Understanding the differential impacts of COVID-19 among hospitalised patients in South Africa for equitable response

Background. There are limited in-depth analyses of COVID-19 differential impacts, especially in resource-limited settings such as South Africa (SA).Objectives. To explore context-specific sociodemographic heterogeneities in order to understand the differential impacts of COVID-19. Methods. Descriptive epidemiological COVID-19 hospitalisation and mortality data were drawn from daily hospital surveillance data, National Institute for Communicable Diseases (NICD) update reports (6 March 2020 - 24 January 2021) and the Eastern Cape Daily Epidemiological Report (as of 24 March 2021). We examined hospitalisations and mortality by sociodemographics (age using 10-year age bands, sex and race) using absolute numbers, proportions and ratios. The data are presented using tables received from the NICD, and charts were created to show trends and patterns. Mortality rates (per 100 000 population) were calculated using population estimates as a denominator for standardisation. Associations were determined through relative risks (RRs), 95% confidence intervals (CIs) and p-values <0.001. Results. Black African females had a significantly higher rate of hospitalisation (8.7% (95% CI 8.5 - 8.9)) compared with coloureds, Indians and whites (6.7% (95% CI 6.0 - 7.4), 6.3% (95% CI 5.5 - 7.2) and 4% (95% CI 3.5 - 4.5), respectively). Similarly, black African females had the highest hospitalisation rates at a younger age category of 30 - 39 years (16.1%) compared with other race groups. Whites were hospitalised at older ages than other races, with a median age of 63 years. Black Africans were hospitalised at younger ages than other race groups, with a median age of 52 years. Whites were significantly more likely to die at older ages compared with black Africans (RR 1.07; 95% CI 1.06 - 1.08) or coloureds (RR 1.44; 95% CI 1.33 - 1.54); a similar pattern was found between Indians and whites (RR 1.59; 95% CI 1.47 - 1.73). Women died at older ages than men, although they were admitted to hospital at younger ages. Among black Africans and coloureds, females (50.9 deaths per 100 000 and 37 per 100 000, respectively) had a higher COVID-19 death rate than males (41.2 per 100 000 and 41.5 per 100 000, respectively). However, among Indians and whites, males had higher rates of deaths than females. The ratio of deaths to hospitalisations by race and gender increased with increasing age. In each age group, this ratio was highest among black Africans and lowest among whites.Conclusions. The study revealed the heterogeneous nature of COVID-19 impacts in SA. Existing socioeconomic inequalities appear to shape COVID-19 impacts, with a disproportionate effect on black Africans and marginalised and low socioeconomic groups. These differential impacts call for considered attention to mitigating the health disparities among black Africans.

Rewriting the Narrative of the Epidemiology of HIV in Sub-Saharan Africa

The fight against HIV remains complicated with contracting donor resources and high burden of HIV among reproductive age adults still often limiting independent economic development. In the widespread HIV epidemics of sub-Saharan Africa (SSA); it is proposed that key populations with specific HIV acquisition and transmission risk factors; such as men who have sex with men (MSM); female sex workers (FSW); and people who use drugs (PUD); are less relevant because HIV transmission is sustained in the general population with average HIV acquisition and transmission risks. However; the understanding that key populations are less relevant in the epidemics of Africa is based on the surveillance system from which these populations are mostly excluded. Outside of SSA; the epidemics of HIV are generally concentrated in the same populations that are excluded from the primary HIV surveillance systems in SSA. The manuscripts included in this special issue present convincing data that FSW; MSM; and PUD carry disproportionate burdens of HIV wherever studied in SSA; are underrepresented in HIV programs and research; and require specific HIV prevention services. These manuscripts collectively suggest that the only effective path forward is one that transcends denial and stigma and focuses on systematically collecting data on all populations at risk for HIV. In addition; there is a need to move to a third generation of HIV surveillance as the current one inadvertently devalues HIV surveillance among key populations in the context of widespread HIV epidemics. Overall; the data reviewed here demonstrate that the dynamics of HIV in Africa are complex and achieving an AIDS-free generation necessitates acceptance of that complexity in all HIV surveillance; research; and prevention; treatment; and care programs

