A cross-sectional study of attitudes and behaviors of snuff use and cessation among people with and without HIV in South Africa.

Background: Despite a high (48%) prevalence of snuff use among women with HIV in South Africa, little is known of the attitudes and behaviors of use, strategies for cessation, and potential health risks. Methods: In a cross-sectional study, a questionnaire was administered to adults (≥18 years) with (HIV+) and without HIV (HIV-) who self-reported current snuff use to collect information on demographics, snuff use and cessation attempts, preferred strategies for cessation, other substance use, history of respiratory illness, and mental health. Results: 150 (74 HIV+, 76 HIV-) participants were enrolled; 115 (77%) were daily snuff users, 6 (4%) were current smokers, and 17 (11%) former smokers. Top reasons for current snuff use included improving health (n = 48, 32%), reducing stress (n = 26, 16%), and "being a habit" (n = 38, 25%). Participants believed snuff use to have mostly positive (n = 68, 46%) or no (n = 54, 36%) health impacts, and 57 (38%) participants believed snuff cures headaches. 103 (69%) participants reported a previous quit attempt, and 110 (73%) indicated high interest in quitting snuff. Although 105 (70%) participants indicated that advice from a healthcare provider would aid them in quitting snuff, only 30 (20%) reported ever receiving that advice. A majority of participants (n = 141, 94%) suffer from moderate to high levels of perceived stress, and overall few differences were seen by HIV status. Conclusions: Education on negative impacts of snuff, advice to quit from healthcare providers, and nicotine replacement therapy should be considered in the development of a snuff cessation program.

HIV incidence, pregnancy, and implementation outcomes from the Sakh'umndeni safer conception project in South Africa: a prospective cohort study.

BACKGROUND: Safer conception strategies empower individuals trying to conceive to minimise HIV transmission risk to partners and potential children; however, effectiveness data are scarce. We aimed to assess adoption of safer conception methods and HIV and pregnancy outcomes from Sakh'umndeni, a novel safer conception service in South Africa. METHODS: In this prospective cohort study, the Sakh'umndeni clinical cohort at Witkoppen Cinic in Johannesburg (South Africa) enrolled adults aged at least 18 years who were trying to conceive and in relationships with an HIV-positive partner. Couples who were pregnant at enrolment or had been previously diagnosed as infertile were excluded. Participants received safer conception care by a nurse, including antiretroviral therapy (ART) for HIV-positive partners, pre-exposure prophylaxis (PrEP) for HIV-negative partners, counselling around timed condomless sex, or syringes for self-insemination. Primary outcomes were pregnancy incidence and HIV transmission to partners and infants. We estimated time to first pregnancy using Kaplan-Meier curves; pregnancy and HIV incidence were estimated as events per person-years of risk. FINDINGS: Between July 16, 2013, and April 5, 2017, 526 individuals (334 women and 192 men) from 334 partnerships enrolled. 162 (48%) of 334 couples were serodifferent, 149 (45%) were HIV-positive seroconcordant, and 23 (7%) were an HIV-positive woman and an unknown status male partner. At enrolment, 176 (61%) of 287 HIV-positive women and 60 (46%) of 131 HIV-positive men were virally suppressed (<50 copies per mL). Among the safer conception strategies, ART was initiated by 73 (91%) of 80 HIV-positive participants not on ART and PrEP was initiated by 28 (28%) of 101 HIV-negative participants. 2719 follow-up visits were completed, and 99 pregnancies were observed in 89 women. Pregnancy incidence was 41·2 per 100 person-years (95% CI 33·4-50·7); 25 (28%) of 89 pregnancies with a known outcome were miscarried or terminated because of risk to the mother. Pregnancy incidence was 79·0 per 100 person-years (95% CI 49·8-125·4) among HIV-negative women and 36·7 per 100 person-years (29·1-46·3) among HIV-positive women. At the time of pregnancy, viral suppression among women was high (68 [87%] of 78 women had viral loads of <50 copies per mL and 77 [99%] had viral loads of <1000 copies per mL). No horizontal or vertical HIV transmission events were observed. INTERPRETATION: Safer conception strategies empowered couples to safely conceive. Pregnancy incidence among service users was high. Integration of safer conception counselling could promote HIV prevention and linkage to care. FUNDING: US Agency for International Development; UJMT Consortium/Fogarty International Center, US National Institutes of Health (NIH); and Johns Hopkins University Center for AIDS Research (NIH).

Infant feeding by South African mothers living with HIV: implications for future training of health care workers and the need for consistent counseling.

