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Will global warming undo the hard-won gains of prevention of mother-to-child transmission of HIV?
Chersich, Matthew
- , 2019, DOI: 10.7196/SAMJ.2019.V109I5.13988
Abstract:
Health system weaknesses constrain access to PMTCT and maternal HIV services in South Africa: a qualitative enquiry
Courtenay Sprague, Matthew F Chersich, Vivian Black
AIDS Research and Therapy , 2011, DOI: 10.1186/1742-6405-8-10
Abstract: In-depth interviews identified considerable weaknesses within operational HIV service delivery. These manifested as missed opportunities for HIV testing in antenatal care due to shortages of test kits; insufficient staff assigned to HIV services; late payment of lay counsellors, with consequent absenteeism; and delayed transcription of CD4 cell count results into patient files (required for ART initiation). By contrast, individual factors undermining access encompassed psychosocial concerns, such as fear of a positive test result or a partner's reaction; and stigma. Data and information systems for monitoring in the three peri-urban facilities were markedly inadequate.A single system- or individual-level delay reduced the likelihood of women accessing ART or PMTCT interventions. These delays, when concurrent, often signalled wholesale denial of prevention and treatment. There is great scope for health systems' reforms to address constraints and weaknesses within PMTCT and ART services in South Africa. Recommendations from this study include: ensuring autonomy over resources at lower levels; linking performance management to facility-wide human resources interventions; developing accountability systems; improving HIV services in labour wards; ensuring quality HIV and infant feeding counselling; and improved monitoring for performance management using robust systems for data collection and utilisation.In 2002, a national programme to prevent mother-to-child transmission of HIV (PMTCT) was established in South Africa, followed by an antiretroviral treatment (ART) initiative in 2004. To enhance ART access for pregnant women and address high mortality among women and children, eligibility criteria for ART initiation were revised in April 2010 to include all women with a CD4 cell count below 350 cells/mm3 [1,2]. This marked a notable departure from previous ART criteria of an AIDS-defining condition or a CD4 count below 200 cells/mm3 [3,4], and is consistent with WHO guid
National Health Insurance and climate change: Planning for South Africa's future
Chersich, Matthew,Mathee, Angela,Wright, Caradee Y.
- , 2019, DOI: 10.17159/sajs.2019/5800
Abstract:
Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa
Matthew F Chersich, Helen V Rees, Fiona Scorgie, Greg Martin
Globalization and Health , 2009, DOI: 10.1186/1744-8603-5-16
Abstract: Globally, HIV and other sexually-transmitted infections (STI) account for 6.3% of the burden of disease and alcohol for 4%, similar to that caused by tobacco (4.1%) and high blood pressure (4.4%) [1]. In some sub-Saharan countries, such as South Africa, for example, the burden attributable to these conditions is even greater - HIV and other STI constitute about a third of disease and alcohol an estimated 7.9% [2]. Overall, much of sub-Saharan Africa carries a massive burden of HIV and of alcohol disease, and these pandemics are inextricably linked. The conditions share many common determinants and together exacerbate the underlying socio-economic inequalities in this region. As we discuss in this article, alcohol disease and HIV have an especially intimate link: alcohol has independent effects on decision-making concerning sex, and on skills for negotiating condoms and their correct use. Thus far global initiatives to prevent HIV and other sexually transmitted infections (STI) have largely ignored the potential mediatory role of alcohol in unsafe sex (for example, note that the list of WHO HIV prevention priorities does not mention alcohol) [3].Alcohol use results in a considerable range of diseases, the occurrence of which is contingent upon three factors: lifetime cumulative volume consumed; patterns of drinking; and drinking contexts [4,5]. Overall lifetime volume of alcohol is linked to chronic social problems (such as unemployment) and to chronic diseases such as alcoholic liver cirrhosis. By contrast, pattern of drinking (amount per drinking episode), in particular frequent episodes of intoxication, is a powerful mediator of acute problems such as accidents, interpersonal violence and high-risk sexual behaviour [5,6]. Context of alcohol use is also a critical determinant of its consequences, as opportunities for sexual encounters and for drinking alcohol often co-exist in both social dynamics and physical locations [7-10]. This means that the impact of alcohol
Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme
Veloshnee Govender,Matthew F. Chersich,Bronwyn Harris,Olufunke Alaba
Global Health Action , 2013, DOI: 10.3402/gha.v6i0.19253
Abstract: Background: In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. Objectives: This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. Methods: Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. Results: Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. Conclusion: Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.
Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services
Matthew F Chersich,Stanley Luchters,Innocent Ntaganira,Antonio Gerbase
Journal of the International AIDS Society , 2013, DOI: 10.7448/ias.16.1.17980
Abstract: Introduction: Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery. Methods: We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes. Results: We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection. Conclusions: There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.
Birth outcomes in South African women receiving highly active antiretroviral therapy: a retrospective observational study
van der Merwe Karin,Hoffman Risa,Black Vivian,Chersich Matthew
Journal of the International AIDS Society , 2011, DOI: 10.1186/1758-2652-14-42
Abstract: Background Use of highly active antiretroviral therapy (HAART), a triple-drug combination, in HIV-infected pregnant women markedly reduces mother to child transmission of HIV and decreases maternal morbidity. However, there remains uncertainty about the effects of in utero exposure to HAART on foetal development. Methods Our objectives were to investigate whether in utero exposure to HAART is associated with low birth weight and/or preterm birth in a population of South African women with advanced HIV disease. A retrospective observational study was performed on women with CD4 counts ≤250 cells/mm3 attending antenatal antiretroviral clinics in Johannesburg between October 2004 and March 2007. Low birth weight (<2.5 kg) and preterm birth rates (<37 weeks) were compared between those exposed and unexposed to HAART during pregnancy. Effects of different HAART regimen and duration were assessed. Results Among HAART-unexposed infants, 27% (60/224) were low birth weight compared with 23% (90/388) of early HAART-exposed (exposed <28 weeks gestation) and 19% (76/407) of late HAART-exposed (exposed ≥28 weeks) infants (p = 0.05). In the early HAART group, a higher CD4 cell count was protective against low birth weight (AOR 0.57 per 50 cells/mm3 increase, 95% CI 0.45-0.71, p < 0.001) and preterm birth (AOR 0.68 per 50 cells/mm3 increase, 95% CI 0.55-0.85, p = 0.001). HAART exposure was associated with an increased preterm birth rate (15%, or 138 of 946, versus 5%, or seven of 147, in unexposed infants, p = 0.001), with early nevirapine and efavirenz-based regimens having the strongest associations with preterm birth (AOR 5.4, 95% CI 2.1-13.7, p < 0.001, and AOR 5.6, 95% CI 2.1-15.2, p = 0.001, respectively). Conclusions In this immunocompromised cohort, in utero HAART exposure was not associated with low birth weight. An association between NNRTI-based HAART and preterm birth was detected, but residual confounding is plausible. More advanced immunosuppression was a risk factor for low birth weight and preterm birth, highlighting the importance of earlier HAART initiation in women to optimize maternal health and improve infant outcomes.
Nothing as Practical as a Good Theory? The Theoretical Basis of HIV Prevention Interventions for Young People in Sub-Saharan Africa: A Systematic Review
Kristien Michielsen,Matthew Chersich,Marleen Temmerman,Tessa Dooms,Ronan Van Rossem
AIDS Research and Treatment , 2012, DOI: 10.1155/2012/345327
Abstract: This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV prevention interventions for youth. Additional articles were identified on websites of international organisations and through searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent ( ), followed by Health Belief Model ( ), and Theory of Reasoned Action/Planned Behaviour ( ). These cognitive behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three articles provided information about why a particular theory was selected. Interventions used theory to inform content ( ), for evaluation purposes ( ) or both ( ). No patterns of differential effectiveness could be detected between studies using and not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual factors. 1. Introduction With an estimated 2.7 million new infections worldwide in 2010, HIV incidence remains at very high levels [1]. Sub-Saharan Africa, accounting for 70% of these infections, remains particularly affected. About 40% of new HIV infections occur in the age group 15 to 24 years [1]. Therefore, targeted prevention programmes for young people are essential in reversing the HIV epidemic [2, 3]. Over the past decades, a considerable number of HIV prevention interventions for young people in sub-Saharan Africa have been developed, implemented, and evaluated. Nevertheless, even though these interventions seem to increase knowledge and encourage positive attitudes, radical changes in sexual behaviour have not occurred [4, 5]. Theory is said to be an essential component of successful health promotion interventions [6, 7]. Behavioural theory can assist to understand the determinants of risky and safe sexual behaviour [8] and hence help to identify underlying principles about how people change their behaviour [9]. Further, it aims to explains why and how behaviours occur and allows us to predict future behaviours by establishing relationships between key variables. Beyond providing
