Feasibility of introducing a comprehensive package of antenatal care services in rural public clinics in South Africa

The Maternal, Child and Women’s Health Unit, in collaboration with the Population Council’s FRONTIERS in Reproductive Health (FRONTIERS) program, the Reproductive Health Research Unit of the University of Witwatersrand, and the Department of Medical Microbiology and Infectious Diseases of the Nelson Mandela School of Medicine, University of Natal, developed and then pilot-tested this revised model in KwaZulu-Natal, South Africa. The project’s objective was to develop and test an improved and integrated antenatal care program for public-sector clinics that would increase the range and quality of services received by pregnant women and improve their reproductive health behavior and status. Various problems, such as trainer and staff turnover, were encountered during and immediately after introduction that influenced the clinics’ capacity to implement and sustain the reorganized services. This implies that efforts to scale-up or replicate this model must consider such resource issues, and that other support systems, such as staff supervision and educational materials, also need attention. It is possible to conclude, however, that interventions such as this, that rely heavily on training staff in new ways of organizing and providing services, must develop and use training and supervisory strategies or systems that are explicitly designed to incorporate relatively rapid rates of staff turnover. This study also highlights the importance of paying attention to health systems when introducing revised or new services, especially HIV-related services

Feasibility, Acceptability, Effectiveness and Cost of Models of Integrating HIV Prevention and Counseling and Testing for HIV within Family Planning Services

This study is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN-A-00-98-00012-00 and In-house project 8811 53089. The contents are the responsibility of the FRONTIERS Program and do not necessarily reflect the views of USAID or the United States Government. ACKNOWLEDGEMENTS The activities reported in this document were accomplished due to the important contributions from various institutions and individuals. We wish to acknowledge the following officials who have played critical roles in the process of implementing the study on the integration of C&T within FP services: Members of the Department of Health, North West Province; Maternal and Child Health, Bojanala Region; and the clinics that actively participated in the study. From the Department we want to thank in particular Ms. Pat Chueu, Mr. N. Matjila, Ms. Dikobe, Ms. Mangezi, Mr. D. Baloyi and Mrs. M. Jordan, and all District Supervisors. Special thanks go to the District Information Officers and Lifeline for assisting in the availability of the data, and field workers who conducted the community data collection component of the study. We also want to thank the retired nurses who were extraordinarily helpful in the client-provider interactions

Feasibility, acceptability, effectiveness and cost of models of integrating HIV prevention and counseling and testing for HIV within family planning services in North West Province, South Africa

The Population Council’s USAID-funded Frontiers in Reproductive Health (FRONTIERS) Program, in collaboration with the National Department of Health and the North West Provincial Department of Health and with support from PEPFAR, initiated a two-phased operations research study to test the acceptability, feasibility, and cost of two different models of integration of counseling and testing for HIV into family planning services in South Africa and to evaluate their effectiveness against standard practice. Based on the studies findings, the report concludes that the integration of HIV prevention activities, including education about prevention, dual protection, and counseling and testing within FP services in public facilities in South Africa is feasible and acceptable to both FP providers and clients. Use of the Balanced Counseling Strategy Plus tool is effective in improving the overall quality of care. Both the testing and referral models were acceptable and effective and so can be used interchangeably depending on client needs and preferences and the skills of the providers. Considering the policy context and the evidence from this study, a number of specific recommendations are proposed

Mapping a Syndemic of Psychosocial Risks During Pregnancy Using Network Analysis

Background: Psychosocial risks during pregnancy impact maternal health in resource-limited settings, and HIV-positive women often bear a heavy burden of these factors. This study sought to use network modeling to characterize co-occurring psychosocial risks to maternal and child health among at-risk pregnant women. Methods: Two hundred pregnant HIV-positive women attending antenatal care in South Africa were enrolled. Measured risk factors included younger age, low income, low education, unemployment, unintended pregnancy, distress about pregnancy, antenatal depression, internalized HIV stigma, violence exposure, and lack of social support. Network analysis between risk factors was conducted in R using mixed graphical modeling. Centrality statistics were examined for each risk node in the network. Results: In the resulting network, unintended pregnancy was strongly tied to distress about pregnancy. Distress about pregnancy was most central in the network and was connected to antenatal depression and HIV stigma. Unintended pregnancy was also associated with lack of social support, which was itself linked to antenatal depression, HIV stigma, and low income. Finally, antenatal depression was connected to violence exposure. Conclusions: Our results characterize a network of psychosocial risks among pregnant HIV-positive women. Distress about pregnancy emerged as central to this network, suggesting that unintended pregnancy is particularly distressing in this population and may contribute to further risks to maternal health, such as depression. Prevention of unintended pregnancies and interventions for coping with unplanned pregnancies may be particularly useful where multiple risks intersect. Efforts addressing single risk factors should consider an integrated, multilevel approach to support women during pregnancy

