Impacts of heat exposure in utero on long-term health and social outcomes: a systematic review.

BACKGROUND: Climate change, particularly global warming, is amongst the greatest threats to human health. While short-term effects of heat exposure in pregnancy, such as preterm birth, are well documented, long-term effects have received less attention. This review aims to systematically assess evidence on the long-term impacts on the foetus of heat exposure in utero. METHODS: A search was conducted in August 2019 and updated in April 2023 in MEDLINE(PubMed). We included studies on the relationship of environmental heat exposure during pregnancy and any long-term outcomes. Risk of bias was assessed using tools developed by the Joanna-Briggs Institute, and the evidence was appraised using the GRADE approach. Synthesis without Meta-Analysis (SWiM) guidelines were used. RESULTS: Eighteen thousand six hundred twenty one records were screened, with 29 studies included across six outcome groups. Studies were mostly conducted in high-income countries (n = 16/25), in cooler climates. All studies were observational, with 17 cohort, 5 case-control and 8 cross-sectional studies. The timeline of the data is from 1913 to 2019, and individuals ranged in age from neonates to adults, and the elderly. Increasing heat exposure during pregnancy was associated with decreased earnings and lower educational attainment (n = 4/6), as well as worsened cardiovascular (n = 3/6), respiratory (n = 3/3), psychiatric (n = 7/12) and anthropometric (n = 2/2) outcomes, possibly culminating in increased overall mortality (n = 2/3). The effect on female infants was greater than on males in 8 of 9 studies differentiating by sex. The quality of evidence was low in respiratory and longevity outcome groups to very low in all others. CONCLUSIONS: Increasing heat exposure was associated with a multitude of detrimental outcomes across diverse body systems. The biological pathways involved are yet to be elucidated, but could include epigenetic and developmental perturbations, through interactions with the placenta and inflammation. This highlights the need for further research into the long-term effects of heat exposure, biological pathways, and possible adaptation strategies in studies, particularly in neglected regions. Heat exposure in-utero has the potential to compound existing health and social inequalities. Poor study design of the included studies constrains the conclusions of this review, with heterogenous exposure measures and outcomes rendering comparisons across contexts/studies difficult. TRIAL REGISTRATION: PROSPERO CRD 42019140136.

A WHO-led global strategy to control greenhouse gas emissions: a call for action.

BACKGROUND: Climate change, driven by anthropogenic greenhouse gas emissions, is among the greatest threats to human health. The World Health Organisation (WHO), has led global efforts to respond to emerging public health threats including the control of hazardous substances such as tobacco, alcohol, lead and asbestos, with remarkable health gains. BODY: Despite WHO's clear messaging on the enormous and growing health risks of climate change, greenhouse gases are not yet classified as hazardous substances, requiring control through a global strategy or framework. Additionally, WHO has not classified disease attributable to climate change as a result of the promulgation of these hazards as a Public Health Emergency of International Concern (PHEIC), despite the serious and preventable health risks it poses globally. Several historical precedents set the stage for WHO to declare excess greenhouse gases as health hazards, including the control of ozone-depleting substances and breast-milk substitutes where the public benefit of control exceeded the potential benefit of their promulgation. In addition, WHO's undertaking within the International Health Regulations to protect global health, providing imperative to declare climate change a PHEIC, with Tedros Adhanom Ghebreyesus, director-general of WHO, declaring: "The climate crisis is a health crisis, fuelling outbreaks, contributing to higher rates of noncommunicable diseases, and threatening to overwhelm our health workforce and health infrastructure". Importantly, the health sector, perhaps more than other sectors, has successfully overcome formidable, vested interests in combatting these threats to health. CONCLUSION: It is thus imperative that WHO make full use of their credibility and influence to establish a global framework for the control of greenhouse gases through the declaration of excess greenhouse gas emissions as a hazardous substance, and declaring climate change a PHEIC. Who else is better placed to drive the considerable societal transformation needed to secure a liveable future?

Increasing global temperatures threaten gains in maternal and newborn health in Africa: A review of impacts and an adaptation framework.

