Between HIV diagnosis and initiation of antiretroviral therapy: Assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa

BACKGROUND: While much is written about the scale up of HIV counselling and testing (HCT) and antiretroviral therapy (ART), little research has been done on the expansion of routine preART HIV care. OBJECTIVE: To assess the quality of preART care in Cape Town and its continuity with HCT and ART. METHODS: The scale up of the HCT, preART and ART service platform and programmatic support in Cape Town is described. Data from the August 2010 routine annual HIV/TB/STI evaluation, from interviews with 133 facility managers and a folder review of 634 HCT s who tested positive and 1115 clients receiving preART HIV care are analysed. RESULTS: Historically the implementation and management of preART care has been relatively neglected compared with the scale-up of HCT and ART. The CD4 count was done on 77.5% positive HCT clients and 46.6% were clinically staged - crucial steps that determine the care path. There were: gaps in quality of care - 32.2% of women had a PAP smear; missed opportunities for integrated care - 67% were symptomatically screened for tuberculosis; and positive prevention - 48.3% had contraceptive needs assessed. Breaks in the continuity of care of preART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service. CONCLUSION: While a package of preART care has been clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality service delivered that undermine the programme objectives of provision of positive prevention and timeous access to ART

Assessing the impact of a waiting time survey on reducing waiting times in urban primary care clinics in Cape Town, South Africa

A waiting time survey (WTS) conducted in several clinics in Cape Town, South Africa provided recommendations on how to shorten waiting times (WT). A follow-up study was conducted to assess whether WT had reduced. Using a stratified sample of 22 clinics, a before and after study design assessed changes in WT. The WT was measured and perceptions of clinic managers were elicited, about the previous survey’s recommendations. The overall median WT decreased by 21 minutes (95%CI: 11.77- 30.23), a 28% decrease from the previous WTS. Although no specific factor was associated with decreases in WT, implementation of recommendations to reduce WT was 2.67 times (95%CI: 1.33-5.40) more likely amongst those who received written recommendations and 2.3 times (95%CI: 1.28- 4.19) more likely amongst managers with 5 or more years’ experience. The decrease in WT found demonstrates the utility of a WTS in busy urban clinics in developing country contexts. Experienced facility managers who timeously receive customised reports of their clinic’s performance are more likely to implement changes that positively impact on reducing WT

Intimate partner violence: How should health systems respond?

Intimate partner violence (IPV) is a common and serious public health concern, worldwide and in South Africa. Exposure to IPV leads to wide-ranging and serious health effects, and there is evidence that intervening for IPV in primary healthcare settings can improve outcomes. World Health Organization guidelines for responding to IPV and sexual violence recommend enquiring about violence when relevant in healthcare encounters and providing women-centred care. Women who have experienced IPV have described an appropriate response by healthcare providers to be non-judgemental, understanding and empathetic. Despite this, the evidence base informing the scale-up of IPV interventions and their integration into health systems is lacking. Further evaluations of health sector responses to IPV are needed to assist health services to determine the most appropriate models of care and how these can be integrated into current systems. The need for this research should not prevent health systems and healthcare providers from implementing IPV care, but rather should guide the development of rigorous, contextually appropriate evaluations. There is also an urgent need for policies and protocols that clearly frame IPV as an important health issue and support healthcare providers in enquiring about and responding to IPV

The contribution of public health medicine specialists to South Africa's health system