Implementation of the National Programme for Prevention of Mother-To-Child Transmission of HIV: a Rapid Assessment in Cacadu District; South Africa

To conduct a rapid assessment of the prevention-of-mother-to-child-transmission-of-HIV (PMTCT) programme in two of the three local service areas in Cacadu district; Eastern Cape province; South Africa; we designed an exploratory study using a mixed-methods approach. Quantitative and qualitative data on PMTCT programme implementation were collected in 2008 through a structured assessment at the 44 health facilities implementing the programme in the province. This included in-depth interviews with 11 clinic supervisors; 31 clinic programme coordinators; and 8 hospital/maternity staff members in order to examine their perceived problems and suggestions regarding PMTCT programme implementation; an assessment of the clinic registers and recording systems; a meeting with stakeholders; and one feedback meeting with clinic managers; sub-district management and other stakeholders in regard to the results of the rapid assessment. Overall; most of the national criteria for PMTCT programme implementation were fulfilled across the health facilities. However; shortcomings were found relating to health policy; health services delivery and clients' health-seeking behaviour. The findings show the need for a well-functioning health system with adequate and trained staff; a reduced staff workload; proper case recording; an improved patient follow-up system; better support for staff; the empowerment of PMTCT clients; strong leadership; and coordination and collaboration between partners

Health-Related Quality of Life in a Sample of HIV-Infected South Africans

The study aims to assess the health-related quality of life and HIV symptoms of a sample of people living with HIV (PLHIV) in South Africa. The sample included 607 PLHIV from all districts of the Eastern Cape Province; recruited either through a health facility; from the community through key informants; or through support groups. At the time of the study; 66of the respondents reported having been given an AIDS diagnosis (advanced stage of HIV disease); 48were on antiretroviral therapy (ART); and 35were receiving a disability grant. The findings indicate a low degree of overall quality of life; with a mean score of 13.4 on the WHOQOL-HIV measure. Among the WHOQOL-HIV BREF subscales; logistic regression identified spirituality; environment; psychological health; and level of independence as predictors for overall quality of life. Among medical variables and HIV symptoms; CD4 cell count and having fewer HIV symptoms but not an AIDS diagnosis were identified as predictors for overall quality of life; among socio-economic variables; having sufficient food and a higher educational level were identified as predictors. The results highlight the need for better access to psychosocial support and medical services for PLHIV in South Africa; as well as the need to consider a patient's general health perceptions during the course of ART

An Investigation into the Perceived Sanitation Challenges in the Eastern Rural Communities

There is a dearth of information on studies that have sought to examine qualitatively the sanitation challenges that rural communities experience. In this regard; an exploratory qualitative study was conducted to determine the perceived structural; economic; educational; social and technological sanitation challenges in the rural communities of the Eastern Cape (EC). A purposive sample of 122 officials was drawn from the identified EC sanitation stakeholder organisations; of these 74 were male and 48 were female. The 122 participants were divided into 15 focus groups (M = 8 participants) by organisation and randomly assigned to five trained moderators for interviews - four groups with the Provincial Sanitation Task Team (PSTT); six with the District Municipalities and three with the Department of Water Affairs and Forestry (DWAF); one with the Mvula Trust and one with the Rural Support Services (RSS). The findings show that rural sanitation is a complex issue that is affected by a wide range of challenges. Structural challenges include lack of physical; natural; human and organisational resources. Lack of funding was identified as the main economic challenge. Educational challenges include lack of advocacy; training; access to information and information exchange with local people. Inadequate community participation was identified as a social challenge. Lack of cultural flexibility; awareness and sensitivity in the development of technologies that recognise; respect and value culture constitute the technological challenge. The results of the study provide a knowledge base on which strategies for promoting good sanitation practices at community level can be built