training session generally found the device easier to use. The main issues concerning women were over-lubrication (27%) and concern that the device was too large (28%). The majority of women said that they would be interested in using the method again (86%) and would recommend it to friends (95%).Conclusions. Overcoming partner opposition is an important issue to address when introducing the method. The study was used to address the national introductory strategy of the female condom, which began in 1998

Acceptability of the female condom in different groups of women in South Africa - A multicentred study to inform the national female condom introductory strategy

Objectives. To assess the acceptability of the female condom to different groups of women and their partners in South Africa. Design. Descriptive, cross-sectional study. Setting. Multicentre study conducted in five sites. Subjects. The study recruited 678 women from five centres-to an acceptability trial of the female condom. Acceptability and successful use varied between the centres. Outcome measures. Factors affecting successful use and willingness and intention to use the method again. Results. In total, 209 women used the condom at least once. Discontinuation rates were high, with partner reluctance to try the method as the main reason given for discontinuation at all sites. Women who had previous experience with the male condom or who received a more intensive training session generally found the device easier to use. The main issues concerning women were over-lubrication (27%) and concern that the device was too large (28%). The majority of women said that they would be interested in using the method again (86%) and would recommend it to friends (95%). Conclusions. Overcoming partner opposition is an important issue to address when introducing the method. The study was used to address the national introductory strategy of the female condom, which began in 1998

Cost of a diagonal sexual and reproductive health package to enhance reproductive health among female sex workers in Durban, South Africa

Background and objectives: In response to HIV epidemic in Sub- Saharan Africa, there has been widespread concern about the structure and delivery of Sexual Reproductive Health (SRH) and HIV services to improve outcomes among high-risk groups, including sex workers. The ‘Diagonal Interventions to Fast-Forward Enhanced Reproductive health’ (DIFFER) project was conceptualised based on the hypothesis that integrating vertical SRH interventions targeted to FSW, with horizontal health systems strengthening, is likely to be more effective and cost-effective than current practice. The aim of the study was to measure the cost of designing and delivering a SRH package for female sex workers in Durban, South Africa, as part of the DIFFER project. / Methods: We measured the total and incremental costs of the DIFFER intervention package in Durban from a provider perspective, using a combination of ingredients and activity based costing approaches. An excel-based data capture tool was developed to collect the intervention package cost data. The intervention costs were collected prospectively from the project accounts of the implementing agencies and costs to the public health providers were collected via key informant interviews using a cost data capture form and subsequently entered into the spreadsheet. The total and average annual costs, as well as total and average annual costs per sex worker covered were estimated. All costs were adjusted for inflation, discounted and converted to 2016 International dollar. / Results: Total and average annual program costs of implementing the DIFFER intervention in Durban were INT$411,239 (INT$ 428,461, including services provided to the general population) and INT$256,594 (INT$ 273,816, including services provided to the general population) respectively. The total cost and average annual cost per sex worker covered were INT$117 and INT$ 73 respectively. Staff costs accounted for the largest proportion of the intervention cost, comprising more than 80% of the total cost, following by material and supplies, accounting for 10% of costs. / Conclusion: The DIFFER intervention package in Durban is a low cost intervention and likely to be cost-effective and sustainable. The intervention can be considered for replication and scale-up in South Africa and similar settings elsewhere

Acceptability of Condom Promotion and Distribution Among 10-19 Year-Old Adolescents in Mpwapwa and Mbeya Rural Districts, Tanzania.

\ud The HIV/AIDS pandemic remains a leading challenge for global health. Although condoms are acknowledged for their key role on preventing HIV transmission, low and inappropriate use of condoms persists in Tanzania and elsewhere in Africa. This study assesses factors affecting acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural districts of Tanzania. Data were collected in 2011 as part of a larger cross-sectional survey on condom use among 10-19 year-olds in Mpwapwa and Mbeya rural districts of Tanzania using a structured questionnaire. Associations between acceptability of condom promotion and distribution and each of the explanatory variables were tested using Chi Square. Multivariate logistic regression model was used to examine independent predictors of the acceptability of condom promotion and distribution using STATA (11) statistical software at 5% significance level. Mean age of the 1,327 adolescent participants (50.5% being males) was 13.5 years (SD = 1.4). Acceptance of condom promotion and distribution was found among 37% (35% in Mpwapwa and 39% in Mbeya rural) of the adolescents. Being sexually active and aged 15-19 was the strongest predictor of the acceptability of condom promotion and distribution (OR = 7.78, 95% CI 4.65-12.99). Others were; not agreeing that a condom is effective in preventing transmissions of STIs including HIV (OR = 0.34, 95% CI 0.20-0.56), being a resident of Mbeya rural district (OR = 1.67, 95% CI 1.28-2.19), feeling comfortable being seen by parents/guardians holding/buying condoms (OR = 2.20, 95% CI 1.40-3.46) and living with a guardian (OR = 1.48, 95% CI 1.08-2.04). Acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural is low. Effect of sexual activity on the acceptability of condom promotion and distribution is age-dependent and was the strongest. Feeling comfortable being seen by parents/guardians buying or holding condoms, perceived ability of condoms to offer protection against HIV/AIDS infections, district of residence and living arrangements also offered significant predictive effect. Knowledge of these factors is vital in designing successful and sustainable condom promotion and distribution programs in Tanzania.\u