Sex Work during the 2010 FIFA World Cup: Results from a Three-Wave Cross-Sectional Survey
Wim Delva, Marlise Richter, Petra De Koker, Matthew Chersich, Marleen Temmerman
PLOS ONE , 2011, DOI: 10.1371/journal.pone.0028363
Abstract: Background In the months leading up to the 2010 FIFA World Cup in South Africa, international media postulated that at least 40,000 foreign sex workers would enter South Africa, and that an increased HIV incidence would follow. To strengthen the evidence base of future HIV prevention and sexual health programmes during international sporting events, we monitored the supply and demand of female sex work in the weeks before, during and after the 2010 FIFA World Cup. Methodology/Principal Findings We conducted three telephonic surveys of female sex workers advertising online and in local newspapers, in the last week of May, June and July 2010. The overall response rate was 73.4% (718/978). The number of sex workers advertising online was 5.9% higher during the World Cup than before. The client turnover rate did not change significantly during (adjusted rate ratio [aRR] = 1.05; 95%CI: 0.90–1.23) or after (aRR = 1.06; 95%CI: 0.91–1.24) the World Cup. The fraction of non-South African sex workers declined during (adjusted odds ratio [aOR] = 0.50; 95%CI: 0.32–0.79) and after (aOR = 0.56; 95%CI: 0.37–0.86) the World Cup. Relatively more clients were foreign during the World Cup among sex workers advertising in the newspapers (aOR = 2.74; 95%CI: 1.37–5.48) but not among those advertising online (aOR = 1.06; 95%CI: 0.60–1.90). Self-reported condom use was high (99.0%) at baseline, and did not change during (aOR = 1.07; 95% CI: 0.16–7.30) or after (aOR = 1.13; 95% CI: 0.16–8.10) the Word Cup. Conclusions/Significance Our findings do not provide evidence for mass-immigration of foreign sex workers advertising online and in local newspapers, nor a spike in sex work or risk of HIV transmission in this subpopulation of sex workers during the World Cup. Public health programmes focusing on sex work and HIV prevention during international sporting events should be based on evidence, not media-driven sensationalism that further heightens discrimination against sex workers and increases their vulnerability.
Sexual behavior of HIV-positive adults not accessing HIV treatment in Mombasa, Kenya: Defining their prevention needs
Avina Sarna, Stanley Luchters, Melissa Pickett, Matthew Chersich, Jerry Okal, Scott Geibel, Nzioki Kingola, Marleen Temmerman
AIDS Research and Therapy , 2012, DOI: 10.1186/1742-6405-9-9
Abstract: Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships; notably with 32% of HIV-negative partners and 54% of partners of unknown HIV status in the last 6 months. Multivariate analysis, controlling for intra-client clustering, showed non-disclosure of HIV status (AOR: 2.38, 95%CI: 1.47-3.84, p < 0.001); experiencing moderate levels of perceived stigma (AOR: 2.94, 95%CI: 1.50-5.75, p = 0.002); and believing condoms reduce sexual pleasure (AOR: 2.81, 95%CI: 1.60-4.91, p < 0.001) were independently associated with unsafe sex. Unsafe sex was also higher in those using contraceptive methods other than condoms (AOR: 5.47, 95%CI: 2.57-11.65, p < 0.001); or no method (AOR: 3.99, 95%CI: 2.06-7.75, p < 0.001), compared to condom users.High-risk sexual behaviors are common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. This population can be identified and reached in the community. Prevention programs need to urgently bring this population into the ambit of prevention and care services. Moreover, beginning HIV treatment earlier might assist in bringing this group into contact with providers and HIV prevention services, and in reducing risk behaviors.HIV transmission remains a significant global concern; in 2009 there were an estimated 2.6 million new infections globally [1]. At the end of 2009, about 36% of the 15 million people in need of antiretroviral treatment (ART) in low- and middle income countries were receiving ART [1].People living with HIV (PLHIV) who receive ART are in regular contact with health workers and presumably exposed to prevention messages and commodities. Indeed, several studies have documen
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