Anatomical, physiologic, and socio-cultural changes during pregnancy and childbirth increase vulnerability of women and newborns to high ambient temperatures. Extreme heat can overwhelm thermoregulatory mechanisms in pregnant women, especially during labor, cause dehydration and endocrine dysfunction, and compromise placental function. Clinical sequelae include hypertensive disorders, gestational diabetes, preterm birth, and stillbirth. High ambient temperatures increase rates of infections, and affect health worker performance and healthcare seeking. Rising temperatures with climate change and limited resources heighten concerns. We propose an adaptation framework containing four prongs. First, behavioral changes such as reducing workloads during pregnancy and using low-cost water sprays. Second, health system interventions encompassing Early Warning Systems centered around existing community-based outreach; heat-health indicator tracking; water supplementation and monitoring for heat-related conditions during labor. Building modifications, passive and active cooling systems, and nature-based solutions can reduce temperatures in facilities. Lastly, structural interventions and climate financing are critical. The overall package of interventions, ideally selected following cost-effectiveness and thermal modeling trade-offs, needs to be co-designed and co-delivered with affected communities, and take advantage of existing maternal and child health platforms. Robust-applied research will set the stage for programs across Africa that target pregnant women. Adequate research and climate financing are now urgent.

How Climate Change May Threaten Progress in Neonatal Health in the African Region.

Climate change is likely to have wide-ranging impacts on maternal and neonatal health in Africa. Populations in low-resource settings already experience adverse impacts from weather extremes, a high burden of disease from environmental exposures, and limited access to high-quality clinical care. Climate change is already increasing local temperatures. Neonates are at high risk of heat stress and dehydration due to their unique metabolism, physiology, growth, and developmental characteristics. Infants in low-income settings may have little protection against extreme heat due to housing design and limited access to affordable space cooling. Climate change may increase risks to neonatal health from weather disasters, decreasing food security, and facilitating infectious disease transmission. Effective interventions to reduce risks from the heat include health education on heat risks for mothers, caregivers, and clinicians; nature-based solutions to reduce urban heat islands; space cooling in health facilities; and equitable improvements in housing quality and food systems. Reductions in greenhouse gas emissions are essential to reduce the long-term impacts of climate change that will further undermine global health strategies to reduce neonatal mortality.

The economics of sex work and major sporting events: Learning from the 2010 FIFA World Cup in South Africa.

Risk-taking in sex work is related to financial gains from condom-protected and condomless-acts alongside vulnerabilities, including socio-economic factors, which influence the safety of sex workers. Large international sporting events have been shown to significantly impact the economies of host countries, but there is a dearth of studies that examine how major sporting events may affect the economics of sex work and the risks taken by sex workers and clients. This study examines the determinants of the price of commercial sex alongside the price premium for and correlates of, condomless sex before, during and after the 2010 world cup in South Africa. We analysed data from three phases of repeated cross-sectional surveys with sex workers. Bivariate and multivariable logistic regression models were fitted to examine the predictors of condomless sex. We also fitted fixed-effect regression models to examine the determinants of the price of commercial sex across each survey phase. Findings suggest that the price of sex was higher during the world cup compared to before and after, whilst the price premium for condomless-sex increased from 36% before the world cup to 40% (p-value<0.001) and 57% (p-value<0.001) during and after the world cup, respectively. Across the survey phases, anal, oral or masturbation sex were more likely to be supplied without a condom compared to vaginal sex. The type of sex was the primary determinant of the price of sex across all phases. We show indicative evidence that the 2010 world cup was associated with an increase in the price of sex and supply of condomless-sex. Although these findings should be interpreted as associations rather than causal relationships, we recommend that countries with substantial sex-worker populations that host major events shouldexplicitly consider the context and structures of sex work, and promote client-focused safe-sex-interventions that explicitly consider the economic pressures faced by sexworkers to provide riskier acts, to minimise health impacts.

Impacts of High Environmental Temperatures on Congenital Anomalies: A Systematic Review.

Links between heat exposure and congenital anomalies have not been explored in detail despite animal data and other strands of evidence that indicate such links are likely. We reviewed articles on heat and congenital anomalies from PubMed and Web of Science, screening 14,880 titles and abstracts in duplicate for articles on environmental heat exposure during pregnancy and congenital anomalies. Thirteen studies were included. Most studies were in North America (8) or the Middle East (3). Methodological diversity was considerable, including in temperature measurement, gestational windows of exposure, and range of defects studied. Associations were detected between heat exposure and congenital cardiac anomalies in three of six studies, with point estimates highest for atrial septal defects. Two studies with null findings used self-reported temperature exposures. Hypospadias, congenital cataracts, renal agenesis/hypoplasia, spina bifida, and craniofacial defects were also linked with heat exposure. Effects generally increased with duration and intensity of heat exposure. However, some neural tube defects, gastroschisis, anopthalmia/microphthalmia and congenital hypothyroidism were less frequent at higher temperatures. While findings are heterogenous, the evidence raises important concerns about heat exposure and birth defects. Some heterogeneity may be explained by biases in reproductive epidemiology. Pooled analyses of heat impacts using registers of congenital anomalies are a high priority.

