People who inject drugs (PWID) and people who use drugs (PWUD) bear a disproportionate burden of hepatitis C virus (HCV) infection globally. In South Africa, HCV testing and treatment remain limited outside externally funded projects. This study investigated the implementation feasibility of assisted HCV self-testing (HCVST) among PWID and PWUD in Johannesburg. Between 12th May 2023 and 28th March 2024, participants were recruited to an implementation study across mobile harm reduction sites and a central clinic. Participants performed self-tests using either oral-fluid or blood-based HCV antibody rapid tests. Reactive results were followed by on-site venous sampling for confirmatory RNA testing and referral for direct-acting antiviral (DAA) therapy at a centralized facility. We describe HCV case-detection, care cascade progression, and behavioral risk factors associated with HCV reactivity using logistic regression. Of 1,566 participants tested, 998 (63.7%) were HCV reactive. The median age was 31 years (IQR 28–35); 82.2% were male and 77.1% identified as PWID. Ever injecting drugs (OR 35.6, 95% CI 23.6–56.0), frequent injecting (≥ daily: OR 36.7, 95% CI 25.1–55.3), and recent needle sharing (OR 7.3, 95% CI 5.8–9.3) were the strongest predictors of HCV reactivity. Histories of incarceration were also independently associated with HCV reactivity (OR 3.2, 95% CI 2.6–4.0). Despite high self-testing acceptability, progression through the care cascade was limited: among 854 RNA-confirmed infections, only 147 (17.2%) were prioritized for treatment, with three participants achieiving sustained virologic response. Thematic analysis identified fear of needles, poor venous access, and structural barriers, notably centralized treatment delivery, as key impediments to linkage. This study showed a high burden of HCV among PWID and PWUD in Johannesburg and demonstrates that assisted HCVST is acceptable. Centralized treatment models severely constrained linkage to care. Simplified delivery of treatment is critical in transforming diagnosis into cure. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial South African National Clinical Trial Registry unique identification number for the registry is DOH-27-122022-4828 ### Funding Statement This work was supported by Unitaid grant (2017-16-PSI-STAR to KH). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for the study was obtained from the University of the Witwatersrand Human Research Ethics Committee (220306), South African Health Products Regulatory Authority (MD20220801), South African National Clinical Trial Registry unique identification number for the registry is DOH-27-122022-4828, and World Health Organization Ethics Review Committee (0003847). All participants provided written informed consent prior to participation. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data are within the paper and its Supporting Information files.

Community advisory boards (CABs) are an important tool in HIV research to support study design, implementation, and dissemination of results. However, there is limited reporting on CABs focused on sexual and gender minorities in African settings given a history of legal, social, and cultural barriers that are also an emerging global concern. Working from a queer theory lens, we explored the perceptions of sexual minority men (SMM) and community stakeholders on setting up a CAB to guide the development of an HIV treatment intervention in Eastern Cape, South Africa. We conducted in-depth interviews with SMM ( n = 15) and focus group discussions with community stakeholders ( n = 7) to identify considerations and preferences for CAB membership. We found that SMM value diversity in identities represented in the CAB, want to use the CAB as a means to occupy community space, want CAB members to be approachable leaders, and are aware of challenges they may have to navigate in their work with other SMM in the community. From these insights, we propose guiding concepts for conducting SMM-focused CAB work in similar HIV research-limited settings. Our hope is that future researchers working with SMM, in Africa and elsewhere, put these guiding concepts into practice when developing CABs and contribute to the project of queering global health.

