Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment.

OBJECTIVES: Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa. METHODS: Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities. RESULTS: We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12). CONCLUSIONS: Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

A systematic review of antimicrobial resistance in Neisseria gonorrhoeae and Mycoplasma genitalium in sub-Saharan Africa.

OBJECTIVES: Limited antimicrobial resistance (AMR) surveillance coupled with syndromic management of sexually transmitted infections (STIs) in sub-Saharan Africa (SSA) could be contributing to an increase in AMR in the region. This systematic review aimed to synthesize data on the prevalence of AMR in common STIs in SSA and identify some research gaps that exist. METHODS: We searched three electronic databases for studies published between 1 January 2000 and 26 May 2020. We screened the titles and abstracts for studies that potentially contained data on AMR in SSA. Then we reviewed the full text of these studies to identify articles that reported data on the prevalence of AMR in Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium in SSA. We summarized the data using a narrative synthesis. RESULTS: The 40 included studies reported on AMR data from 7961 N. gonorrhoeae isolates from 15 countries in SSA and 350 M. genitalium specimens from South Africa. All four SSA regions reported very high rates of ciprofloxacin, tetracycline and penicillin resistance in N. gonorrhoeae. Resistance to cefixime or ceftriaxone was observed in all regions except West Africa. Azithromycin resistance, recommended as part of dual therapy with an extended-spectrum cephalosporin for gonorrhoea, was reported in all the regions. Both macrolide and fluoroquinolone-associated resistance were reported in M. genitalium in South Africa. Studies investigating AMR in C. trachomatis and T. vaginalis were not identified. CONCLUSIONS: There is a need to strengthen AMR surveillance in SSA for prompt investigation and notification of drug resistance in STIs.

Pre-exposure prophylaxis (PrEP) awareness, attitudes and uptake willingness among young people: gender differences and associated factors in two South African districts.

Background: Pre-exposure prophylaxis (PrEP) for HIV prevention is safe and effective in reducing HIV incidence. However, more evidence of PrEP knowledge, willingness and distribution preferences is required for scale-up among young people at-risk. Objective: To understand young people PrEP awareness, willingness and roll-out preferences. Methods: Young people (18-24y) were selected through multi-stage sampling in a cross-sectional household survey in low-income communities. Self-administered interviews collected participants' data about PrEP awareness, attitudes, willingness and HIV-risk practices. Data were descriptively analysed by gender. Regression models assessed factors associated with PrEP awareness and willingness by district. Results: Of the 1917 participants interviewed 44.6% (men = 39.4% vs women = 49%, p = 0.001) were PrEP aware, 49.0% were willing to use PrEP. Participants most preferred PrEP distribution channels were public clinics (51.2%) and hospitals (23.8%). More men than women preferred distribution through schools (11.9% vs7.8%; p = 0.002) and NGOs (8.5%vs5.4%; p = 0.008). The biggest barrier to PrEP willingness was inadequate PrEP knowledge (10.0%) but more men than women disliked taking pills daily (4.1%vs2.0%; p-value = 0.007). Gendered determinants to use PrEP were side effects (51%; men = 47% vs women = 55%; p = 0.001) and pill effectiveness (29.5%; men = 26.4% vs women = 32.6%; p = 0.003). In both districts PrEP knowledge was associated with being female and media use. The associations between PrEP awareness and having multiple sexual partnerships, HIV knowledge, HIV self-test willingness and belonging to social clubs differed by district. PrEP willingness was positively associated with having TB and PrEP knowledge in each district but district differences were observed in media and occupation factors. Conclusions: The study shows young people's low levels of PrEP awareness. It also shows relatively increased willingness, gendered PrEP awareness and distribution preferences. Promoting youth's PrEP awareness requires a multifarious media strategy. Abbreviations: HIV: human immunodeficiency virus; AIDS: Acquired immunodeficiency syndrome; aOR: Adjusted Odds ratio; PLWH: People living with HIV; PrEP: Pre-exposure Prophylaxis; UNAIDS: Joint United Nations Programme on HIV and AIDS; uOR: Unadjusted odds ratio; TB: Tuberculosis; WHO: World health Organisation; MSM: Men who have sex with men.

Does a history of sexual and physical childhood abuse contribute to HIV infection risk in adulthood? A study among post-natal women in Harare, Zimbabwe.

BACKGROUND: Sexual and physical abuse in childhood creates a great health burden including on mental and reproductive health. A possible link between child abuse and HIV infection has increasingly attracted attention. This paper investigated whether a history of child physical and sexual abuse is associated with HIV infection among adult women. METHODS: A cross sectional survey was conducted among 2042 postnatal women (mean age = 26y) attending six public primary health care clinics in Harare, Zimbabwe within 6 weeks post-delivery. Clinic records were reviewed for mother's antenatal HIV status. Participants were interviewed about childhood abuse including physical or sexual abuse before 15 years of age, forced first sex before 16, HIV risk factors such as age difference at first sex before age 16. Multivariate analyses assessed the associations between mother's HIV status and child physical and sexual abuse while controlling for confounding variables. RESULTS: More than one in four (26.6%) reported abuse before the age of 15: 14.6% physical abuse and 9.1% sexual abuse,14.3% reported forced first sex and 9.0% first sex before 16 with someone 5+ years older. Fifteen percent of women tested HIV positive during the recent antenatal care visit. In multivariate analysis, childhood physical abuse (aOR 3.30 95%CI 1.58-6.90), sexual abuse (3.18 95%CI: 1.64-6.19), forced first sex (aOR 1.42, 95%CI: 1.00-2.02), and 5+ years age difference with first sex partner (aOR 1.66 95%CI 1.09-2.53) were independently associated with HIV infection. CONCLUSION: This study highlights that child physical and/or sexual abuse may increase risk for HIV acquisition. Further research is needed to assess the pathways to HIV acquisition from childhood to adulthood. Prevention of child abuse must form part of the HIV prevention agenda in Sub-Saharan Africa.