Research priorities for control of zoonoses in South Africa.

BACKGROUND: Zoonoses pose major threats to the health of humans, domestic animals and wildlife, as seen in the COVID-19 pandemic. Zoonoses are the commonest source of emerging human infections and inter-species transmission is facilitated by anthropogenic factors such as encroachment and destruction of wilderness areas, wildlife trafficking and climate change. South Africa was selected for a 'One Health' study to identify research priorities for control of zoonoses due to its complex disease burden and an overstretched health system. METHODS: A multidisciplinary group of 18 experts identified priority zoonotic diseases, knowledge gaps and proposed research priorities for the next 5 y. Each priority was scored using predefined criteria by another group of five experts and then weighted by a reference group (n=28) and the 18 experts. RESULTS: Seventeen diseases were mentioned with the top five being rabies (14/18), TB (13/18), brucellosis (11/18), Rift Valley fever (9/11) and cysticercosis (6/18). In total, 97 specific research priorities were listed, with the majority on basic epidemiological research (n=57), such as measuring the burden of various zoonoses (n=24), followed by 20 on development of new interventions. The highest research priority score was for improving existing interventions (0.77/1.0), followed by health policy and systems research (0.72/1.0). CONCLUSION: Future zoonotic research should improve understanding of zoonotic burden and risk factors and new interventions in public health. People with limited rural services, immunocompromised, in informal settlements and high-risk occupations, should be the highest research priority.

Effect of a mobile phone intervention for female sex workers on unintended pregnancy in Kenya (WHISPER or SHOUT): a cluster-randomised controlled trial.

BACKGROUND: Female sex workers in low-income and middle-income countries face high risks of unintended pregnancy. We developed a 12-month, multifaceted short messaging service intervention (WHISPER) for female sex workers in Kenya who had the potential to become pregnant, to improve their contraceptive knowledge and behaviours. The aim of this study was to assess the effectiveness of the intervention to reduce the incidence of unintended pregnancy among sex workers in Kenya compared with an equal-attention control group receiving nutrition-focused messages (SHOUT). METHODS: Our two-arm, cluster-randomised controlled trial was done in sex-work venues in two subcounties of Mombasa, Kenya (Kisauni and Changamwe). Participants, aged 16-34 years, not pregnant or planning pregnancy, able to read text messages in English, residing in the study area, and who had a personal mobile phone with one of two phone networks, were recruited from 93 randomly selected sex-work venues (clusters). Random cluster allocation (1:1) to the intervention or control group was concealed from participants and researchers until the intervention started. Both groups received text messages in English delivered two to three times per week for 12 months (137 messages in total), as well as additional on-demand messages. Message content in the intervention group focused on promotion of contraception, particularly long-acting reversible contraception and dual method contraceptive use; message content in the control group focused on promotion of nutritional knowledge and practices, including food safety, preparation, and purchasing. The primary endpoint, analysed in all participants who were randomly assigned and attended at least one follow-up visit, compared unintended pregnancy incidence between groups using discrete-time survival analysis at 6 and 12 months. This trial is registered with Australian New Zealand Clinical Trials Registry, ACTRN12616000852459, and is closed to new participants. FINDINGS: Between Sept 14, 2016, and May 16, 2017, 1728 individuals were approached to take part in the study. Of these, 1155 were eligible for full screening, 1035 were screened, and 882 were eligible, enrolled, and randomly assigned (451 participants from 47 venues in the intervention group; 431 participants from 46 venues in the control group). 401 participants from the intervention group and 385 participants from the control group were included in the primary analysis. Incidence of unintended pregnancy was 15·5 per 100 person-years in the intervention group and 14·7 per 100 person-years in the control group (hazard ratio 0·98, 95% CI 0·69-1·39). INTERPRETATION: The intervention had no measurable effect on unintended pregnancy incidence. Mobile health interventions, even when acceptable and rigorously designed, are unlikely to have a sufficient effect on behaviour among female sex workers to change pregnancy incidence when used in isolation. FUNDING: National Health and Medical Research Council of Australia.

