Timely linkage to HIV care is essential for achieving South Africa’s treatment goals, yet significant gaps persist in the early stages of the HIV care continuum. This study examined multilevel factors influencing linkage to care in a high HIV-prevalence rural district. A prospective convergent mixed-methods cohort study was conducted over 21 months among 1,194 adults newly diagnosed with HIV across 18 facilities in KwaZulu-Natal. Quantitative analyses (Pearson’s chi-square, Mann-Whitney tests, and logistic regression) were used to identify factors associated with linkage to care within three months of diagnosis. Qualitative data from in-depth interviews with 38 purposively selected participants were analysed thematically and triangulated with quantitative findings to provide contextual insights. Overall, 83

There is limited data on the association between pesticide exposure in children and anthropometric outcomes, particularly in non-agricultural communities and developing countries. This study investigated the association between organophosphate pesticide (OPP) exposure and anthropometric outcomes in primary schoolchildren from four informal settlements in Western Cape Province in South Africa. Using a repeated cross-sectional design of 600 schoolchildren over a 12-month period, urinary dialkyl phosphate (DAP) metabolites, diethylphosphate (DEP), dimethylphosphate (DMP), and dimethylthiophosphate (DMTP) were measured at baseline with DEP and DMP measured at follow-up. Anthropometric measurements height, weight, and Body Mass Index (BMI) were collected at both time points. The mean age for all participants at baseline was 9.93 ± 0.90 years and mean ΣDAP at baseline was 41.78 ± 33.80 ng/mL. Mean changes in weight, height, and BMI from baseline to follow-up for all participants were 6.04 ± 5.29 kg, 6.83 ± 4.00 cm, and 1.05 ± 2.01 kg/m2, respectively. Eighty percent of participants measured below the 50th percentile in height-for-age at baseline, and 76.8% at follow-up. No consistent associations were found between DAPs and anthropometric outcomes. Urinary OPP metabolite measurements and the prevalence of short stature among children in the study were high compared to other settings. The study did not find evidence of an association between OPP exposure and child anthropometric outcomes. Large longitudinal studies with follow-up periods exceeding two years and incorporating pesticide biomonitoring at multiple time-points are recommended.

