To identify the unmet needs for HIV prevention among older adults in rural South Africa.
We analyzed data from a population-based sample of 5059 men and women aged 40 years and older from the study ...Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI), which was carried out in the Agincourt health and sociodemographic surveillance system in the Mpumalanga province of South Africa. We estimated the prevalence of HIV (laboratory-confirmed and self-reported) and key sexual behaviors by age and sex. We compared sexual behavior profiles across HIV status categories with and without age-sex standardization.
HIV prevalence was very high among HAALSI participants (23%, 95% confidence interval CI: 21 to 24), with no sex differences. Recent sexual activity was common (56%, 95% CI: 55 to 58) across all HIV status categories. Condom use was low among HIV-negative adults (15%, 95% CI: 14 to 17), higher among HIV-positive adults who were unaware of their HIV status (27%, 95% CI: 22 to 33), and dramatically higher among HIV-positive adults who were aware of their status (75%, 95% CI: 70 to 80). Casual sex and multiple partnerships were reported at moderate levels, with slightly higher estimates among HIV-positive compared to HIV-negative adults. Differences by HIV status remained after age-sex standardization.
Older HIV-positive adults in an HIV hyperendemic community of rural South Africa report sexual behaviors consistent with high HIV transmission risk. Older HIV-negative adults report sexual behaviors consistent with high HIV acquisition risk. Prevention initiatives tailored to the particular prevention needs of older adults are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.
By August, 2021, South Africa had been affected by three waves of SARS-CoV-2; the second associated with the beta variant and the third with the delta variant. Data on SARS-CoV-2 burden, ...transmission, and asymptomatic infections from Africa are scarce. We aimed to evaluate SARS-CoV-2 burden and transmission in one rural and one urban community in South Africa.
We conducted a prospective cohort study of households in Agincourt, Mpumalanga province (rural site) and Klerksdorp, North West province (urban site) from July, 2020 to August, 2021. We randomly selected households for the rural site from a health and sociodemographic surveillance system and for the urban site using GPS coordinates. Households with more than two members and where at least 75% of members consented to participate were eligible. Midturbinate nasal swabs were collected twice a week from household members irrespective of symptoms and tested for SARS-CoV-2 using real-time RT-PCR (RT-rtPCR). Serum was collected every 2 months and tested for anti-SARS-CoV-2 antibodies. Main outcomes were the cumulative incidence of SARS-CoV-2 infection, frequency of reinfection, symptomatic fraction (percent of infected individuals with ≥1 symptom), the duration of viral RNA shedding (number of days of SARS-CoV-2 RT-rtPCR positivity), and the household cumulative infection risk (HCIR; number of infected household contacts divided by the number of susceptible household members).
222 households (114 at the rural site and 108 at the urban site), and 1200 household members (643 at the rural site and 557 at the urban site) were included in the analysis. For 115 759 nasal specimens from 1200 household members (follow-up 92·5%), 1976 (1·7%) were SARS-CoV-2-positive on RT-rtPCR. By RT-rtPCR and serology combined, 749 of 1200 individuals (62·4% 95% CI 58·1–66·4) had at least one SARS-CoV-2 infection episode, and 87 of 749 (11·6% 9·4–14·2) were reinfected. The mean infection episode duration was 11·6 days (SD 9·0; range 4–137). Of 662 RT-rtPCR-confirmed episodes (>14 days after the start of follow-up) with available data, 97 (14·7% 11·9–17·9) were symptomatic with at least one symptom (in individuals aged <19 years, 28 7·5% of 373 episodes symptomatic; in individuals aged ≥19 years, 69 23·9% of 289 episodes symptomatic). Among 222 households, 200 (90·1% 85·3–93·7) had at least one SARS-CoV-2-positive individual on RT-rtPCR or serology. HCIR overall was 23·9% (195 of 817 susceptible household members infected 95% CI 19·8–28·4). HCIR was 23·3% (20 of 86) for symptomatic index cases and 23·9% (175 of 731) for asymptomatic index cases (univariate odds ratio OR 1·0 95% CI 0·5–2·0). On multivariable analysis, accounting for age and sex, low minimum cycle threshold value (≤30 vs >30) of the index case (OR 5·3 2·3–12·4) and beta and delta variant infection (vs Wuhan-Hu-1, OR 3·3 1·4–8·2 and 10·4 4·1–26·7, respectively) were associated with increased HCIR. People living with HIV who were not virally supressed (≥400 viral load copies per mL) were more likely to develop symptomatic illness when infected with SAR-CoV-2 (OR 3·3 1·3–8·4), and shed SARS-CoV-2 for longer (hazard ratio 0·4 95% CI 0·3–0·6) compared with HIV-uninfected individuals.