HIV infections among female sex workers in Mombasa, Kenya: current prevalence and trends over 25 years.

Over 20 years, interventions have targeted HIV among female sex workers (FSWs) in Kenya given their central role in new infections. To determine the effects of these interventions, we assessed the prevalence and correlates of HIV among a random sample of FSWs and modelled prevalence estimates from studies since 1993. FSWs aged 16-34 years were enrolled through multi-stage sampling. Regression models identified correlates of HIV infection. Generalised linear mixed modelling estimated temporal changes in prevalence between 1993 and 2016. 882 FSWs were enrolled. Prevalence rose from 3.6% among 16-20-year-olds to 31.6% among 31-34-year-old FSWs. Those aged 31 to 34 years had greater odds of HIV compared to those 16 to 20 years (AOR 14.2, 95% CI, 5.5-36.8). Infection was less prevalent among FSWs with tertiary education compared to those with primary or no education (AOR 0.23, 95% CI, 0.07-0.78). There was an overall 30% reduction in prevalence from 1993 to 2016 with an average annual decline of 3%. About one in ten FSWs in Mombasa are currently infected with HIV. Considering FSWs' central role in sustaining population-level infections, these initiatives require continued support, focusing on reducing transmission from older FSWs and those with less education.

COVID-19 in Africa: care and protection for frontline healthcare workers.

Medical staff caring for COVID-19 patients face mental stress, physical exhaustion, separation from families, stigma, and the pain of losing patients and colleagues. Many of them have acquired SARS-CoV-2 and some have died. In Africa, where the pandemic is escalating, there are major gaps in response capacity, especially in human resources and protective equipment. We examine these challenges and propose interventions to protect healthcare workers on the continent, drawing on articles identified on Medline (Pubmed) in a search on 24 March 2020. Global jostling means that supplies of personal protective equipment are limited in Africa. Even low-cost interventions such as facemasks for patients with a cough and water supplies for handwashing may be challenging, as is 'physical distancing' in overcrowded primary health care clinics. Without adequate protection, COVID-19 mortality may be high among healthcare workers and their family in Africa given limited critical care beds and difficulties in transporting ill healthcare workers from rural to urban care centres. Much can be done to protect healthcare workers, however. The continent has learnt invaluable lessons from Ebola and HIV control. HIV counselors and community healthcare workers are key resources, and could promote social distancing and related interventions, dispel myths, support healthcare workers, perform symptom screening and trace contacts. Staff motivation and retention may be enhanced through carefully managed risk 'allowances' or compensation. International support with personnel and protective equipment, especially from China, could turn the pandemic's trajectory in Africa around. Telemedicine holds promise as it rationalises human resources and reduces patient contact and thus infection risks. Importantly, healthcare workers, using their authoritative voice, can promote effective COVID-19 policies and prioritization of their safety. Prioritizing healthcare workers for SARS-CoV-2 testing, hospital beds and targeted research, as well as ensuring that public figures and the population acknowledge the commitment of healthcare workers may help to maintain morale. Clearly there are multiple ways that international support and national commitment could help safeguard healthcare workers in Africa, essential for limiting the pandemic's potentially devastating heath, socio-economic and security impacts on the continent.

A Mobile Phone-Based Sexual and Reproductive Health Intervention for Female Sex Workers in Kenya: Development and Qualitative Study.