BackgroundThe most frequent transmission modes of blood-borne infections (BBI), including HIV, hepatitis B virus (HBV) and C (HCV), are well documented. South Africa, an HIV epicentre, with HBV endemicity and an additional HCV burden, raises the possibility of novel transmission means. A unique style of close shave haircut that can elicit folliculitis keloidalis nuchea (FKN), may produce bleeding during haircuts and possible BBI transmission. We designed a prospective case control study to evaluate the potential risk of BBI transmission.MethodsMen with FKN and non-FKN controls were recruited from 2 centres in South Africa, Cape Town and Mthatha. The presence of FKN was diagnosed by a dermatologist and clinical photographs independently corroborated by 3 other dermatologists not involved in the study. A comprehensive confidential questionnaire was administered to each participant interrogating risk factors for potential HIV, HBV, and HCV infection. Each participant was screened for HIV 1/2 (Alere Determine), HBsAg (Alere Determine) and HCV antibody (SD Bioline) using point of care tests. Positive HIV screens were confirmed with a second test, Vikia HIV 1/2 test (bioMerieux). Logistic regression analysis adjusting for the relevant confounder was used to assess the associations.ResultsA total of 1163 men, median age 33.4 years [IQR 27.8-42.0], were evaluated. Those who screened positive for any viral infections were significantly older than those who did not, 37.1 [IQR 31.0-44.4) vs. 32.3 [IQR 26.9-41.0] years, p < 0.001, respectively. Overall, the seroprevalence of HIV, HBV, and HCV, was 17.2%, 6.9% and 0.4%, respectively. There was no significant difference in seroprevalence for these potential BBIs between those with FKN and without, p = 0.33, 0.66 and 0.29, respectively. For HIV co-infection with HBV and HCV, findings were similar, p = 0.64 and 0.51, respectively. When controlled for whether participants knowingly bleed during haircuts, HIV seropositivity was significantly more likely in those who regularly bleed, OR = 2.51 [95% CI 1.16-5.42], p = 0.02. Other transmission risk factors for HIV, were also significantly more likely - reported sexually transmitted genital lesions or discharge, aOR = 1.58 [95% CI 1.13-2.22], p = 0.01; and a tattoo/piercing informally done, aOR = 1.84, [95% CI 1.13-2.22], p = 0.01. Similarly, although overall HCV seroprevalence was low, those HIV/HCV co-infection was more likely in those who usually bleed with a haircut, aOR = 2.43; [95% CI 1.13-5.25]; p = 0.02, those with a sexually transmitted genital lesion or discharge, aOR = 1.58 [95% CI 1.13-2.21]; p = 0.01 and those with a tattoo/piercing informally done, aOR = 1.85 [95% CI 1.27-2.72]; p < 0.01. This was not so for HBV mono-infection, p = 0.89. Overall rates of known and recorded HBV vaccination in childhood were low, however in those with no viral infection, the rate of known vaccination was higher, 25.0% vs. 16.2%; p = 0.01 respectively.ConclusionHaircut related bleeding but not FKN was associated with a higher prevalence of HIV and HIV/HCV co-infection. HBV risk was not increased and related to either vaccination and/or dominant early childhood acquisition risk of HBV in sub-Saharan Africa. HIV and HBV prevalence remains concerningly high. Risk reduction through public education is key to prevention.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy for high-risk populations, including adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). While various PrEP-delivery models exist in South Africa, little is known about optimizing PrEP-uptake and adherence for AGYW and ABYM. This study explored preferred and feasible PrEP care models to enhance initiation and adherence among at-risk adolescents and young adults (AYAs) in a high-HIV prevalent rural district in South Africa. We conducted a longitudinal, population-based cohort study from August 2021 to July 2022 across 22 service delivery points (SDPs) in KwaZulu-Natal. High-risk, sexually active HIV-negative AGYW (15-24 years) and ABYM (15-35 years) were recruited from clinics, schools, and community-based youth zones. PrEP-uptake and adherence, based on national guidelines, were assessed using Pearson's Chi square test and binomial regression. Of 2,772 HIV-negative AYA, 781 (28%) initiated PrEP. Despite 65% being classified as high risk for HIV (p < 0.001), only 22% initiated PrEP. Initiation was higher in female (82%, p < 0.001) and among the 15-19 years (51%, p = 0.11). PrEP uptake varied significantly by SDPs, lowest in clinics (9%, p < 0.001), higher in youth zones (58%, p < 0.001), and highest in schools (73%, p < 0.001). Adherence declined significantly over time, dropping from 12% at one month to 2% at six months (p < 0.001). These findings highlight the need for targeted interventions in schools and communities, addressing barriers such as awareness, side effects, and accessibility. Expanding PrEP services to non-traditional settings may enhance uptake and adherence, reducing HIV risk among young people.

This study explores the decentralisation of PrEP services through primary health care (PHC) re-engineering structures such as schools, pharmacies, youth zones, community halls, and mobile clinics to improve PrEP uptake and adherence among adolescents and young adults (AYAs) in KwaZulu-Natal, South Africa. In-depth interviews were conducted from August 2021 to July 2023 with 48 purposively selected participants from a cohort of 2,772 newly diagnosed HIV-negative, sexually active, high-risk individuals. These included 36 adolescent girls and young women aged 15–24 years and adolescent boys and young men aged 15–35 years who initiated PrEP within one month at various service delivery points, including clinics, schools, and community-based services. An additional 12 participants who had not initiated PrEP were also included. Data were analysed thematically using a comprehensive codebook developed to guide the coding process. All transcripts and audio recordings were validated for completeness and accuracy before coding. The study identifies critical factors that support successful PrEP implementation and expansion among high-risk, sexually active AYAs. The PHC re-engineering programme emerged as a crucial strategy for increasing both PrEP uptake and adherence. Participants expressed a strong preference for decentralised service models, including community-based facilities, outreach teams, and home delivery systems. These models were most appealing to AYAs compared to traditional healthcare facilities. They effectively addressed common barriers such as long waiting times, unfriendly healthcare professionals, overcrowding, stigma, and transportation challenges. Some participants noted that home delivery of PrEP saved both time and money, contributing to better adherence. Decentralised, community-based approaches play a vital role in improving PrEP uptake, adherence, and continuation among AYAs in South Africa. The findings underscore the importance of addressing key barriers such as distance, stigma, and accessibility. By decentralizing PrEP services and embedding them within familiar, youth-friendly spaces at community level, this study demonstrates how HIV prevention can be made more accessible and acceptable to AYAs.