In this study, 565 (85·3%) SARS-CoV-2 infections were asymptomatic and index case symptom status did not affect HCIR, suggesting a limited role for control measures targeting symptomatic individuals. Increased household transmission of beta and delta variants was likely to have contributed to successive waves of SARS-CoV-2 infection, with more than 60% of individuals infected by the end of follow-up.
US CDC, South Africa National Institute for Communicable Diseases, and Wellcome Trust.
Most hypertension-related genome-wide association studies (GWASs) focus on non-African populations, despite hypertension (a major risk factor for cardiovascular disease) being highly prevalent in ...Africa. The AWI-Gen study GWAS meta-analysis for blood pressure (BP)-related traits (systolic and diastolic BP, pulse pressure, mean-arterial pressure and hypertension) from three sub-Saharan African geographic regions (N = 10,775), identifies two novel genome-wide significant signals (p < 5E-08): systolic BP near P2RY1 (rs77846204; intergenic variant, p = 4.95E-08) and pulse pressure near LINC01256 (rs80141533; intergenic variant, p = 1.76E-08). No genome-wide signals are detected for the AWI-Gen GWAS meta-analysis with previous African-ancestry GWASs (UK Biobank (African), Uganda Genome Resource). Suggestive signals (p < 5E-06) are observed for all traits, with 29 SNPs associating with more than one trait and several replicating known associations. Polygenic risk scores (PRSs) developed from studies on different ancestries have limited transferability, with multi-ancestry PRS providing better prediction. This study provides insights into the genetics of BP variation in African populations.
The real-world association between male circumcision and HIV status has important implications for policy and intervention practice. For instance, women may assume that circumcised men are safer sex ...partners than non-circumcised men and adjust sexual partnering and behavior according to these beliefs. Voluntary medical male circumcision (VMMC) is highly efficacious in preventing HIV acquisition in men and this biological efficacy should lead to a negative association between circumcision and HIV. However, behavioral factors such as differential selection into circumcision based on current HIV status or factors associated with future HIV status could reverse the association. Here, we examine how HIV prevalence differs by circumcision status in older adult men in a rural South African community, a non-experimental setting in a time of expanding VMMC access.
We analyzed data collected from a population-based sample of 2345 men aged 40 years and older in a rural community served by the Agincourt Health and socio-Demographic Surveillance System site in Mpumalanga province, South Africa. We describe circumcision prevalence and estimate the association between circumcision and laboratory-confirmed HIV status with log-binomial regression models.
One quarter of older men reported circumcision, with slightly more initiation-based circumcisions (56%) than hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in HIV prevalence between circumcised and uncircumcised men; however, those who reported hospital-based circumcision were more likely to test HIV-positive PR (95% CI): 1.28 (1.03, 1.59) while those who reported initiation-based circumcision were less likely to test HIV-positive PR (95% CI): 0.68 (0.51, 0.90). Effects were attenuated, but not reversed after adjustment for key covariates.
Medically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns.