BACKGROUND: Female sex workers (FSWs) have high rates of both unintended pregnancy and HIV, but few health promotion interventions address their contraceptive needs or other sexual and reproductive health and rights (SRHR) concerns. A broader approach integrates contraceptive promotion with HIV and sexually transmitted infection (STI) prevention and management, alcohol awareness, gender-based violence and rights, and health care utilization. The Women's Health Intervention using SMS for Preventing Pregnancy (WHISPER) mobile phone intervention uses a participatory development approach and behavior change theory to address these high-priority concerns of FSWs in Mombasa, Kenya. OBJECTIVE: This paper aimed to (1) describe the process of development of the WHISPER intervention, its theoretical framework, key content domains and strategies and (2) explore workshop participants' responses to the proposed intervention, particularly with regard to message content, behavior change constructs, and feasibility and acceptability. METHODS: The research team worked closely with FSWs in two phases of intervention development. First, we drafted content for three different types of messages based on a review of the literature and behavior change theories. Second, we piloted the intervention by conducting six workshops with 42 FSWs to test and refine message content and 12 interviews to assess the technical performance of the intervention. Workshop data were thematically analyzed using a mixed deductive and inductive approach. RESULTS: The intervention framework specified six SRHR domains that were viewed as highly relevant by FSWs. Reactions to intervention content revealed that social cognitive strategies to improve knowledge, outcome expectations, skills, and self-efficacy resonated well with workshop participants. Participants found the content empowering, and most said they would share the messages with others. The refined intervention was a 12-month SMS program consisting of informational and motivational messages, role model stories portraying behavior change among FSWs, and on-demand contraceptive information. CONCLUSIONS: Our results highlight the need for health promotion interventions that incorporate broader components of SRHR, not only HIV prevention. Using a theory-based, participatory approach, we developed a digital health intervention that reflects the complex reality of FSWs' lives and provides a feasible, acceptable approach for addressing SRHR concerns and needs. FSWs may benefit from health promotion interventions that provide relevant, actionable, and engaging content to support behavior change.

Implementation of a PMTCT programme in a high HIV prevalence setting in Johannesburg, South Africa: 2002-2015.

BACKGROUND: Great strides have been made in decreasing paediatric human immunodeficiency virus (HIV) infections, especially in sub-Saharan Africa. In South Africa, new paediatric HIV infections decreased by 84% between 2009 and 2015. This achievement is a result of a strong political will and the rapid evolution of the country's prevention of mother-to-child transmission (PMTCT) guidelines. OBJECTIVES: In this paper we report on the implementation of a large PMTCT programme in Soweto, South Africa. METHODS: We reviewed routinely collected PMTCT data from 13 healthcare facilities, for the period 2002-2015. Antiretroviral therapy (ART) coverage among pregnant women living with HIV (PWLHIV) and the mother-to-child transmission (MTCT) rate at early infant diagnosis were evaluated. RESULTS: In total, 360 751 pregnant women attended the facilities during the review period, and the HIV prevalence remained high throughout at around 30%. The proportion of PWLHIV presenting with a known HIV status increased from 14.3% in 2009 when the indicator was first collected to 45% in 2015, p < 0.001. In 2006, less than 10% of the PWLHIV were initiated on ART, increasing to 88% by 2011. The MTCT rate decreased from 6.9% in 2007 to under 1% from 2013 to 2015, p < 0.001. CONCLUSION: The achievements in decreasing paediatric HIV infections have been hailed as one of the greatest public health achievements of our times. While there are inherent limitations with using routinely collected aggregate data, the Soweto data reflect progress made in the implementation of PMTCT programmes in South Africa. Progress with PMTCT has, however, not been accompanied by a decline in HIV prevalence among pregnant women.

Human Papillomavirus Seroprevalence and Seroconversion Among Men Living With HIV: Cohort Study in South Africa.

BACKGROUND: Men living with HIV (MLHIV) have a high burden of human papillomavirus (HPV)-related cancer. Understanding serological dynamics of HPV in men can guide decisions on introducing HPV vaccination and monitoring impact. We determined HPV seroprevalence and evaluated factors associated with HPV seroconversion among MLHIV in Johannesburg, South Africa. METHODS: We enrolled 304 sexually active MLHIV 18 years and older and collected sociobehavioral data, blood samples (CD4 counts, HIV-1 plasma viral load, and HPV serology), and genital and anal swabs [HPV DNA and HPV viral load (VL)] at enrollment and 6-monthly for up to 18 months. Antibodies to 15 HPV types were measured using HPV pseudovirions. Generalized estimating equations were used to evaluate correlates of HPV seroconversion. RESULTS: Median age at enrollment was 38 years (IQR: 22-59), 25% reported >1 sexual partner in the past 3 months, and 5% reported ever having sex with other men. Most participants (65%) were on antiretroviral therapy (ART), with median CD4 count of 445 cells/µL (IQR: 328-567). Seroprevalence for any HPV type was 66% (199/303). Baseline seropositivity for any bivalent (16/18), quadrivalent (6/11/16/18), and nonavalent (6/11/16/18/31/33/45/52/58) vaccine types was 19%, 37%, and 60%, respectively. At 18 months, type-specific seroconversion among 59 men whose genital samples were HPV DNA positive but seronegative for the same type at enrollment was 22% (13/59). Type-specific seroconversion was higher among men with detectable HIV plasma viral load (adjusted odds ratio = 2.78, 95% CI: 1.12 to 6.77) and high HPV VL (adjusted odds ratio = 3.32, 95% CI: 1.42 to 7.74). CONCLUSIONS: Seropositivity and exposure to nonavalent HPV types were high among MLHIV. HPV vaccination of boys before they become sexually active could reduce the burden of HPV infection among this at-risk population.