Background Alcohol use is a well-established potentially modifiable risk factor for suicide, yet few studies have investigated the impact of alcohol restrictions on suicide rates, particularly in low- and middle-income countries.Methods We used data from nationally representative annual surveys of postmortem investigations in 2017 (n=6117) and 2020/21 (n=6586) to estimate changes in suicide rates associated with the COVID-19 pandemic and related alcohol restrictions.Findings Age standardised suicide mortality rates per 100 000 were 10.91 (10.64, 11.18) in 2017 and 10.82 (10.56, 11.08) in 2020/2021, with approximately 4.4 times more deaths among males than females in both periods. No significant differences were observed between overall suicide rates during the 2020/2021 pandemic period compared with 2017 (risk ratio=1.04 (1.00, 1.07)), but in the 15–24-year age group, suicide rates were 11% higher among males and 31% higher among females than in 2017. Partial alcohol restrictions during the pandemic were not associated with lower suicide risk. However, the shift from partial to full restriction on the sale of alcohol was associated with an 18% (95% CI 10% to 25%) reduction in suicides for both sexes combined and a 22% (95% CI 13% to 30%) reduction in suicides among men, but no significant reduction among women.Interpretation Our findings offer some support for the hypothesis that restricting access to alcohol at a population level is associated with a reduction in suicide rates and suggests that restricted access to alcohol may have been one of the reasons global suicide rates did not increase during the pandemic in some countries.

Background The availability of HIV guidelines, infrastructure, essential medicines and diagnostic tests for HIV services is a prerequisite to effective universal test-and-treat (UTT) services. However, evidence on public facility readiness for UTT services in rural, high HIV prevalence areas remain limited. This study provides a snapshot of facility readiness for UTT services in selected public health facilities within the uThukela district, KwaZulu-Natal, South Africa.Methods A cross-sectional survey was conducted at 15 healthcare facilities in the uThukela district, KwaZulu-Natal Province, South Africa. Data were collected from public primary healthcare points, including three mobile clinics, three gateway clinics and nine Outpatient Departments, Community Health Centres and Hospitals (OPD-CHC-H). Questionnaires were programmed into Research Electronic Data Capture. Analysis was performed using STATA Software V.18, and results were summarised in percentages (%) and presented in tables and graph.Results The study highlights gaps in UTT services in uThukela district, with variability in infrastructure availability across health facility types. Mean readiness was 86% (95% CI: 77.6% to 92.1%) for OPD-CHC-H; 70% (95% CI: 60.0% to 78.7) for gateway clinics and 67% (95% CI: 56.8% to 76.0%) for mobile clinics. Mean availability of indicators for basic amenities was 61% (95% CI: 50.7% to 70.5%); 90.4% (95% CI: 82.3% to 95.0%); and 80.9% (95% CI: 70.8% to 87.3%) in mobile clinics, gateway clinics, and OPD-CHC-H, respectively. HIV test kits, palliative care guidelines and improved water sources was limited across all facility types. Overall, facility readiness was 74% (95% CI: 64.2% to 82.2%), which was deemed satisfactory according to WHO-Service Availability and Readiness Assessment criteria.Conclusions Persistent shortages in antiretrovirals, HIV test kits, palliative care guidance and logistics/operations hinder care; integrating HIV testing into routine screenings, expanding self-testing and adopting digital and personalised care models can ease burdens and improve outcomesCite Now

