Behavioral and cognitive interventions to improve treatment adherence and access to HIV care among older adults in sub-Saharan Africa: an updated systematic review

BACKGROUND: Approximately 14% of Africans infected with HIV are over the age of 50, yet few intervention studies focus on improving access to care, retention in care, and adherence to antiretroviral therapy (ART) in this population. A review of the published literature until 2012, found no relevant ART management and care interventions for older people living with HIV (OPLHIV) in sub-Saharan Africa. The aim of this systematic review is to update the original systematic review of intervention studies on OPLHIV, with a focus on evidence from sub-Saharan Africa. METHODS: We conducted a systematic review of the available published literature from 2012 to 2017 to explore behavioral and cognitive interventions addressing access to ART, retention in HIV care and adherence to ART in sub-Saharan Africa that include older adults (50+). We searched three databases (MEDLINE, EMBASE, and Education Resources Information Center) using relevant Medical Subject Headings (MeSH) terms as well as a manual search of the reference lists. No language restrictions were placed. We identified eight articles which were analyzed using content analysis with additional information obtained directly from the corresponding authors. RESULTS AND DISCUSSION: There were no studies that exclusively focused on OPLHIV. Three studies referred only to participants being over 18 years and did not specify age categories. Therefore, it is unclear whether these studies actively considered people living with HIV over the age of 50. Although the studies sampled older adults, they lacked sufficient data to draw conclusions about the relevance of the outcomes of this group. CONCLUSIONS: These findings underscore the need to increase the evidence-base of which interventions will work for older Africans on ART

Successfully controlling malaria in South Africa

Following major successes in malaria control over the past 75 years, South Africa is now embarking on a malaria elimination campaign with the goal of zero local transmission by the year 2018. The key control elements have been intensive vector control, primarily through indoor residual spraying, case management based on parasitological diagnosis using evidence-based drug policies with artemisinin-based combination therapy since 2001, active health promotion in partnership with communities living in the malaria transmission areas, and cross-border collaborations. Political commitment and long-term funding for the malaria control programme have been a critical component of the programme’s success. Breaking the cycle of transmission through strengthening of active surveillance using sensitive molecular tests and field treatment of asymptomatic persons, monitoring for antimalarial drug resistance and insecticide resistance, strengthening cross-border initiatives, and ongoing programme advocacy in the face of a significant decrease in disease burden are key priorities for achieving the elimination goal.http://www.samj.org.zaam201

Mastering your Fellowship

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the FCFP(SA) examination. The series aims to help family medicine registrars and their supervisors prepare for this examination. Model answers are available online

Therapeutic efficacy of sulfadoxine-pyrimethamine in uncomplicated Plasmodium falciparum malaria 3 years after introduction in Mpumalanga

No Abstrac

Increased gametocytemia after treatment: an early parasitological indicator of emerging sulfadoxine-pyrimethamine resistance in falciparum malaria.

BACKGROUND: Although malaria treatment aims primarily to eliminate the asexual blood stages that cause illness, reducing the carriage of gametocytes is critical for limiting malaria transmission and the spread of resistance. METHODS: Clinical and parasitological responses to the fixed-dose combination of sulfadoxine and pyrimethamine in patients with uncomplicated falciparum malaria were assessed biannually since implementation of this treatment policy in 1998 in Mpumalanga Province, South Africa. RESULTS: Despite sustained cure rates of > 90% (P = .14), the duration of gametocyte carriage increased from 3 to 22 weeks (per 1000 person-weeks) between 1998 and 2002 (P < .001). The dhfr and dhps mutations associated with sulfadoxine-pyrimethamine resistance were the most important drivers of the increased gametocytemia, although these mutations were not associated with increased pretreatment asexual parasite density or slower asexual parasite clearance times. The geometric mean gametocyte duration and area under the gametocyte density time curve (per 1000 person-weeks) were 7.0 weeks and 60.8 gametocytes/microL per week, respectively, among patients with wild-type parasites, compared with 45.4 weeks (P = .016) and 1212 gametocytes/microL per week (P = .014), respectively, among those with parasites containing 1-5 dhfr/dhps mutations. CONCLUSIONS: An increased duration and density of gametocyte carriage after sulfadoxine-pyrimethamine treatment was an early indicator of drug resistance. This increased gametocytemia among patients who have primary infections with drug-resistant Plasmodium falciparum fuels the spread of resistance even before treatment failure rates increase significantly

Assessing changes in adolescent girls’ and young women’s sexual and reproductive health service utilisation following a COVID-19 lockdown in eSwatini

The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls’ and young women’s (AGYW; aged 15–24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini’s electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW’s SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period

Using a geographical information system to plan a malaria control programme in South Africa

INTRODUCTION: Sustainable control of malaria in sub-Saharan Africa is jeopardized by dwindling public health resources resulting from competing health priorities that include an overwhelming acquired immunodeficiency syndrome (AIDS) epidemic. In Mpumalanga province, South Africa, rational planning has historically been hampered by a case surveillance system for malaria that only provided estimates of risk at the magisterial district level (a subdivision of a province). METHODS: To better map control programme activities to their geographical location, the malaria notification system was overhauled and a geographical information system implemented. The introduction of a simplified notification form used only for malaria and a carefully monitored notification system provided the good quality data necessary to support an effective geographical information system. RESULTS: The geographical information system displays data on malaria cases at a village or town level and has proved valuable in stratifying malaria risk within those magisterial districts at highest risk, Barberton and Nkomazi. The conspicuous west-to-east gradient, in which the risk rises sharply towards the Mozambican border (relative risk = 4.12, 95% confidence interval = 3.88-4.46 when the malaria risk within 5 km of the border was compared with the remaining areas in these two districts), allowed development of a targeted approach to control. DISCUSSION: The geographical information system for malaria was enormously valuable in enabling malaria risk at town and village level to be shown. Matching malaria control measures to specific strata of endemic malaria has provided the opportunity for more efficient malaria control in Mpumalanga province