Prevalent, persistent anal HPV infection and squamous intraepithelial lesions: Findings from a cohort of men living with HIV in South Africa.

OBJECTIVE: To estimate the prevalence, incidence and persistence of anal HPV infection and squamous intra-epithelial lesions (SILs) among men living with HIV (MLHIV), and determine their risk factors. METHODS: We enrolled MLHIV ≥18 years, who attended 6-monthly visits for 18 months. Socio-behavioural data were collected by questionnaire. Clinicians collected blood sample (CD4+ count and HIV plasma viral load), anal swabs (HPV DNA testing) and anal smears (Bethesda classification) at each visit. HPV DNA testing and classification of smears were done at enrolment and last follow-up visit (two time points). Factors associated with persistent anal HPV infection and SILs were evaluated with generalized estimating equations logistic regression and standard logistic regression respectively. RESULTS: Mean age of 304 participants was 38 (Standard Deviation, 8) years; 25% reported >1 sexual partner in the past 3 months. Only 5% reported ever having sex with other men. Most (65%) participants were taking antiretroviral treatment (ART), with a median CD4+ count of 445 cells/µL (IQR, 328-567). Prevalence of any-HPV infection at enrolment was 39% (88/227). In total, 226 men had anal HPV DNA results at both enrolment and final visits. Persistence of any-anal HPV infection among 80 men who had infection at enrolment was 26% (21/80). Any persistent anal HPV infection was more frequent among MLHIV with low CD4+ count (<200 vs. >500 cells/µL; aOR = 6.58; 95%CI: 2.41-17.94). Prevalence of anal SILs at enrolment was 49% (118/242) while incidence of SILs among MLHIV who had no anal dysplasia at enrolment was 27% (34/124). Of the 118 men who had anal dysplasia at enrolment, 15% had regressed and 38% persisted by month 18. Persistent anal HPV infection was associated with persistent SILs (aOR = 2.95; 95%CI: 1.08-10.89). ART status or duration at enrolment were not associated with persistent anal HPV infection or persistent SILs during follow-up. CONCLUSION: In spite of a high prevalence of anal HPV, HIV-positive heterosexual men have a low burden of anal HPV related disease. HPV vaccine and effective ART with immunological reconstitution could reduce this burden of infection.

Type-Specific Human Papillomavirus Prevalence, Incident Cases, Persistence, and Associated Pregnancy Outcomes Among HIV-Infected Women in Kenya.

BACKGROUND: Persistent infection with high-risk types of human papillomavirus (HPV) is the preeminent factor driving the development of cervical cancer. There are large gaps in knowledge about both the role of pregnancy in the natural history of HPV infection and the impact of HPV on pregnancy outcomes. METHODS: This single-site prospective cohort substudy, nested within an international multisite randomized controlled trial, assessed prevalence, incident cases, and persistence of type-specific HPV infection, and the association between persistence of high-risk HPV infection with pregnancy outcomes among HIV-infected pregnant women in Kenya, including HIV transmission to infants. Type-specific HPV was assessed using a line probe assay in pregnancy and again at 3 months after delivery. HIV status of children was determined using polymerase chain reaction at 6 weeks. RESULTS: In total, 84.1% (206/245) of women had a high-risk HPV infection at enrollment. Three quarters (157/206) of these infections persisted postpartum. Persistence of HPV16 and/or HPV18 types was observed in more than half (53.4%; 39/73) of women with this infection at enrollment. Almost two-thirds had an incident high-risk HPV infection postpartum, which was not present in pregnancy (62.5%), most commonly HPV52 (19.0%). After adjustments, no association was detected between persistent high-risk HPV and preterm birth. All mothers of the 7 cases of infant HIV infection had persistent high-risk HPV infection (P = 0.044). CONCLUSIONS: High levels of high-risk HPV infection and type-specific persistence were documented, heightening the urgency of mass role out of HPV vaccination. The association between HPV persistence and HIV transmission is a novel finding, warranting further study.