Background: Human papillomavirus (HPV) vaccination programs are a key intervention in protecting individuals against HPV-related disease. HIV1-infected individuals are at increased risk of HPV-associated cancers. This study was conducted to evaluate the potential role of prophylactic HPV vaccines in preventing new HPV infections among participants with perinatally acquired HIV who received the quadrivalent HPV vaccine at least five years before this study. Methods: This cross-sectional study was conducted at Newlands Clinic, Harare, Zimbabwe. The clinic provided the Gardasil quadrivalent HPV vaccine (4vHPV) to 624 adolescents living with HIV starting in December 2015. Vaginal and penile swabs were collected and tested for HPV types from the study participants who had received the 4vHPV vaccine 5–6 years before enrolment. Results: We present the results of 98 participants (44.6% female) vaccinated at a median age of 15 years (IQR 12–16). The mean amount of time since vaccination was 6 years (SD: ±0.4). The HPV-positive rate amongst the analyzed swabs was 69% (68/98). Among 30/98 (31%) HPV-positive participants, 13/98 (13%) had low-risk HPV types, and 17/98 (17%) had high-risk HPV types. Twelve participants tested positive for HPV18, only one participant tested positive for HPV16, and an additional four (4.3%) tested positive for either type 6 or 11, with respect to vaccine-preventable low-risk HPV types. Conclusion: The Gardasil quadrivalent HPV vaccine (4vHPV) was expected to protect against infection with HPV types 16, 18, 6, and 11. We demonstrated a possible waning of immunity to HPV18 in 17% of the participants, and an associated loss in cross-protection against HPV45. We observed a relatively high prevalence of ‘opportunistic non-vaccine HPV types’ or ‘ecological niche occupiers’ in this cohort, and suggest further research on the involvement of these types in cervical and other genital cancers. Our study is one of the few, if not the first, to report on HPV vaccine immunoprotection among people living with HIV (PLWH), thereby setting a baseline for further studies on HPV vaccine effectiveness among PLWH.

Background Neonatal Cardiac Surgery has developed significantly since its advent, with improved outcomes, survival, and physiological repair. Limited programs offer neonatal cardiac surgery in emerging economies. We report our experience with neonates undergoing cardiac surgery in our cardiac surgery program.Methods We performed a secondary data analysis on all neonates aged <= 30 days undergoing congenital cardiac surgery from April 1, 2017 to March 31, 2020, including outcomes up to 30-days post-surgery.Results A total of 859 patients underwent cardiac surgery at our center, of these 81 (9.4%) were neonates. The proportion of neonates increased annually (8.7%, 9.6%, and 10.2%). There were 49 (60%) male patients, and 32 (40%) had surgery in the second week of life. Fourteen (17%) were premature, four (5%) had a major chromosomal abnormality, five (6%) a major medical illness, and eight (10%) a major noncardiac structural anomaly. The Risk Adjustment for Congenital Heart Surgery (RACHS) categorization of surgery was predominantly RACHS 3; n = 28 (35%) and 4; n = 23 (29%). Hours in the intensive care unit (ICU) were extensive; median 189 [interquartile range (IQR): 114-286] as were hours of ventilation; median 95 [IQR 45-163]. Almost 60% (n = 48) of procedures were complicated by sepsis, as defined in our database. The in-hospital mortality rate was 16% (n = 13); the 30-day mortality rate was 19.8% (n = 16).Conclusion The proportion of neonates in our service increased over the period. Focused strategies to shorten prolonged ICU stay and decrease rates of bacterial sepsis in neonates are needed. A multidisciplinary, collaborative heart-team approach is crucial for best outcomes.

Abstract Introduction Despite the numerous efforts and initiatives, males with HIV are still less likely than women to receive HIV treatment. Across Sub-Saharan Africa, men are tested, linked, and retained in HIV care at lower rates than women, and South Africa is no exception. This is despite the introduction of the universal test-and-treat (UTT) prevention strategy anticipated to improve the uptake of HIV services. The aim of this study was to investigate linkage to and retention in care rates of an HIV-positive cohort of men in a high HIV prevalence rural district in KwaZulu-Natal province, South Africa. Methods From January 2018 to July 2019, we conducted an observational cohort study in 18 primary health care institutions in the uThukela district. Patient-level survey and clinical data were collected at baseline, 4-months and 12-months, using isiZulu and English REDCap-based questionnaires. We verified data through TIER.Net, Rapid mortality survey (RMS), and the National Health Laboratory Service (NHLS) databases. Data were analyzed using STATA version 15.1, with confidence intervals and p-value of ≤0.05 considered statistically significant. Results The study sample consisted of 343 male participants diagnosed with HIV and who reside in uThukela District. The median age was 33 years (interquartile range (IQR): 29–40), and more than half (56%; n = 193) were aged 18–34 years. Almost all participants (99.7%; n = 342) were Black African, with 84.5% (n = 290) being in a romantic relationship. The majority of participants (85%; n = 292) were linked to care within three months of follow-up. Short-term retention in care (≤ 12 months) was 46% (n = 132) among men who were linked to care within three months. Conclusion While the implementation of the UTT strategy has had positive influence on improving linkage to care, men’s access of HIV treatment remains inconsistent and may require additional innovative strategies.