Intimate partner violence, forced first sex and adverse pregnancy outcomes in a sample of Zimbabwean women accessing maternal and child health care.

BACKGROUND: Intimate partner violence (IPV) remains a serious problem with a wide range of health consequences including poor maternal and newborn health outcomes. We assessed the relationship between IPV, forced first sex (FFS) and maternal and newborn health outcomes. METHODS: A cross sectional study was conducted with 2042 women aged 15-49 years attending postnatal care at six clinics in Harare, Zimbabwe, 2011. Women were interviewed on IPV while maternal and newborn health data were abstracted from clinic records. We conducted logistic regression models to assess the relationship between forced first sex (FFS), IPV (lifetime, in the last 12 months and during pregnancy) and maternal and newborn health outcomes. RESULTS: Of the recent pregnancies 27.6% were not planned, 50.9% booked (registered for antenatal care) late and 5.6% never booked. A history of miscarriage was reported by 11.5%, and newborn death by 9.4% of the 2042 women while 8.6% of recent livebirths were low birth weight (LBW) babies. High prevalence of emotional (63,9%, 40.3%, 43.8%), physical (37.3%, 21.3%, 15.8%) and sexual (51.7%, 35.6%, 38.8%) IPV ever, 12 months before and during pregnancy were reported respectively. 15.7% reported forced first sex (FFS). Each form of lifetime IPV (emotional, physical, sexual, physical/sexual) was associated with a history of miscarrying (aOR ranges: 1.26-1.38), newborn death (aOR ranges: 1.13-2.05), and any negative maternal and newborn health outcome in their lifetime (aOR ranges: 1.32-1.55). FFS was associated with a history of a negative outcome (newborn death, miscarriage, stillbirth) (aOR1.45 95%CI: 1.06-1.98). IPV in the last 12 months before pregnancy was associated with unplanned pregnancy (aOR ranges 1.31-2.02) and booking late for antenatal care. Sexual IPV (aOR 2.09 CI1.31-3.34) and sexual/physical IPV (aOR2.13, 95%CI: 1.32-3.42) were associated with never booking for antenatal care. Only emotional IPV during pregnancy was associated with low birth weight (aOR1.78 95%CI1.26-2.52) in the recent pregnancy and any recent pregnancy negative outcomes including LBW, premature baby, emergency caesarean section (aOR1.38,95%CI:1.03-1.83). CONCLUSIONS: Forced first sex (FFS) and intimate partner violence (IPV) are associated with adverse maternal and newborn health outcomes. Strengthening primary and secondary violence prevention is required to improve pregnancy-related outcomes.

Factors associated with past year physical and sexual intimate partner violence against women in Zimbabwe: results from a national cluster-based cross-sectional survey.

Background: Intimate partner violence (IPV) against women continues to be a public health burden globally. Objectives: To assess prevalence and factors associated with women's experiences of past 12 months physical/sexual IPV Methods: A two-stage cluster-based national cross-sectional survey in which women were randomly selected for participation was conducted among 5295 women aged 15-49 years. IPV in the last 12 months was assessed using the WHO interviewer-administered questionnaire for measuring violence against women. Participants' wife beating attitudes, partner controlling behaviours, household decision-making, STI history, HIV status and demographic characteristics were assessed. Multivariate logistic regression was conducted to assess factors associated with IPV. Results: Of the 5292 women interviewed, mean age was 31.5 years and 84.7% were married. Over one-fifth of the women (20.2: 95%CI 19.1-21.3) were physically/sexually abused in the last 12 months. IPV was associated with gender inequitable norms and practices which include lacking household decision-making power (aOR 2.05, 1.71-2.47), experiencing low (aOR 2.05; 1.71-2.47) or high (aOR 4.5; 3.62-5.60) partner controlling behaviours (vs none) and endorsing low (aOR 1.29) or high (aOR 1.36) wife beating attitudes (vs none), having sexual self-efficacy (aOR 1.19; 1.10-1.41), experiencing emotional abuse (aOR 4.50; 3.62-5.60) and having a sexually transmitted infection (STI) (aOR 1.36, 1.04-1.77). IPV was also associated with women's empowerment factors including possessing household assets (aOR 1.26, 1.03-1.54) and reporting current media usage (aOR 1.29; 1.04-1.61). Demographic factors associated with IPV were age and number of children. Conclusions: This study provides evidence that IPV is a significant public health and societal problem as one in five women were abused in the past year. Younger women, less empowered women, women in inequitable intimate relationships and women endorsing traditional gender norms were at increased risk of abuse. IPV prevention programmes must prioritise transforming traditional gender norms and women's economic empowerment.