Use of long-acting reversible contraception in a cluster-random sample of female sex workers in Kenya.

OBJECTIVE: To assess correlates of long-acting reversible contraceptive (LARC) use, and explore patterns of LARC use among female sex workers (FSWs) in Kenya. METHODS: Baseline cross-sectional data were collected between September 2016 and May 2017 in a cluster-randomized controlled trial in Mombasa. Eligibility criteria included current sex work, age 16-34 years, not pregnant, and not planning pregnancy. Peer educators recruited FSWs from randomly selected sex-work venues. Multiple logistic regression identified correlates of LARC use. Prevalence estimates were weighted to adjust for variation in FSW numbers recruited across venues. RESULTS: Among 879 participants, the prevalence of contraceptive use was 22.6% for implants and 1.6% for intra-uterine devices (IUDs). LARC use was independently associated with previous pregnancy (adjusted odds ratio for one pregnancy, 11.4; 95% confidence interval, 4.25-30.8), positive attitude to and better knowledge of family planning, younger age, and lower education. High rates of adverse effects were reported for all methods. CONCLUSION: The findings suggest that implant use has increased among FSWs in Kenya. Unintended pregnancy risks remain high and IUD use is negligible. Although LARC rates are encouraging, further intervention is required to improve both uptake (particularly of IUDs) and greater access to family planning services.

Incidence, Persistence, Clearance, and Correlates of Genital Human Papillomavirus Infection and Anogenital Warts in a Cohort of Men Living With Human Immunodeficiency Virus in South Africa.

OBJECTIVE: To estimate the incidence; persistence and correlates of human papillomavirus (HPV) infection and anogenital warts (AGW) among men living with human immunodeficiency virus (MLHIV). METHODS: Overall, 304 MLHIV 18 years or older were enrolled and attended follow-up visits at 6, 12, and 18 months. Clinicians examined for AGW, collected blood, and penile swabs for HPV testing (Roche Linear Array) at each visit. Time to AGW incidence or clearance was estimated by Kaplan-Meier method. Factors associated with persistent HPV infection and AGW clearance were evaluated with generalized estimating equations and Cox regression, respectively. RESULTS: Mean age of participants was 38 years (standard deviation, 8 years); 25% reported more than 1 sexual partner in the past 3 months. Most (65%) participants were on antiretroviral treatment (ART) with a median CD4 count of 445 cells/µL (interquartile range, 328-567). Prevalence of HPV infection and AGW at enrolment were 79% (224 of 283) and 12% (36 of 304), respectively. Two hundred fifty-nine men were followed up for a median (interquartile range) 1.4 years (0.5-1.7 years). Incidence of any-genital HPV infection was 2.9 (95% confidence interval, 1.5-5.5) per 100 person-years. Persistence of any-genital HPV infection was 35% (68 of 192) and was higher among MLHIV with low CD4 count (adjusted odds ratio, 3.54; 95% confidence interval, 2.07-6.05). Incidence of AGW was 1.4 per 100 person-years. Men living with human immunodeficiency virus with high CD4 count were more likely to clear AGW than those with low CD4 count (adjusted hazard ratio, 3.69; 95% confidence interval, 1.44-9.47). No associations were observed between persistent genital HPV infection, AGW clearance with enrolment ART status or duration. CONCLUSIONS: Human immunodeficiency virus-positive men have a high burden of genital HPV infection and AGW. The ART and HPV vaccine could reduce this burden.

Climate change adaptation in South Africa: a case study on the role of the health sector.

BACKGROUND: Globally, the response to climate change is gradually gaining momentum as the impacts of climate change unfold. In South Africa, it is increasingly apparent that delays in responding to climate change over the past decades have jeopardized human life and livelihoods. While slow progress with mitigation, especially in the energy sector, has garnered much attention, focus is now shifting to developing plans and systems to adapt to the impacts of climate change. METHODS: We applied systematic review methods to assess progress with climate change adaptation in the health sector in South Africa. This case study provides useful lessons which could be applied in other countries in the African region, or globally. We reviewed the literature indexed in PubMed and Web of Science, together with relevant grey literature. We included articles describing adaptation interventions to reduce the impact of climate change on health in South Africa. All study designs were eligible. Data from included articles and grey literature were summed thematically. RESULTS: Of the 820 publications screened, 21 were included, together with an additional xx papers. Very few studies presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country's preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers. CONCLUSIONS: Overall, the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. More effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as predominately a health issue, one necessitating an urgent, adequately-resourced response. Such a shift in South Africa, but also beyond the country, may play a key role in accelerating climate change adaptation and mitigation.