Abstract Introduction Pre-exposure prophylaxis (PrEP) is an HIV prevention strategy that can reduce the risk of HIV acquisition by more than 90% if taken consistently. Although South Africa has been implementing PrEP since 2016, initially for selected population groups before expanding access to more people, there is a dearth of research focused on PrEP among adolescent boys and young men (ABYM), despite them experiencing high rates of HIV infection. To address this gap, we compared PrEP initiation rates by service delivery points (SDPs) among ABYM in KwaZulu-Natal, South Africa. Methods We conducted a population-based prospective study in 22 SDPs from July 2021 to July 2022 in KwaZulu-Natal, South Africa. Sexually active ABYM aged 15–35 years who tested HIV negative were recruited at purposively selected PrEP SDPs (i.e., healthcare facilities, secondary schools and Technical Vocational Education and Training (TVET) colleges, and community-based youth zones). We collected baseline quantitative data from each participant using self-administered electronic questionnaires built into REDCap, including demographic information such as age, sex, employment status and level of education, as well as PrEP initiation outcomes. We extracted data from REDCap and exported it to Stata version 17.0 for analysis, and then eliminated discrepancies and removed duplicates. We described baseline characteristics using summary and descriptive statistics (median, interquartile range [IQR] and proportions) and reported PrEP initiation proportions overall and by SDPs. Results The study included 1104 ABYM, with a median age of 24 years (interquartile range (IQR): 21–28)). Almost all participants were black African (n = 1090, 99%), with more than half aged 15–24 years (n = 603, 55%) and 45% (n = 501) aged 25–35 years. The majority (n = 963; 87%) had attained a secondary level of education. Overall PREP initiation rate among adolescent boys and young men was low: among 1078 participants who were eligible for PrEP, 13% (n = 141) were started on PrEP. Among the participants who were initiated on PrEP, over three quarters (78%, n = 58) were initiated from high schools, compared with community-based youth zones (40%, n = 37), TVET colleges (26%, n = 16) and healthcare facilities (4%, n = 30). Conclusions This study provided evidence suggesting that expanding PrEP services to non-traditional settings, such as high schools, TVET colleges, and community-based organizations, may have a potential to increase PrEP access among ABYM in South Africa.

Background South Africa had an estimated 7.5 million people living with HIV (PLHIV), accounting for approximately 20% of the 38.4 million PLHIV globally in 2021. In 2015, the World Health Organization recommended the universal test and treat (UTT) intervention which was implemented in South Africa in September 2016. Evidence shows that UTT implementation faces challenges in terms of human resources capacity or infrastructure. We aim to explore healthcare providers (HCPs)’ perspectives on the implementation of the UTT strategy in uThukela District Municipality in KwaZulu-Natal province. Methods A qualitative study was conducted with one hundred and sixty-one (161) healthcare providers (HCPs) within 18 healthcare facilities in three subdistricts, comprising of Managers, Nurses, and Lay workers. HCPs were interviewed using an open ended-survey questions to explore their perceptions providing HIV care under the UTT strategy. All interviews were thematically analysed using both inductive and deductive approaches. Results Of the 161 participants (142 female and 19 male), 158 (98%) worked at the facility level, of which 82 (51%) were nurses, and 20 (12.5%) were managers (facility managers and PHC manager/supervisors). Despite a general acceptance of the UTT policy implementation, HCPs expressed challenges such as increased patient defaulter rates, increased work overload, caused by the increased number of service users, and physiological and psychological impacts. The surge in the workload under conditions of inadequate systems’ capacity and human resources, gave rise to a greater burden on HCPs in this study. However, increased life expectancy, good quality of life, and immediate treatment initiation were identified as perceived positive outcomes of UTT on service users. Perceived influence of UTT on the health system included, increased number of patients initiated, decreased burden on the system, meeting the 90-90-90 targets, and financial aspects. Conclusion Health system strengthening such as providing more systems’ capacity for expected increase in workload, proper training and retraining of HCPs with new policies in the management of patient readiness for lifelong ART journey, and ensuring availability of medicines, may reduce strain on HCPs, thus improving the delivery of the comprehensive UTT services to PLHIV.