Background: While South Africa's Constitution, health legislation and policies value public health (PH) approaches, Public Health Medicine (PHM) specialists are largely invisible in the health services. Despite this, many undertake specialist training. The reasons for this mismatch, for doctors' motivations for this training, and the career paths of PHM specialists are not known – nor is it known if their practice is aligned with the intentions of trainers, policy makers and employers. Postulates for their invisibility are that they are not required, are unknown, are interchangeable, not 'service-ready' or unavailable. Aims: This thesis investigates the match between 'desired', 'actual' and 'intended' use of doctors with PH expertise in contemporary South Africa. It explores the motivations of doctors undertaking PH studies, the actual careers of PHM specialists and the intended roles of this cadre of staff. Methods: Firstly, through an electronic survey, motivations for studying and career paths of doctors completing Master of Public Health (MPH) at the University of Cape Town – the foundational PH training for selected specialist training – were examined. Secondly, through focus groups and in-depth interviews, motivations for specialist training, anticipated career paths and perspectives of the future of PHM and of specialists-intraining (registrars), were probed. An on-line survey of PHM specialists' career paths, their reflections on the speciality's value and future was undertaken. Finally, through in-depth interviews, a qualitative study explored the perspectives of key stakeholders in South Africa's health service about PHM's value in the context of current health system reform. Findings: A number of factors underlie PHM's absence in the services. In post-apartheid South Africa, PH functions have been overshadowed by an inordinate focus on 'personal' curative services. Under current legislation, PHM is largely not a requirement for service positions, resulting in many participants (20%) not registering as specialists. PH practice is context-specific and its core functions are practised by others, resulting in overlapping boundaries between PHM and other trained professionals. Together with poor advocacy for the speciality, these resulted in PHM largely being eclipsed in health system design. In 2010, PHM comprised less than 200 specialists, mainly mature doctors who are increasingly female. There was a close match between 'desired', 'actual' and 'intended' roles of PHM specialists. Unlike doctors who undertook MPH studies to obtain research and technical skills, together with population approaches for career progression, PHM registrars and specialists trained to impact on health systems, underpinned by a commitment to social justice. Specialists' broad theoretical and experiential training produced versatile professionals able to work in complex service settings, with competencies spanning strategic and technical functions, which fast-tracked them for leadership. In 2010, a third of PHM specialists worked for the state health sector and a third for universities, mostly as managers or academics; the rest in NGOs, research institutions or independently. Besides those in 'joint appointment' health service and academic posts, less than a handful worked in designated service specialist posts. Specialists were highly satisfied with their careers. The majority had worked in the state sector at one time, but many had left to pursue academic and other careers. Although salaried specialists' remuneration had improved following the Occupational Specific Dispensation (OSD), this had not affected those in management and would not attract prospective specialists to management positions unless the work environment favouring autonomy and innovation improved. Despite an uneven presence, study participants agreed that the PHM's contribution centred on a 'public health intelligence' function – finding and interpreting information; supporting services through management and leadership; providing policy making and planning capacity and research at various levels. Some argued for PHM to be a requirement for senior line management posts in the future. Conclusions and recommendations: South Africa's current health reform is an opportunity for PHM to refine its professional identity, competencies and location. Being cognisant of its multi-disciplinary nature, it must locate itself in a common identity of a profession and workforce, in "a fabric of many professions dedicated to a common endeavour".10 A 'public health identity' needs to be constructed, reflecting the diverse PH professional functions.11 The desired size, shape and roles of the PH workforce, including PHM specialists, needs to be addressed through fora of PH stakeholders – the governmental health sector, civil society employers, universities, existing and prospective specialists - focussing on positions for specialists and PH professionals, the creation of posts, the design of training curricula, and registrar placements. Research that evaluates and explores the development of the PH workforce in South Africa, comparing it with other country settings, will inform the development and competency of the profession, and the health sector that aims to "improve quality of life for all"

Using online spaces to recruit Kenyan queer womxn and trans men in restrictive offline settings