Qualitative assessment of South African healthcare worker perspectives on an instrument-free rapid CD4 test.

BACKGROUND: Accurate measurement of CD4 cell counts remains an important tenet of clinical care for people living with HIV. We assessed an instrument-free point-of-care CD4 test (VISITECT® CD4) based on a lateral flow principle, which gives visual results after 40 min. The test involves five steps and categorises CD4 counts as above or below 350 cells/µL. As one component of a performance evaluation of the test, this qualitative study explored the views of healthcare workers in a large women and children's hospital on the acceptability and feasibility of the test. METHODS: Perspectives on the VISITECT® CD4 test were elicited through in-depth interviews with eight healthcare workers involved in the performance evaluation at an antenatal care facility in Johannesburg, South Africa. Audio recordings were transcribed in full and analysed thematically. RESULTS: Healthcare providers recognised the on-going relevance of CD4 testing. All eight perceived the VISITECT® CD4 test to be predominantly user-friendly, although some felt that the need for precision and optimal concentration in performing test procedures made it more challenging to use. The greatest strength of the test was perceived to be its quick turn-around of results. There were mixed views on the semi-quantitative nature of the test results and how best to integrate this test into existing health services. Participants believed that patients in this setting would likely accept the test, given their general familiarity with other point-of-care tests. CONCLUSIONS: Overall, the VISITECT® CD4 test was acceptable to healthcare workers and those interviewed were supportive of scale-up and implementation in other antenatal care settings. Both health workers and patients will need to be oriented to the semi-quantitative nature of the test and how to interpret the results of tests.

Efficacy and Safety of Tenofovir Disoproxil Fumarate Versus Low-Dose Stavudine Over 96 Weeks: A Multicountry Randomized, Noninferiority Trial.

BACKGROUND: Reducing doses of antiretroviral drugs, including stavudine (d4T), may lower toxicity, while preserving efficacy. There are substantial concerns about renal and bone toxicities of tenofovir disoproxil fumarate (TDF). SETTING: HIV-1-infected treatment-naive adults in India, South Africa, and Uganda. METHODS: A phase-4, 96-week, randomized, double-blind, noninferiority trial compared d4T 20 mg twice daily and TDF, taken in combination with lamivudine (3TC) and efavirenz (EFV). The primary endpoint was the proportion of participants with HIV-1 RNA <50 copies per milliliter at 48 weeks. Adverse events assessments included measures of bone density and body fat. The trial is registered on Clinicaltrials.gov (NCT02670772). RESULTS: Between 2012 and 2014, 536 participants were recruited per arm. At week 96, trial completion rates were 75.7% with d4T/3TC/EFV (n = 406) and 82.1% with TDF/3TC/EFV (n = 440, P = 0.011). Noncompletion was largely due to virological failure [6.2% (33) with d4T/3TC/EFV versus 5.4% (29) with TDF/3TC/EFV; P = 0.60]. For the primary endpoint, d4T/3TC/EFV was noninferior to TDF/3TC/EFV (79.3%, 425/536 versus 80.8% 433/536; difference = -1.49%, 95% CI: -6.3 to 3.3; P < 0.001). Drug-related adverse event discontinuations were higher with d4T (6.7%, 36), than TDF (1.1%, 6; P < 0.001). Lipodystrophy was more common with d4T (5.6%, 30) than TDF (0.2%, 1; P < 0.001). Creatinine clearance increased in both arms, by 18.1 mL/min in the d4T arm and 14.2 mL/min with TDF (P = 0.03). Hip bone density measures, however, showed greater loss with TDF. CONCLUSIONS: Low-dose d4T combined with 3TC/EFV demonstrated noninferior virological efficacy compared with TDF/3TC/EFV, but mitochondrial toxicity remained high. Little renal toxicity occurred in either arm. Implications of bone mineral density changes with TDF warrant investigation.