In South Africa, sexual minority men (SMM) face high HIV rates and challenges with antiretroviral therapy (ART) adherence, hindering viral suppression. Factors, such as non-disclosure, stigma, and partner dynamics, complicate adherence. Long-acting ART options, like injectables, could help address these challenges; however, their acceptability among SMM in South Africa remains unclear. Between April and June 2024, qualitative interviews were conducted with 21 SMM who participated in the Speaking Out & Allying Relationships (SOAR) a video- and skills-based HIV intervention, supporting SMM's communication and coping skills for status-sharing and treatment adherence in South Africa, to explore their initial impressions of injectable ART. Interviews explored disclosure, adherence, partner dynamics, and attitudes toward injectable ART. Participants viewed injectables as a major improvement over daily pills, citing benefits, such as reduced mental burden and increased privacy and safety. They felt that injectables could give them more control over disclosure, and flexibility to manage treatment during social interactions. These findings suggest that long-acting ART could improve adherence and reduce stigma, aligning with SMMs dynamic lifestyle. Further research is necessary to evaluate the effectiveness and accessibility of injectable ART for SMM in South Africa, emphasizing supportive healthcare systems and training providers in this emerging treatment landscape.Abbreviations: ART: antiretroviral therapy; SMM: sexual minority men; U = U: undetectable = untransmittable (HIV campaigns and messaging).

BACKGROUND:The HIV continuum of care for men who have sex with men (MSM) in South Africa remains inadequately characterised, hindering the tracking of progress towards ending the HIV epidemic. We estimated HIV prevalence and care continuum indicators for MSM in three South African cities. METHODS AND FINDINGS:MSM were recruited via respondent-driven sampling (RDS) methods in Cape Town, Johannesburg, and Mahikeng. Eligibility criteria included age ≥ 18 years, assigned male sex at birth, recent oral or anal sex with a man, and living, working, or socialising in one of the selected cities within the past six months. Participants completed a survey, and dried blood spots were collected to test for HIV antibodies, antiretrovirals, and HIV viral load. RDS weights were used to estimate HIV prevalence and 95-95-95 care continuum indicators. From May to October 2019, 1,790 cisgender MSM were sampled. HIV prevalence was highest in Johannesburg (weighted prevalence = 40.7%, 95% confidence interval 34.4-47.3), followed by Cape Town (25.2%, 20.9-30.1) and Mahikeng (14.7%, 12.0-17.8). Among MSM living with HIV, awareness of status was 67.0% (56.8-75.8) in Cape Town, 67.8% (56.7-77.1) in Johannesburg, and 60.2% (49.9-69.8) in Mahikeng. ART coverage among those aware of their status was 65.1% (53.4-75.2) in Cape Town, 77.9% (67.2-85.8) in Johannesburg, and 72.5% (58.6-83.0) in Mahikeng. Viral suppression among those on ART was 79.3% (59.5-90.9) in Cape Town, 88.7% (77.8-94.6) in Johannesburg, and 90.7% (78.1-96.4) in Mahikeng. CONCLUSIONS:Achievements towards HIV care indicators were sub-optimal for MSM in three South African sites, revealing potential gaps in the reach and uptake of HIV testing and treatment services. Research identifying multi-level determinants of these gaps is needed to guide the development of contextually appropriate and effective interventions.

Sexual minority men (SMM) and transgender women in South Africa engage in HIV care at lower rates than other persons living with HIV and may experience population-specific barriers to HIV treatment and viral suppression (VS). As part of a pilot trial of an SMM-tailored peer navigation (PN) intervention in Ehlanzeni district, South Africa, we assessed factors associated with ART use and VS among SMM at trial enrolment. A total of 103 HIV-positive SMM and transgender women enrolled in the pilot trial. Data on clinical visits and ART adherence were self-reported. VS status was verified through laboratory analysis (<1000 copies/ml). We assessed correlates of VS at baseline using Poisson generalized linear model (GLM) with a log link function, including demographic, psychosocial, clinical, and behavioral indicators. Among participants, 52.4% reported ART use and only 42.2% of all participants had evidence of VS. Of the 49.5% who reported optimal engagement in HIV care (consistent clinic visits with pills never missed for ≥ 4 consecutive days) in the past 3-months, 56.0% were virally suppressed. In multivariable analysis, SMM were significantly more likely to be virally suppressed when they were ≥ 25 years of age (Adjusted prevalence ratio [APR] = 2.0, CI 95%:1.0-3.8); in a relationship but not living with partner, as compared to married, living together, or single (APR = 1.7, CI 95%:1.0-2.7), and optimally engaged in care (APR = 2.1, 95% CI:1.3-3.3). Findings indicate a need for targeted treatment and care support programming, especially for SMM and transgender women who are young and married/living with their partners to improve treatment outcomes among this population.