Background Understanding and addressing healthcare and service delivery inequalities is essential to increase equity and overcome health disparities and service access discrimination. While tremendous progress has been made towards the inclusion of sexual and gender minorities in health and other research, gaps still exist. Innovative methods are needed to close these. This case study describes and reflects on using online-based data collection to ascertain sexual health decision-making and health service utilisation among Kenyan queer womxn and trans men. Methods Case study The study used a mixed-methods approach in two phases with triangulated quantitative and qualitative elements. Both elements used web-based technology to gather data. Results Using online spaces to recruit and collect data from queer womxn and trans men exceeded expectations. A total of 360 queer womxn and trans men responded to the digitally distributed survey, and 33 people, queer womxn and trans men, as well as key informants, participated in the interviews, which were primarily conducted on Zoom and Skype. The case study analyses the risks and benefits of this approach and concludes that online sampling approaches can mitigate risks and enable effective and safe sampling of a marginalised group in a restrictive legal setting: Kenyan queer womxn and trans men. Conclusion Using online spaces when researching marginalised populations could effectively overcome risks around stigma, discrimination and violence. It could be an effective way to understand these populations’ healthcare needs better. Factors contributing to success included building trusting relationships with key members of the community, strategic and opportune timing, a nuanced understanding of the mobile landscape, and carefully chosen safety and security measures. However, it should be noted that conducting research online could increase the risk of further marginalising and excluding those without access to web-based technology

Adolescent girls’ perceptions of breastfeeding in two low-income periurban communities in South Africa

In South Africa, exclusive breastfeeding rates are low, and rates of teenage pregnancy are high. Educational policy enables mothers’ return to school, which conflicts with policy emphasizing exclusive breastfeeding. We elicited adolescent women’s perceptions and experiences of infant feeding choices, and conducted six focus groups (N ¼ 57) in two periurban settlements. Participants knew arguments in favor of and against breast and formula-feeding, but in practice, mixed feeding occurred early after birth. While completion of high school was emphasized, exclusive breastfeeding was viewed as impractical. Congruent education policies and infant feeding policies/guidelines must address the constraints and contexts of adolescent mothers

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems

Abstract Background The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries. Methods Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature. Results The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting. Conclusion This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice

Assessing care for patients with TB/HIV/STI infections in a rural district in KwaZulu-Natal

Setting. Despite the prioritisation of TB, HIV and STI programmes in South Africa, service targets are not achieved, have had little effect, and the magnitude of the epidemics continues to escalate. Objective. To report on a participatory quality improvement intervention designed to evaluate these priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal. Methods. A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. Results. We highlight weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. In the 25 facilities audited, 71% of the clinical staff had received no training in TB diagnosis and management, and 46% of the facilities were visited monthly by a PHC supervisor. Eighty per cent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for ART and starting treatment was 47 days. Conclusion. Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level

Investigating the disjoint between education and health policy for infant feeding among teenage mothers in South Africa: a case for intersectoral work

Background: Many low-and-middle-income countries, including South Africa, have high rates of teenage preg‑ nancy. Following the World Health Organisation recommendations, South African health policy on infant feeding promotes exclusive breastfeeding until six months of age, with gradual weaning. At the same time, South Africa’s education department, in the interest of learners, promotes adolescents’ early return to school post-partum. Yet infant feeding at school is currently not perceived as a realistic option. Methods: Recognising his this policy tension, we aimed to explore how policies are interpreted and implemented by the health and education sectors through interviews with key informants who produce, interpret and implement these policies. Using an interview guide developed for this study, we conducted in-depth interviews with 24 health policy makers, managers in both sectors, school principals and nursing staf who manage adolescent mothers (aged 16-19) and their babies. Data was analysed using thematic analysis. Results: Informants from both sectors expressed discomfort at pregnant learners remaining in school late in preg‑ nancy and were uncertain about policy regarding when to return to school and how long to breast-feed. Educators reported that new mothers typically returned to school within a fortnight after delivery and that breastfeeding was not common. While health professionals highlighted the benefts of extended breastfeeding for infants and mothers, they recognised the potential confict between the need for the mother to return to school and the recommenda‑ tion for longer breastfeeding. Additionally, the need for ongoing support of young mothers and their families was highlighted. Conclusions: Our fndings suggest educators should actively encourage school attendance in a healthy pregnant adolescent until delivery with later return to school, and health providers should focus attention on breastfeeding for the initial 4-6weeks postpartum, followed by guided support of formula-feeding. We encourage the active engage‑ ment of adolescents’ mothers and extended families who are often involved in infant feeding and care decisions. Edu‑ cation and health departments must engage to facilitate the interests of both the mother and infant: some exclusive infant feeding together with a supported return to school for the adolescent mothe