Key informant perspectives on policy- and service-level challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa

BACKGROUND: Integration of sexual and reproductive health (SRH) and HIV services is a policy priority, both globally and in South Africa. Recent studies examining SRH/HIV integration in South Africa have focused primarily on the SRH needs of HIV patients, and less on the policy and service-delivery environment in which these programs operate. To fill this gap we undertook a qualitative study to elicit the views of key informants on policy-and service-level challenges and opportunities for improving integrated SRH and HIV care in South Africa. This study comprised formative research for the development of an integrated service delivery model in KwaZulu-Natal (KZN) Province. METHODS: Semi-structured in-depth interviews were conducted with 21 expert key informants from the South African Department of Health, and local and international NGOs and universities. Thematic codes were generated from a subset of the transcripts, and these were modified, refined and organized during coding and analysis. RESULTS: While there was consensus among key informants on the need for more integrated systems of SRH and HIV care in South Africa, a range of inter-related systems factors at policy and service-delivery levels were identified as challenges to delivering integrated care. At the policy level these included vertical programming, lack of policy guidance on integrated care, under-funding of SRH, program territorialism, and weak referral systems; at the service level, factors included high client load, staff shortages and insufficient training and skills in SRH, resistance to change, and inadequate monitoring systems related to integration. Informants had varying views on the best way to achieve integration: while some favored a one-stop shop approach, others preferred retaining sub-specialisms while strengthening referral systems. The introduction of task-shifting policies and decentralization of HIV treatment to primary care provide opportunities for integrating services. CONCLUSION: Now that HIV treatment programs have been scaled up, actions are needed at both policy and service-delivery levels to develop an integrated approach to the provision of SRH and HIV services in South Africa. Concurrent national policies to deliver HIV treatment within a primary care context can be used to promote more integrated approaches

Longitudinal experiences and risk factors for common mental health problems and suicidal behaviours among female sex workers in Nairobi, Kenya.

BACKGROUND: Female sex workers (FSWs) are at high risk of mental health problems and suicide risk. Few longitudinal studies have examined risk factors for poor mental health among FSWs. METHODS: Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme clinics across Nairobi. Behavioural-biological survey data were collected at baseline (n = 1003, June-December 2019), midline (n = 366) (Jan-March 2020) and endline (n = 877) (June 2020-Jan 2021). Women reporting mental health problems were offered counselling services. Multivariable mixed logistic regression models were used to examine factors associated with mental health problems and suicidal behaviours. RESULTS: There was a decline in the proportion of women reporting any mental health problem (depression and/or anxiety and/or PTSD) (baseline: 29.9%, midline: 13.3%, endline: 11.8%). There was strong evidence that any mental health problem was associated with recent hunger (aOR 1.99; 95% CI 1.37-2.88) and recent violence from non-intimate partners (2.23; 95% CI 1.55-3.19). Recent suicidal behaviour prevalence was similar across survey rounds (baseline: 10.2%; midline: 10.2%; endline: 10.4%), and was associated with recent violence from non-intimate partners (aOR 1.96; 95% CI 1.31-2.95), recent hunger (aOR 1.69; 95% CI 1.15-2.47) and having an additional employment to sex work (aOR 1.50; 95% CI 1.00-2.23). CONCLUSIONS: Our study found a decline in mental health problems but high levels of persistent suicidal behaviours among FSWs. Syndemic risk factors including food insecurity and violence were longitudinally associated with mental health problems and recent suicidal behaviours. There is a need for accessible mental health services for FSWs, alongside structural interventions addressing poverty and violence