Availability of HIV self-testing may increase HIV testing frequency among men who have sex with men (MSM). It is unclear, however, if self-testing may impact HIV-related sexual behaviors among MSM, including HIV status disclosure and condom use. We conducted a mixed methods analysis of changes in HIV-related behaviors after HIV self-testing introduction, using data from 110 MSM participating in a feasibility and acceptability study of HIV self-testing in Mpumalanga Province, South Africa. We found increased HIV status disclosure from study participants to sexual partners after HIV self-testing introduction, from 61.8% at baseline to 75.5% at 6-month follow-up (p = 0.04), but decreased condom use with female partners (p = 0.03). Qualitative interviews reveal that some participants used test results to inform condom use. Distribution of self-testing kits can improve mutual disclosure, but should be accompanied by information stressing that the tests may not detect early HIV infections or other sexually transmitted infections.

OBJECTIVE To assess whether exposure to high temperatures in pregnancy is associated with increased risk for preterm birth, low birth weight, and stillbirth. DESIGN Systematic review and random effects meta-analysis. DATA SOURCES Medline and Web of Science searched up to September 2018, updated in August 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Clinical studies on associations between high environmental temperatures, and preterm birth, birth weight, and stillbirths. RESULTS 14 880 records and 175 full text articles were screened. 70 studies were included, set in 27 countries, seven of which were countries with low or middle income. In 40 of 47 studies, preterm births were more common at higher than lower temperatures. Exposures were classified as heatwaves, 1 degrees C increments, and temperature threshold cutoff points. In random effects metaanalysis, odds of a preterm birth rose 1.05-fold (95% confidence interval 1.03 to 1.07) per 1 degrees C increase in temperature and 1.16-fold (1.10 to 1.23) during heatwaves. Higher temperature was associated with reduced birth weight in 18 of 28 studies, with considerable statistical heterogeneity. Eight studies on stillbirths all showed associations between temperature and stillbirth, with stillbirths increasing 1.05-fold (1.01 to 1.08) per 1 degrees C rise in temperature. Associations between temperature and outcomes were largest among women in lower socioeconomic groups and at age extremes. The multiple temperature metrics and lag analyses limited comparison between studies and settings. CONCLUSIONS Although summary effect sizes are relatively small, heat exposures are common and the outcomes are important determinants of population health. Linkages between socioeconomic status and study outcomes suggest that risks might be largest in low and middle income countries. Temperature rises with global warming could have major implications for child health.

Weather conditions, especially temperature and precipitation, play a critical role in shaping patterns of diarrhoeal diseases. They determine the frequency of outbreaks, and the spatial and seasonal distribution of cases. Not surprisingly, it is anticipated that the burden of diarrhoeal diseases will escalate with climate change, in tandem with gradual increments in mean temperatures, but also during episodic heatwaves. The degree and nature of this escalation will, however, vary with the mix of pathogens in an area, the quality of sanitation services, food hygiene regulations and their enforcement, and the age structure of the population, among other factors. Understanding these patterns can inform the design of measures to prevent and control heat-related diarrhoea. In this editorial, we sum evidence on the heat sensitivity of enteric infections in South Africa (SA) and other parts of sub-Saharan Africa (19 studies), drawing on articles located in a systematic review (methods detailed in Manyuchi et al. [1]), and consider the implications of these findings for control of diarrhoea in SA in the context of climate change.

Africa is one of the most vulnerable continents to climate change because of its heightened sensitivity to climate variability and inadequate institutional adaptive capacity. Notwithstanding these challenges, Africa, and its inhabitants, have been confronting the vagaries of climate for centuries, including severe droughts and floods. Given this context, this paper provides a commentary on the efforts to ensure and enable climate services on the continent as well as a critical, reflexive assessment of activities in this varied landscape. A special focus on the institutional frameworks and the underlying knowledge systems that support and interface with climate services will be examined. A central question underpinning the paper is: to what extent is the expanding landscape of climate services being endogenously driven in Africa? Finally, some recommendations for future efforts to enhance effective institutions and knowledge brokering and facilitate better climate services in Africa are suggested.