PMTCT Adherence in Pregnant South African Women: The Role of Depression, Social Support, Stigma, and Structural Barriers to Care

Pregnant South African women living with HIV who experienced more depressive symptoms and stigma were less likely to report social support, which may impact antiretroviral medication adherence

Breastfeeding Practices Among Women Living with HIV in KwaZulu-Natal, South Africa: An Observational Study

Introduction Exclusive breastfeeding (EBF) is the safest infant feeding option in resource-limited settings, though women living with HIV have the lowest rates of EBF. Barriers to EBF in the absences of a formal intervention in women living with HIV in KwaZulu-Natal, where the prevalence of HIV among pregnant women is among the highest in the world, are understudied. Thus, this study sought to describe barriers to EBF and examine differences in social support, disclosure status, mood, and HIV-related stigma among women with different feeding methods. Methods Women living with HIV enrolled in preventing mother-to-child transmission treatment (n = 156) were interviewed postpartum (M = 13.1 weeks) at a district hospital and self-reported infant feeding method, reasons not breastfeeding (if applicable), and HIV disclosure status. Mood, HIV-related stigma, functional social support, and HIV-related social support were also assessed. Results No participants reported mixed feeding, 30% reported EBF, and 70% reported exclusive formula feeding. Commonly reported reasons for not breastfeeding included fear of HIV transmission to the infant and being away from the infant for extended periods of time. Social support (p = 0.02) and HIV-related social support (p \u3c 0.01) were significantly higher in women who had attempted breastfeeding compared to women who never attempted breastfeeding. Discussion Rates of EBF in this sample are lower than in other recent studies, suggesting this sample experiences multiple barriers to EBF. Healthcare providers should seek to correct misconceptions regarding HIV transmission and breastfeeding practices. Social and logistical support for EBF may be important considerations for future interventions

“I am scared, I do not want to lie”: exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa

Abstract Background COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. Methods A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. Results Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. Conclusions About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing

Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings

Men living with HIV ( MLWH ) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: ( 1 ) safer conception care acceptability is high but structural barriers challenge participation; ( 2 ) communication skills trainings helped overcome barriers to disclose serostatus; ( 3 ) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners

Trajectories of Initiation for the Heroin-based Drug Whoonga – Qualitative Evidence from South Africa

Background: Whoonga is a smoked heroin-based street drug that first emerged in South Africa a decade ago. While previous scientific reports suggest that use is growing and youth are particularly vulnerable, trajectories of initiation are not well characterized. Methods: In 2015, 30 men undergoing residential addiction treatment for this smoked heroin drug in KwaZulu-Natal, South Africa participated in semi-structured interviews about their experiences using the drug. Interview data were coded using qualitative content analysis. Results: Participant trajectories to initiating smoked heroin were “vertical” in the context of marijuana use or “horizontal” in the context of other hard drug use. Participants reporting vertical trajectories began smoking heroin as youth at school or in other settings where people were smoking marijuana. Several participants with horizontal trajectories started smoking heroin to address symptoms of other drug or alcohol addiction. Social influences on initiation emerged as an overarching theme. Members of participants’ social networks who were smoking or distributing heroin figured prominently in initiation narratives. Surprisingly, references to injection drug use were absent from initiation narratives. Participants reported people who smoke heroin differ from those who inject heroin by race. Conclusion: Consistent with theories implicating social and structural influences on substance use initiation, people who started smoking heroin had social contacts who smoked heroin and frequented places where substance use was common. Smoked heroin initiation for several participants with horizontal trajectories may have been averted if they accessed evidence-based treatments for stimulant or alcohol use disorders. With increasing reports of heroin use across Africa, a coordinated approach to address this growing epidemic is needed. However, because smoked heroin and injection heroin use occur in distinct risk environments, interventions tailored to people who use smoked heroin will be needed to prevent smoked heroin use, prevent transition to injection use, and mitigate other social harms