An Evaluation of the Level of Integration and Alignment of the Malabo Commitments

The Sustainable Development Goals (SDGs) have introduced greater integration of development objectives across traditional sectors. This integration is also reflected in Africa’s Agenda 2063 vision for development. Africa’s agricultural and food security initiatives through the 2003 Comprehensive African Agricultural Development Programme (CAADP) seeks to achieve the goals of Agenda 2063 and contribute to the achievement of the SGDs. This commitment is set out in the 2014 Malabo Declaration on Accelerated Agricultural Growth and Transformation for Shared Prosperity and Improved Livelihoods. The African Union recently (2017) established a Biennial Review (BR) mechanism to support the implementation of the Malabo Declaration and hold countries accountable for making progress on the commitments. Currently, many African countries are revising their first five-year CAADP implementation plans and drafting their second five-year National Agriculture and Food Security Investment Plans (or NAIP IIs) in line with the Malabo commitments. This paper set out to assess ten NAIP IIs from the perspective of the indicator sets contained in the NAIPs against the BR, the First 10-year Implementation Plan of the African Union’s Agenda 2063 (2014 to 2023) and the SDG’s. The research was conducted in three steps. i. An assessment of the NAIP monitoring and evaluation frameworks of ten available NAIPs to determine the alignment between: a. Country NAIPs and the BR indicators, b. Country NAIPs and Agenda 2063’s First 10-year Implementation Plan (2014-2023) indicators, c. Country NAIPs and the SDG indicators with a specific focus on food security and nutrition elements, ii. The identification of novel and innovative practices and indicators and establish where there are gaps that could be improved; and iii. Documenting the insights gained from the analysis and drafting of suggestions to improve the design of monitoring and evaluation frameworks in relation to food security and nutrition components of development programmes across the world. We find that the NAIP monitoring and evaluation frameworks were generally compliant with the SDG indicators that were directly related to agriculture and food security. However, they do not exploit the opportunities to align in the areas of the SDGs that address some of the core aspirations of the CAADP agenda – seeking to advance agricultural transformation to reduce poverty, inequality and unemployment. Furthermore, a misalignment exists between the monitoring and evaluation frameworks of the NAIPs, the indicators of the BR and the first ten-year implementation plans for Agenda 2063. At a minimum, alignment of the NAIP indicators with the BR could provide more comprehensive coverage of indicators that generally overlap with both Agenda 2030 and the First 10-year Implementation Plan (2014 – 2023) of Agenda 2063. However, the BR could be strengthened from closer alignment with the SGDs and in some areas, adopting the broader specifications in the SDGs could lend more direction to the BR indicators and the CAADP process in general. For example, the SDGs include monitoring of the incomes of smallholders and the reduction in the rate of unemployment among vulnerable groups (including youth). In addition, a significant number of indicators were included in the NAIPs that were not in the BR and could be considered in improving the BR indicator set. Some countries adopted a more progressive approach to designing their monitoring and evaluation frameworks, resulting in a higher proportion of indicators aligned with the three indicator sets. The lack of appreciation of the full scope of food security (beyond production) led to an imbalanced focus on production by some countries. Malawi and Liberia responded well to interventions by the team and improved their indicator set. As is evident from this analysis, country-level planning does not seem to take into account the international and African transversal sectoral frameworks in the drafting of policies, legislation, strategies and action plans. An insufficient number of indicators focussed on the impact indicators of the CAADP] Results Framework, namely wealth creation; food security and nutrition; economic opportunities, poverty alleviation and shared prosperity; and resilience and sustainability. Although the second highest performance area coverage was in resilience to climate change, the focus in the BR on climate change meant the NAIPs neglected other elements of resilience related to food security, peace and migration. There is room for improvement in the inclusion of more food security and related indicators, shifting the focus to the inclusion of impact indicators. We recommend a review of the drafting process and the composition of the drafting team to ensure that NAIP II monitoring and evaluation frameworks include a comprehensive, integrated indicator set that is aligned with the BR, Agenda 2063’s First 10-year Implementation Plan (2014 – 2023) and the SDGs. Clearer guidance, supported by oversight and the development of enhanced guidance tools and regular updates (such as the NAIP toolkit) are essential to support country teams in their efforts, especially in view of the rapidly changing circumstances and events such as the passing of new agreements that affect the policy context (such as the recently signed African Free Trade Agreement). The findings of the analysis raise the need for considerably more training on the BR, the design of the NAIP monitoring and evaluation and the alignment of these with Agenda 2063 and the SGDs to ensure alignment and compliance, as well as improve the quality of reporting across the transversal development space. Mid-term reviews of the NAIPs and their monitoring and evaluation frameworks could provide opportunities for updating and strengthening the frameworks and aligning these more closely with the First 10-year Implementation Plan (2014 – 2023) of Agenda 2063 and the SDGs. Although we have not analysed the alignment of the NAIP monitoring and evaluation frameworks with the individual countries’ long-term national development plans and medium-term (five years) Growth and Development Strategies (GDSs; sometimes referred to as Medium Term Strategic Frameworks (MTSFs), this is an area for further analysis and assessment