A data triangulation exercise was carried out between 2013 and 2015 to assess the HIV epidemic and response among gay, bisexual and other men who have sex with men (GBMSM) in South Africa. We used the findings to assess progress in achieving the UNAIDS 90-90-90 goals for GBMSM in the country. Three scenarios were developed using different GBMSM population factors (2.0, 3.5 and 5.0% of males aged ≥15) to estimate the population size, HIV prevalence of 13.2–49.5%, and 68% of GBMSM knowing their status. Due to data gaps, general population data were used as estimates of GBMSM on antiretroviral therapy (ART) and virologically suppressed (25.7 and 84.0%, respectively). The biggest gap is access to ART. To address the data gap we recommend developing data collection tools, indicators, and further quantification of HIV cascades. Targeted testing, linkage to services and scaled-up prevention interventions (including pre-exposure prophylaxis) are also required.

Background Robust population size estimates of female sex workers and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators. This has, consequently, challenged the appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-2014 integrated biological and behavioral surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among female sex workers in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation methods. Objective The objective of our study was to present the selected population size estimation methods used in an IBBS survey and the subsequent participatory process used to estimate the number of female sex workers in three South African cities. Methods In 2013-2014, we used respondent-driven sampling to recruit independent samples of female sex workers for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based population size estimation methods into the survey, from which investigators calculated weighted estimates and ranges of population size estimates for each city’s female sex worker population. Following data analysis, investigators consulted civil society stakeholders to present survey results and size estimates and facilitated stakeholder vetting of individual estimates to arrive at consensus point estimates with upper and lower plausibility bounds. Results In total, 764, 650, and 766 female sex workers participated in the survey in Johannesburg, Cape Town, and eThekwini, respectively. For size estimation, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey and presented these to a civil society-convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, ensuring inclusion only of plausible point estimates in median calculation. After vetting, stakeholders adopted three consensus point estimates with plausible ranges: Johannesburg 7697 (5000-10,895); Cape Town 6500 (4579-9000); eThekwini 9323 (4000-10,000). Conclusions Using several population size estimates methods embedded in an IBBS survey and a participatory stakeholder consensus process, the South Africa Health Monitoring Survey produced female sex worker size estimates representing approximately 0.48%, 0.49%, and 0.77% of the adult female population in Johannesburg, Cape Town, and eThekwini, respectively. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically based size estimates procedures to ensure adoption and utilization of data-informed size estimates for coordinated national and subnational benchmarking. It also has the potential to increase coherence in national and key population-specific HIV responses and to decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around estimates and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available, as these additional data points may minimize the impact of the known and unknown biases inherent in any single, investigator-calculated method.

BACKGROUND:HIV self-testing (HIVST) may increase HIV testing uptake, facilitating earlier treatment for key populations like MSM who experience barriers accessing clinic-based HIV testing. HIVST usability among African MSM has not been explored.METHODS:We assessed usability of oral fluid (OF) and fingerstick (FS; blood) HIVST kits during three phases among MSM with differing degrees of HIVST familiarity in Mpumalanga, South Africa. In 2015, 24 HIVST-naïve MSM conducted counselor-observed OF and FS HIVST after brief demonstration. In 2016 and 2017, 45 and 64 MSM with experience using HIVST in a pilot study chose one HIVST to conduct with a counselor-observer present. In addition to written, the latter group had access to video instructions. We assessed frequency of user errors and reported test use ease, changes in error frequency by phase, and covariates associated with correct usage using log-Poisson and Gaussian generalized estimating equations.RESULTS:Among OF users (n = 57), 15-30% committed errors in each phase; however, observers consistently rated participants as able to test alone. Among FS users (n = 100), observers noted frequent errors, most commonly related to blood collection and delivery. We found suggestive evidence (not reaching statistical significance) that user errors decreased, with 37.5%, to 28.1%, and 18.2% committing errors in phases I, II, and III, respectively (p-value:0.08), however observer concerns remained constant. Ease and confidence using HIVST increased with HIV testing experience. Participants using three HIVST were more likely (RR:1.92, 95% CI:1.32, 2.80) to report ease compared to those without prior HIVST experience. Never testers (RR:0.66, 95% CI:0.44-0.99) reported less ease performing HIVST compared to participants testing in the past six months.CONCLUSIONS:MSM were able to perform the OF test. Fingerstick test performance was less consistent; however preference for fingerstick was strong and performance may improve with exposure and instructional resources. Continued efforts to provide accessible instructions are paramount.