BackgroundPre-exposure prophylaxis (PrEP) is an emerging biomedical prevention intervention. Documenting PrEP service delivery models (SDMs) that promote linkage to and continuation of PrEP will inform guidelines and maximise roll-out.ObjectivesTo synthesise and appraise the effectiveness and feasibility of PrEP SDMs designed to promote linkage to PrEP care among adolescent girls and young women (AGYW) and men in sub-Saharan Africa (SSA).Eligibility criteriaPrimary quantitative and qualitative studies published in English and conducted in SSA were included. No restrictions on the date of publication were applied.Sources of evidenceMethodology outlined in the Joanna Briggs Institute reviewers’ manual was followed. PubMed, Cochrane library, Scopus, Web of Science and online-conference abstract archives were searched.Charting methodsData on article, population, intervention characteristics and key outcomes was charted in REDCap.Results and conclusionOf the 1204 identified records, 37 (met the inclusion criteria. Health facility-based integrated models of PrEP delivery with family planning, maternal and child health or sexual and reproductive services to AGYW resulted in PrEP initiation of 16%–90%. Community-based drop-in centres (66%) was the preferred PrEP outlet for AGYW compared with public clinics (25%) and private clinics (9%). Most men preferred community-based delivery models. Among individuals who initiated PrEP, 50% were men, 62% were <35 years old and 97% were tested at health fairs compared with home testing. Integrated antiretroviral therapy (ART)-PrEP delivery was favoured among serodiscordant couples with 82.9% of couples using PrEP or ART with no HIV seroconversions. PrEP initiation within healthcare facilities was increased by perceived client-friendly services and non-judgemental healthcare workers. Barriers to PrEP initiation included distance to travel to and time spent at health facilities and perceived community stigma. PrEP SDMs for AGYW and men need to be tailored to the needs and preferences for each group. Programme implementers should promote community-based SDMs to increase PrEP initiation among AGYW and men.

Background Surgery remains an adjunctive treatment for drug-resistant tuberculosis (DR-TB) treatment failure despite the use of bedaquiline. However, there are few data about the role of surgery when combined with newer drugs. There are no outcome data from TB endemic countries, and the prognostic significance of pre-operative PET-CT remains unknown. Methods We performed a prospective observational study of 57 DR-TB patients referred for surgery at Groote Schuur Hospital between 2010 and 2016. PET-CT was performed if there was nodal disease or disease outside the area of planned resection but did not influence treatment decisions. 24-month treatment success post-surgery (cure or treatment completion), including all-cause mortality, was determined. Findings 35/57 (61.4%) patients (median age 40 years; 26% HIV-infected) underwent surgery and 22/57 (38.6%) did not (11 patients were deemed unsuitable due to bilateral cavitary disease and 11 patients declined surgery). Treatment failure was significantly lower in those who underwent surgery compared to those eligible but declined surgery [15/35 (43%) versus 11/11 (100%); relative risk 0.57 (0.42-0.76); p < 0.01). In patients treated with surgery, a post-operative regimen containing bedaquiline was associated with a lower odds of treatment failure [OR (95%CI) 0.06 (0.00-0.48); p = 0.007]. Pre-operative PET-CT (n = 25) did not predict treatment outcome. Interpretation Resectional surgery for DR-TB combined with chemotherapy was associated with significantly better outcomes than chemotherapy alone. A post-operative bedaquiline-containing regimen was associated with improved outcome; however, this finding may have been confounded by higher use of bedaquiline and less loss to follow-up in the surgical group. However, PET-CT had no prognostic value. These data inform clinical practice in TB-endemic settings. Copyright (C) 2022 Published by Elsevier Ltd.