Background: Since 2010, the World Health Organization recommends lifelong antiretroviral treatment for all women living with HIV, and exclusive breastfeeding for six-months followed by breastfeeding until 24-months for all HIV positive mothers. Nevertheless, many mothers living with HIV do not initiate breastfeeding or stop prematurely, and many countries are still in the process of updating their national infant feeding guidelines to align with World Health Organization recommendations. We sought to understand uptake of breastfeeding and factors that influence decision-making regarding infant feeding in women living with and without HIV who receive ante- and postnatal care at a primary healthcare setting. Methods: Programmatic data on infant feeding intentions and practices among women attending an ante-and postnatal clinic service at a primary care clinic in Johannesburg, South Africa were summarized using descriptive statistics. Qualitative interviews were conducted with 12 healthcare providers, 12 women living with HIV who were breastfeeding and 10 who were formula feeding. Interviews were analyzed using a content analysis approach. Results: Pregnant women living with HIV were less likely to express an intent to breastfeed (71% vs 99%). During the first 6 months postpartum, mothers living with HIV were also less likely to exclusively breastfeed compared to HIV-negative mothers. Mixed messages during infant feeding counselling, social and economic factors, and fear of HIV transmission influenced women's choices to initiate and continue breastfeeding. Conclusions: As infant feeding guidelines for women living with HIV have evolved rapidly in the past 10 years, uniform messages on the low risk of mother-to-child transmission of HIV associated with breastfeeding while on ART and on introduction of complementary foods after 6 months of age are needed.

Client uptake of safer conception strategies: implementation outcomes from the Sakh'umndeni Safer Conception Clinic in South Africa.

INTRODUCTION: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh'umndeni, which is a safer conception clinic in South Africa. METHODS: Sakh'umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around periconception HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression. RESULTS: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p < 0.001). Male medical circumcision (MMC) was used by 28% of HIV-negative men. Over 80% of clients took up at least one recommended safer conception strategy. Continuation of selected strategies over attempted conception attempts was >60%. CONCLUSIONS: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms.

Acceptability and Preferences among Men and Women for Male Involvement in Antenatal Care.

Introduction. Male involvement in antenatal care (ANC) has been associated with improved prevention of mother-to-child transmission outcomes in Sub-Saharan Africa; yet it remains uncommon. We assess acceptability of male involvement from the male and female perspectives and potential incentives for men to attend ANC. Methods. Adult pregnant women and men attending primary healthcare at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, from October 2013 to January 2014, were recruited using stratified random sampling to ensure equal representation across gender and HIV status. Results. 300/332 individuals (93.8%) offered participation consented. Among the 150 women, 97% had a partner; the majority (92%) preferred partner attendance at ANC, and 14% reported partner attendance during this pregnancy. The 150 men had low knowledge of services rendered at ANC outside of pregnancy monitoring, and few (19%) had previously attended ANC. Blood pressure screening, fatherhood information, and HIV testing were identified by men as incentives for attendance. Women and men expressed high willingness to, respectively, deliver (95%) and respond (97%) to ANC letter invitations. Conclusion. Invitation letters to promote male involvement in ANC are highly acceptable to pregnant women and men. Focusing invitation messages on fatherhood and primary healthcare rather than HIV testing may provide greater motivation for male involvement.

"I don't know if this is right but this is what I'm offering": healthcare provider knowledge, practice, and attitudes towards safer conception for HIV-affected couples in the context of Southern African guidelines.

The 2011 guidelines for safer conception for HIV-affected individuals and couples were adopted by the South African Department of Health in December 2012. We assessed implementation gaps and facilitators and barriers to delivering safer conception services through examining patient and healthcare provider (HCP) experiences. At Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, we conducted in-depth interviews (IDIs) with nine HCPs (doctors, nurses, and counselors) and IDIs and focus group discussions with 42 HIV-affected men and women interested in having a child. Data were analyzed using a grounded theory approach. HCPs were supportive of fertility intentions of HIV-affected couples and demonstrated some knowledge of safer conception methods, especially ART initiation to suppress viral load in infected partners. Unfortunately, HCPs did not follow the key recommendation that HCPs initiate conversations on fertility intentions with HIV-affected men and women. Providers and clients reported that conversations about conception only occur when client-initiated, placing the onus on HIV-affected individuals. Important barriers underlying this were the misconception held by some HCPs that uninfected partners in serodiscordant partnerships are "latently" infected and the desire by most HCPs to protect or control knowledge around fertility and safer conception methods out of concern over what clients will do with this knowledge before they are virally suppressed or ready to conceive. Almost all participants who had conceived or attempted conception did so without safer conception methods knowledge. HCP concern over conception readiness, perception of what clients will do with safer conception knowledge, and gaps in safer conception knowledge prevent HCPs from initiating conversations with HIV-affected patients on the issue of childbearing. Examining these findings in the context of existing South African guidelines illuminates areas that need to be addressed to facilitate implementation of the guidelines.

