Objective Tuberculosis (TB) stigma is a critical barrier to timely diagnosis and treatment, yet few studies have quantified community-level TB stigma or its variability across geographic contexts. This study describes methods for capturing community-level TB stigma and examines stigma variability and correlations with community-level sociodemographic and TB-related factors across urban, periurban and rural communities.Design Ecological study.Setting 93 demarcated study communities in Buffalo City Metropolitan Health District, Eastern Cape, South Africa.Participants 3869 heads of household, age ≥18 years, were surveyed in a geographically clustered random sample of households across the 93 study communities.Primary outcome measures Validated scales were used to measure perceived TB stigma. Community levels of TB stigma were generated by aggregating individual responses within each study community.Results Median community TB stigma scores varied significantly by community location: compared with urban communities, rural communities had lower TB stigma scores (beta=−0.235; 95% CI −0.362 to −0.108) while periurban communities had higher scores (beta=0.136; 95% CI 0.017 to 0.254). Community TB stigma was positively associated with community HIV stigma, with the strongest associations in urban (beta=0.977 (95% CI 0.634 to 1.321) and rural (beta=0.816 (95% CI 0.186 to 1.446) communities. No associations were observed between TB stigma and TB prevalence, TB knowledge or household demographics after adjusting for community location.Conclusions TB stigma varied meaningfully across communities and was associated with urbanicity and HIV stigma. Stigma is a complex social process and there may be many other factors shaping TB stigma at the community level. Future research and stigma-reduction interventions should consider local contexts and community-level determinants beyond individual demographics, TB knowledge or community TB burden.
We examined the association between educational attainment and HIV positivity among pregnant women in a high HIV-prevalence setting and assessed how this relationship varies by age to inform targeted prevention strategies. This cross-sectional study included 2003 pregnant women aged 21-44 years attending their first antenatal visit (<27 weeks' gestation) at four public health facilities in East London, South Africa, between March 2021 and May 2024. Educational attainment was categorized as pre-high school (< grade 10), high school (grades 10-12), diploma (post-high school), or degree (associate's or bachelor's). Age was categorized into four groups (21-24, 25-29, 30-34, and 35-44 years). HIV status was determined through routine antenatal testing. We used logistic regression to assess associations between educational attainment and HIV positivity, adjusting for age, partner's HIV status, and participant sexually transmitted infection (STI) status. Overall HIV prevalence was 31.0% (95% CI, 28.9%-33.0%). Compared with women with less than a high school education, the odds of HIV infection were lower among women who attained high school education (adjusted odds ratio [AOR], 0.59; 95% CI, 0.40-0.87), a diploma (AOR, 0.40; 95% CI, 0.24-0.67), or a degree (AOR, 0.21; 95% CI, 0.09-0.43). However, this inverse association was not observed among women aged 35-44 years. In conclusion, higher educational attainment was associated with lower HIV prevalence among pregnant women, but this protective association diminished with increasing age. HIV prevention strategies should account for both socioeconomic factors and age-related interpersonal dynamics influencing HIV vulnerability.
Background:Community-based tuberculosis screening can identify asymptomatic tuberculosis, but microbiological confirmation has been sputum-dependent. We evaluated the diagnostic performance, yield, and operational characteristics of centralized qPCR testing of community-collected tongue swabs (TS). Methods:We conducted a cross-sectional study among household contacts (HHCs; ≥18 years) of individuals receiving treatment for pulmonary TB in South Africa. During household visits, health workers collected TS specimens and, where possible, sputum, which was tested in participants' homes using Xpert MTB/RIF Ultra. TSs were transported non-refrigerated in molecular transport medium to a distant central laboratory for manual qPCR assay. The primary outcome was diagnostic performance of TS qPCR compared with sputum Xpert Ultra using paired results. Secondary outcomes were diagnostic yield by TS and operational indicators of the centralized testing workflow. Findings:909 HHCs were enrolled; median age 39 years (IQR 28-55), 532 (58·5%) were asymptomatic, 617 (67·9%) were sputum scarce. TS were collected from 901/909 (99·1%) and sputum from 292/909 (32·1%) participants. Among 271 paired TS-sputum results, TS qPCR sensitivity was 60·9% (95% CI 38·5-80·3), specificity 95·2% (91·7-97·5), and overall agreement 92·3% (88·5-95·0). Yield increased from 1·8% (95% CI 1·0-2·8) with symptom-restricted sputum testing to 3·2% (2·1-4·5) with symptom-agnostic sputum testing and 5·9% (4·5-7·7) when TS testing was implemented among sputum-scarce individuals, identifying 25 additional HHCs with positive molecular test results (86·2% increase). Operational indicators demonstrated successful implementation, with 2·3% specimen loss and valid molecular results for 93·8% who provided a TS. Interpretation:Despite lower per-test sensitivity than sputum testing, TS may provide a scalable strategy for expanding microbiological screening beyond sputum-dependent pathways, thereby substantially increasing tuberculosis detection among HHCs. Funding:U.S. NIH; Australian Department of Foreign Affairs and Trade; UK Foreign, Commonwealth and Development Office.
In a South African antenatal cohort, an immediate test-and-treat model for syphilis of unknown duration showed that adverse birth outcomes—including stillbirth and preterm birth—were similar between women without syphilis and those treated with penicillin, regardless of completion of the three-dose regimen. Further studies are needed to evaluate optimal treatment strategies in pregnancy.
Quality of life (QoL) for people affected by tuberculosis (TB) is generally poor. However, little is known about when and why it changes during treatment. Such knowledge is key to the development and implementation of meaningful interventions. We sought to explore perceptions of QoL amongst people with pulmonary TB during and after treatment. This study was embedded within a larger study exploring multilevel determinants on TB cascade-of-care outcomes in Eastern Cape, South Africa. Between November 2023 and April 2024, 33 adults were purposively sampled for individual semi-structured interviews early, mid, and at the conclusion of treatment. Questions explored perspectives on current QoL and changes in specific domains (e.g., role functioning, mental wellbeing) during illness and treatment. Inductive and deductive techniques were combined in thematic analysis which incorporated QoL and chronic illness frameworks. Participants described a common trajectory in QoL changes; however, overall assessments of QoL were highly personal. Shared trajectory was characterized by four phases: ‘progressive disability to diagnosis’, ‘treatment challenges and QoL bottom’, ‘inflection and hope’, and ‘stability and incomplete resolution’. TB symptoms limited functional mobility, causing a financial crisis for many. Intense need for caregiving, emotional, and financial support persisted for weeks and months until physical gains eased problems in other domains. However, many who had completed treatment described continued weakness and inability to work. Participants provided highly varied assessments of current QoL rooted in personal priorities and individual circumstances. While few clear trends were noted, those with recurrent TB (48