Background: Antimicrobial stewardship principles guide the clinical use of antimicrobials, including vancomycin, but paediatric vancomycin prescribing practices have not been evaluated in South Africa. Objectives: To document the use, prescribing practices and monitoring of intravenous vancomycin and the spectrum of bacteria isolated on microbiological culture in children treated with intravenous vancomycin during a 12-month period at Red Cross War Memorial Children's Hospital (RCWMCH). Method: A retrospective audit of intravenous vancomycin use in children admitted to RCWMCH during 2019 was performed. Results: All 158 vancomycin prescription episodes for 143 children were included. Overall usage of intravenous vancomycin was 63 days of therapy per 1000 patient days (interquartile range [IQR]: 38-72). The median starting dose was 15 mg/kg per dose (IQR: 14-15) and median daily dose was 45 mg/kg per day (IQR: 43-60). Vancomycin was prescribed as empiric (127/158, 80%) and directed (31/158, 20%) treatment. The median duration of treatment for the directed group (7 days) was longer than the empiric group (4 days) (p = 0.001). Vancomycin serum trough concentrations were performed in 65/98 (66%) episodes where vancomycin treatment exceeded 3 days, with only 16/65 (25%) of these samples obtained before the fourth dose. Prolonged antibiotic treatment of 14 days or more was not associated with Gram-positive bacteria on culture (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 0.17-4.2). Conclusion: Dosing errors, prolonged empiric treatment and inappropriate vancomycin monitoring were problems associated with vancomycin prescriptions. Contribution: The study identified multiple opportunities for improved vancomycin prescribing and monitoring. Further research and implementation of improved prescribing practices could contribute to the preservation of vancomycin as an effective antibiotic.

Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the ‘Universal Test and Treat’ (UTT) strategy – initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients’ perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV-positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had been linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors that facilitated or inhibited linkage-to-care were found at individual, family, community, as well as health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, and friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experiences with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system-level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training healthcare providers, community outreach and the provision of psychological, social, and financial support.

Abstract Background Candida bloodstream infection (BSI) causes appreciable mortality in neonates and children. There are few studies describing the epidemiology of Candida BSI in children living in sub-Saharan Africa. Methods A retrospective descriptive study was conducted at three public sector hospitals in Cape Town, South Africa. Demographic and clinical details, antifungal management and patient outcome data were obtained by medical record review. Candida species distribution and antifungal susceptibility testing results were obtained from the National Health Laboratory Service database. Results Of the 97 Candida BSI episodes identified during a five-year period, 48/97 (49%) were Candida albicans (C. albicans), and 49/97 (51%) were non-C. albicans species. The overall incidence risk was 0.8 Candida BSI episodes per 1000 admissions at Red Cross War Memorial Children’s Hospital. Of the 77/97 (79%) Candida BSI episodes with available clinical information, the median age (interquartile range) at the time of BSI was 7 (1–25) months, 36/77 (47%) were associated with moderate or severe underweight-for-age and vasopressor therapy was administered to 22/77 (29%) study participants. Most of the Candida BSI episodes were healthcare-associated infections, 63/77 (82%). Fluconazole resistance was documented among 17%, 0% and 0% of C. parapsilosis, C. tropicalis and C. albicans isolates, respectively. All Candida isolates tested were susceptible to amphotericin B and the echinocandins. The mortality rate within 30 days of Candida BSI diagnosis was 13/75 (17%). On multivariable analysis, factors associated with mortality within 30 days of Candida BSI diagnosis included vasopressor therapy requirement during Candida BSI, adjusted Odds ratio (aOR) 53 (95% confidence interval 2–1029); hepatic dysfunction, aOR 13 (95% CI 1–146); and concomitant bacterial BSI, aOR 10 (95% CI 2–60). Conclusion The study adds to the limited number of studies describing paediatric Candida BSI in sub-Saharan Africa. Non-C. Albicans BSI episodes occurred more frequently than C. albicans episodes, and vasopressor therapy requirement, hepatic dysfunction and concomitant bacterial BSI were associated with an increase in 30-day mortality.

