Effects of enhanced STI partner notification counselling and provider-assisted partner services on partner referral and the incidence of STI diagnosis in Cape Town, South Africa: randomised controlled trial.

OBJECTIVES: We investigated the effects of an enhanced partner notification (PN) counselling intervention with the offer of provider-assisted referral among people diagnosed with STI in a Cape Town public clinic. METHODS: Participants were adults diagnosed with STI at a community clinic. After the standard STI consultation, participants were randomly allocated in a 1:1:1 ratio to (1) 'HE': 20 min health education; (2) 'RR': 45 min risk reduction skills counselling; or (3) 'ePN': 45 min enhanced partner notification communication skills counselling and the offer of provider-assisted referral. The primary outcome was the incidence of repeat STI diagnoses during the 12 months after recruitment, and the secondary outcome was participants' reports 2 weeks after diagnosis of notifying recent partners. Incidence rate ratios (IRRs) were used to compare the incidence rates between arms using a Poisson regression model. RESULTS: The sample included 1050 participants, 350 per group, diagnosed with STI between June 2014 and August 2017. We reviewed 1048 (99%) participant records, and identified 136 repeat STI diagnoses in the ePN arm, 138 in the RR arm and 141 in the HE arm. There was no difference in the annual incidence of STI diagnosis between the ePN and HE arms (IRR: 1.0; 95% CI 0.7 to 1.3), or between the RR and HE arms (IRR: 0.9; 95% CI 0.7 to 1.2). There was a greater chance of a partner being notified in the ePN condition compared with the HE condition, 64.3% compared with 53.8%, but no difference between the RR and HE arms. CONCLUSIONS: PN counselling and education with provider-assisted services has the potential to change the behaviour of people diagnosed with STIs, increasing the number of partners they notify by more than 10%. However, these changes in behaviour did not lead to a reduction of repeat STI diagnoses. TRIAL REGISTRATION NUMBER: PACTR201606001682364.

Brief Enhanced Partner Notification and Risk Reduction Counseling to Prevent Sexually Transmitted Infections, Cape Town, South Africa.

BACKGROUND: Evidence-based interventions are needed to stem sexually transmitted infections (STIs). Clinic-delivered counseling remains an important avenue for effective STI prevention. METHODS: A 3-arm randomized clinical trial compared (a) STI health education control condition, (b) risk reduction counseling, and (c) enhanced partner notification counseling. Men and women (n = 1050) were recruited from an STI clinic in Cape Town, South Africa. After baseline assessments, participants were randomly allocated to receive 1 of the 3 single-session counseling interventions and were followed up for 9 months of behavioral assessments and 12 months of electronic medical records abstraction for STI clinic services. RESULTS: Sexual risk reduction counseling reported greater condom use than did the other 2 conditions during the 3 and 6 months follow-ups. In addition, women receiving risk reduction counseling were significantly less likely to have returned for STI clinic services but did not differ in the number of STI clinic visits over the year. CONCLUSIONS: Brief single-session STI prevention counseling demonstrates significant targeted outcomes. The findings suggest that counseling approaches to both increase condom use and enhance partner notification may offer more robust and sustained outcomes and should be tested in future research.

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.

The importance of identified cause-of-death information being available for public health surveillance, actions and research.

An amendment to the South African Births and Deaths Registration Act has compromised efforts to strengthen local mortality surveillance to provide statistics for small areas and enable data linkage to provide information for public health actions. Internationally it has been recognised that a careful balance needs to be kept between protecting individual patient confidentiality and enabling effective public health intelligence to guide patient care and service delivery and prevent harmful exposures. This article describes the public health benefits of a local mortality surveillance system in the Western Cape Province, South Africa (SA), as well as its potential for improving the quality of vital statistics data with integration into the national civil registration and vital statistics system. It also identifies other important uses for identifiable cause-of-death data in SA that have been compromised by this legislation.

High burden of STIs among HIV-infected adults prior to initiation of ART in South Africa: a retrospective cohort study.

OBJECTIVES: To assess the burden of sexually transmitted infections (STIs) among HIV-positive South Africans in the period prior to antiretroviral therapy (ART) initiation compared with the period once on ART. METHODS: We linked the clinic records of 1465 patients currently on ART to the electronic database which records all visits to city clinics. We used a mixed effects Poisson model to assess the relative rates of occurrence of treatment seeking for an STI in the periods prior to initiation of ART and while on ART. RESULTS: We accumulated 4214 person-years of follow-up, divided nearly equally between the pre-ART and on-ART periods. The rate of treatment seeking for new STIs was 5.50 (95% CI 5.43 to 5.78) per 100 person-years, and individuals had on average a sevenfold higher rate of seeking treatment for STIs in the period prior to initiating ART (9.57 per 100 person-years) compared with the period once on ART (5.5 per 100 person-years) (adjusted rate ratio (RR) 7.01, 95% CI 4.64 to 10.59). Being male (RR 1.73, 95% CI 1.18 to 2.55) or younger (age <25) (RR 2.67, 95% CI 1.53 to 4.65) was associated with higher incidence of clinic visits for STI treatment, while advanced stage of HIV disease (WHO stage 4) (RR 0.33, 95% CI 0.15 to 0.69) was associated with lower incidence. CONCLUSIONS: The period prior to the initiation of ART is a critical period where increased attention should be focused on the detection and treatment of STIs. A successful effort to treat STIs in this period will likely reduce further HIV transmission and fits within a test-and-treat approach.

Local-level mortality surveillance in resource-limited settings: a case study of Cape Town highlights disparities in health.

OBJECTIVE: To identify the leading causes of mortality and premature mortality in Cape Town, South Africa, and its subdistricts, and to compare levels of mortality between subdistricts. METHODS: Cape Town mortality data for the period 2001-2006 were analysed by age, cause of death and sex. Cause-of-death codes were aggregated into three main cause groups: (i) pre-transitional causes (e.g. communicable diseases, maternal causes, perinatal conditions and nutritional deficiencies), (ii) noncommunicable diseases and (iii) injuries. Premature mortality was calculated in years of life lost (YLLs). Population estimates for the Cape Town Metro district were used to calculate age-specific rates per 100,000 population, which were then age-standardized and compared across subdistricts. FINDINGS: The pattern of mortality in Cape Town reflects the quadruple burden of disease observed in the national cause-of-death profile, with HIV/AIDS, other infectious diseases, injuries and noncommunicable diseases all accounting for a significant proportion of deaths. HIV/AIDS has replaced homicide as the leading cause of death. HIV/AIDS, homicide, tuberculosis and road traffic injuries accounted for 44% of all premature mortality. Khayelitsha, the poorest subdistrict, had the highest levels of mortality for all main cause groups. CONCLUSION: Local mortality surveillance highlights the differential needs of the population of Cape Town and provides a wealth of data to inform planning and implementation of targeted interventions. Multisectoral interventions will be required to reduce the burden of disease.