Robust population size estimates (PSEs) for female sex workers (FSW) and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators; this has consequently challenged appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-14 Integrated Biological and Behavioral Surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among FSW in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation (PSE) methods. To present the selected PSE methods used in an IBBS survey and subsequent participatory process used to estimate the number of FSW in three South African cities. In 2013-14 we used respondent driven sampling (RDS) to recruit independent samples of FSW for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based PSE methods into the survey, from which investigators calculated a range of PSEs for each city’s FSW population. Following data analysis, investigators consulted civil society stakeholders to present survey results and PSEs and facilitated stakeholder vetting of individual PSEs to arrive at consensus point estimates with upper and lower plausibility bounds. A total of 2,180 FSW participated in the SAHMS survey. To perform the size estimate exercise, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey, and presented these to a civil-society convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, to ensure that only plausible point estimates were included in the calculation of the median. After vetting, stakeholders adopted three consensus point estimates with plausible ranges (PR): Johannesburg 7,697 (plausible range (PR) 5,000 - 10,895); Cape Town 6,500 (PR 4,579-9,000); eThekwini 9,323 (PR 4,000-10,000). Through the use of several PSE methods embedded in an IBBS survey and a participatory stakeholder consensus process, SAHMS produced FSW size estimates representing approximately 0.48%, 0.49% and 0.77% of the adult female population in Johannesburg, Cape Town and eThekwini. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically-based PSE procedures to ensure adoption and utilization of data-informed PSEs for coordinated national and sub-national benchmarking. Incorporating stakeholder consensus in PSE methodology has the potential to increase coherence in national and key populations-specific HIV responses, and decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around PSE and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available in order to increase accuracy and precision over time, and decrease biases inherent in any single, investigator calculated method.

We describe the accuracy of serial rapid HIV testing among men who have sex with men (MSM) in South Africa and discuss the implications for HIV testing and prevention.This was a cross-sectional survey conducted at five stand-alone facilities from five provinces.Demographic, behavioral, and clinical data were collected. Dried blood spots were obtained for HIV-related testing. Participants were offered rapid HIV testing using 2 rapid diagnostic tests (RDTs) in series. In the laboratory, reference HIV testing was conducted using a third-generation enzyme immunoassay (EIA) and a fourth-generation EIA as confirmatory. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, false-positive, and false-negative rates were determined.Between August 2015 and July 2016, 2503 participants were enrolled. Of these, 2343 were tested by RDT on site with a further 2137 (91.2%) having definitive results on both RDT and EIA. Sensitivity, specificity, positive predictive value, negative predictive value, false-positive rates, and false-negative rates were 92.6% [95% confidence interval (95% CI) 89.6-94.8], 99.4% (95% CI 98.9-99.7), 97.4% (95% CI 95.2-98.6), 98.3% (95% CI 97.6-98.8), 0.6% (95% CI 0.3-1.1), and 7.4% (95% CI 5.2-10.4), respectively. False negatives were similar to true positives with respect to virological profiles.Overall accuracy of the RDT algorithm was high, but sensitivity was lower than expected. Post-HIV test counseling should include discussions of possible false-negative results and the need for retesting among HIV negatives.