IntroductionAdolescent girls and young women (AGYW) aged 15-24 years and adolescent boys and young men (ABYM) aged 15-34 years represent one of the populations at highest risk for HIV-infection in South Africa. The National Department of Health adopted the universal test and treat (UTT) strategy in 2016, resulting in increases in same-day antiretroviral therapy initiations and linkage to care. Monitoring progress towards attainment of South Africa's 95-95-95 targets amongst AGYW and ABYM relies on high quality data to identify and address gaps in linkage to care. The aim of this study is to describe the current approaches for engaging AGYW and ABYM in the treatment continuum to generate knowledge that can guide efforts to improve linkage to, and retention in, HIV care among these populations in KwaZulu-Natal, South Africa. Methods and analysisThis is a mixed methods study, which will be conducted in uMgungundlovu district of KwaZulu-Natal, over a 24-month period, in 22 purposively selected HIV testing and treatment service delivery points (SDPs). For the quantitative component, a sample of 1100 AGYW aged 15-24 years and ABYM aged 15-35 years old will be recruited into the study, in addition to 231 healthcare providers (HCPs) involved in the implementation of the UTT program. The qualitative component will include 30 participating patients who were successfully linked to care, 30 who were not, and 30 who have never tested for HIV. Key informant interviews will also be conducted with 24 HCPs. Logistic regression will be used to model the primary outcomes on SDP types, while a time to event analysis will be conducted using a Cox regression model and adjusting the standard errors of the hazard ratio for the clustering of participants within SDPs. For qualitative data, a general inductive approach of analysis will be used. DisseminationFindings from the study will be communicated to the study population and results will be presented to stakeholders and at appropriate local and international conferences. Outputs will also include a policy brief, peer reviewed journal articles and research capacity building through research degrees.

Objectives: Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity.Methods: A prospective study of children aged 1-13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1-2 (mild-moderate) and MOS 3-4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) & GE;20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded. Results: One hundred and seventy children median age 3.8 years (IQR 2.7-6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH. Conclusion: PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.

Background: IgE to galactose alpha-1,3 galactose (alpha-gal) causes alpha-gal syndrome (delayed anaphylaxis after ingestion of mammalian meat). Development of sensitization has been attributed to tick bites; however, the possible role of other parasites has not been well studied. Objective: Our aims were to assess the presence, relative abundances, and site of localization of alpha-gal-containing proteins in common ectoparasites and endoparasites endemic in an area of high prevalence of alpha-gal syndrome, as well as to investigate the ability of ascaris antigens to elicit a reaction in a humanized rat basophil in vitro sensitization model. Methods: Levels of total IgE, Ascaris-specific IgE, and alpha-gal IgE were measured in sera from patients with challenge-proven alpha-gal syndrome and from controls without allergy. The presence, concentration, and localization of alpha-gal in parasites were assessed by ELISA, Western blotting, and immunohistochemistry. The ability of Ascaris lumbricoides antigen to elicit IgE-dependent reactivity was demonstrated by using the RS-ATL8 basophil reporter system. Results: Alpha-gal IgE level correlated with A lumbricoides-specific IgE level. Alpha-gal protein at 70 to 130 kDa was detected in A lumbricoides at concentrations higher than those found in Rhipicephalus evertsi and Amblyomma hebraeum ticks. Immunohistochemistry was used to localize alpha-gal in tick salivary acini and the helminth gut. Non-alpha-gal-containing A lumbricoides antigens activated RS-ATL8 basophils primed with serum from subjects with alpha-gal syndrome. Conclusion: We demonstrated the presence, relative abundances, and site of localization of alpha-gal-containing proteins in parasites. The activation of RS-ATL8 IgE reporter cells primed with serum from subjects with alpha-gal syndrome on exposure to non-alpha-gal-containing A lumbricoides proteins indicates a possible role of exposure to A lumbricoides in alpha-gal sensitization and clinical reactivity.