Acceptability and preferences for safer conception HIV prevention strategies: a qualitative study.

Safer conception strategies to reduce the HIV transmission risk include antiretroviral therapy for HIV-positive partners, pre-exposure prophylaxis for HIV-negative partners, condomless sex limited to fertile periods, and home-based self-insemination. Resistance to taking treatment or cultural concerns may limit uptake of strategies and intervention success. Understanding the acceptability and preferences between different approaches is important to optimise service delivery. Between February and July 2013, 42 adults (21 HIV-positive and 21 HIV-negative) receiving primary care at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, participated in focus group discussions or in-depth interviews. Themes were analysed using a grounded theory approach. Acceptability of antiretroviral-based strategies varied. Concerns over side effects, antiretroviral treatment duration and beliefs that treatment is only for the sick were common barriers; however, desperation for a child was noted as a facilitator for uptake. HIV-negative men and HIV-positive women had favourable attitudes towards self-insemination, though paternity and safety concerns were raised. Self-insemination was generally preferred over pre-exposure prophylaxis by HIV-negative men, and antiretroviral-based strategies were preferred by couples with HIV-negative female partners, despite concerns raised about condomless sex while virally suppressed. Knowledge about the fertile window was low. A strong counselling component will be required for effective uptake and adherence to safer conception services.

Acceptability and Feasibility of a Mobile Phone-Based Case Management Intervention to Retain Mothers and Infants from an Option B+ Program in Postpartum HIV Care.

The objective of this study was to assess the acceptability and feasibility of a cell phone based case manager intervention targeting HIV-infected pregnant women on highly-active antiretroviral therapy (HAART). Pregnant women ≥36 weeks gestation attending antenatal care and receiving HAART through the Option B+ program at a primary care clinic in South Africa were enrolled into a prospective pilot intervention to receive text messages and telephone calls from a case manager through 6 weeks postpartum. Acceptability and feasibility of the intervention were assessed along with infant HIV testing rates and 10-week and 12-month postpartum maternal retention in care. Retention outcomes were compared to women of similar eligibility receiving care prior to the intervention. Fifty women were enrolled into the pilot from May to July 2013. Most (70%) were HAART-naive at time of conception and started HAART during antenatal care. During the intervention, the case manager sent 482 text messages and completed 202 telephone calls, for a median of 10 text messages and 4 calls/woman. Ninety-six percent completed the postpartum interview and 47/48 (98%) endorsed the utility of the intervention. Engagement in 10-week postpartum maternal HIV care was >90% in the pre-intervention (n = 50) and intervention (n = 50) periods; by 12-months retention fell to 72% and was the same across periods. More infants received HIV-testing by 10-weeks in the intervention period as compared to pre-intervention (90.0 vs. 63.3%, p < 0.01). Maternal support through a cell phone based case manager approach was highly acceptable among South African HIV infected women on HAART and feasible, warranting further assessment of effectiveness.

"What they wanted was to give birth; nothing else": barriers to retention in option B+ HIV care among postpartum women in South Africa.

BACKGROUND: Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count. METHODOLOGY: We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa. RESULTS: Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma. CONCLUSIONS: We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.

Implementation of a safer conception service for HIV-affected couples in South Africa.

OBJECTIVE: To describe the development and implementation of a safer conception service in a resource-limited setting. METHODS: Qualitative work to inform the design of a safer conception service was conducted with clients and providers at Witkoppen Health and Welfare Centre, a primary health center in Johannesburg, South Africa. Services began in July 2013 for HIV-affected participants planning conception within 6 months and included counseling about timed unprotected intercourse and home-based self-insemination, early initiation of combined antiretroviral therapy (cART) for HIV-infected individuals, pre-exposure prophylaxis for HIV-uninfected partners and circumcision for men. Participants were enrolled into an implementation science study evaluating method uptake, acceptability, and pregnancy and HIV transmission outcomes. RESULTS: Findings to-date from 51 qualitative participants and 128 clinical cohort participants (82 women and 46 men, representing 82 partnerships) are presented. All men were accompanied by female partners, whereas 56% of women attended with their male partner. Fifteen of the 46 couples (33%) were in confirmed serodiscordant relationships; however, of the 36 additional women attending alone, 56% were unaware of their partners' HIV status or believed them to be HIV-uninfected. The majority of the HIV-infected women (86%) and men (71%) were on cART at enrollment; however, only 47% on cART were virally suppressed. Timed unprotected intercourse, self-insemination and cART were common choices for participants; few elected pre-exposure prophylaxis. CONCLUSIONS: Lessons learned from early implementation demonstrate feasibility of safer conception services; however, reaching discordant couples, cART-naïve infected partners, and men remain challenges. Creating demand for safer conception services among those at highest risk for HIV transmission is necessary.