ObjectiveIn 2011, The National Department of Health introduced the Integrated Chronic Disease Management (ICDM) model as a pilot programme in selected primary healthcare facilities in South Africa. ...The objective of this study was to determine individual-level and facility-level predictors of controlled CD4 count and blood pressure (BP) in patients receiving treatment for HIV and hypertension, respectively.DesignA panel study.Setting and participantsThis study was conducted in the Bushbuckridge Municipality, South Africa from 2011 to 2013. Facility records of patients aged ≥18 years were retrieved from the integrated chronic disease management (ICDM) pilot (n=435) and comparison facilities (n=443) using a three-step probability sampling process. CD4 count and BP control are defined as CD4 count >350 cells/mm3 and BP <140/90 mm Hg. A multilevel Least Absolute Shrinkage and Selection Operator binary logistic regression analysis was done at a 5% significance level using STATA V.16.Primary outcome measuresCD4 (cells/mm3) count and BP (mm Hg).ResultsCompared with the comparison facilities, patients receiving treatment in the pilot facilities had increased odds of controlling their CD4 count (OR=5.84, 95% CI 3.21–8.22) and BP (OR=1.22, 95% CI 1.04–2.14). Patients aged 50–59 (OR=6.12, 95% CI 2.14–7.21) and ≥60 (OR=7.59, 95% CI 4.75–11.82) years had increased odds of controlling their CD4 counts compared with those aged 18–29 years. Likewise, patients aged 40–49 (OR=5.73, 95% CI 1.98–8.43), 50–59 (OR=7.28, 95% CI 4.33–9.27) and ≥60 (OR=9.31, 95% CI 5.12–13.68) years had increased odds of controlling their BP. In contrast, men had decreased odds of controlling their CD4 count (OR=0.12, 95% CI 0.10–0.46) and BP (OR=0.21, 95% CI 0.19–0.47) than women.ConclusionThe ICDM model had a small but significant effect on BP control, hence, the need to more effectively leverage the HIV programme for optimal BP control in the setting.
HIV testing and antiretroviral therapy (ART) remain critical for curbing the spread of HIV/AIDS, but stigma can impede access to these services. Using data from the Health and Aging in Africa: A ...Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we used a multivariable logistic regression to examine the correlation between HIV-related stigma, HIV testing and ART uptake in older adults. We used four questions to measure stigma, with three assessing social stigma (reflecting social distancing preferences) and one assessing anticipated stigma (disclosure concern). We combined the three social stigma questions to generate a social stigma score ranging from 0 to 3, with higher scores indicating higher stigma. Anticipated stigma was prevalent 85% (95% CI 0.84–0.86), and social stigma was also frequent 25% (95% CI 0.24–0.27). Higher social stigma scores correlated with decreased HIV testing for all participants with social stigma. Compared to those with a score of 0, odds of testing decreased with higher stigma scores (OR = 0.66, 95% CI 0.53–0.81, p = 0.000) for a score of 1 and (OR = 0.56, 95% CI 0.38–0.83, p = 0.004) for a score of 3. ART uptake also decreased with higher social stigma scores among people living with HIV (PLWH), although it was significant for those with a score of 2 (OR = 0.41, 95% CI 0.19–0.87, p = 0.020). These findings emphasize that HIV-related stigma hampers testing and ART uptake among older adults in rural South Africa. Addressing stigma is crucial for improving testing rates, early diagnosis, and treatment initiation among the older population and achieving UNAIDS 95–95–95 targets.
Understanding how depression is associated with chronic conditions and sociodemographic characteristics can inform the design and effective targeting of depression screening and care interventions. ...In this study, we present some of the first evidence from sub-Saharan Africa on the association between depressive symptoms and a range of chronic conditions (diabetes, HIV, hypertension, and obesity) as well as sociodemographic characteristics.
A questionnaire was administered to a population-based simple random sample of 5,059 adults aged 40 years and older in Agincourt, South Africa. Depressive symptoms were measured using a modified version of the eight-item Center for Epidemiological Studies-Depression screening tool. Diabetes was assessed using a capillary blood glucose measurement and HIV using a dried blood spot.
17.0% (95% confidence interval: 15.9%-18.1%) of participants had at least three depressive symptoms. None of the chronic conditions were significantly associated with depressive symptoms in multivariable regressions. Older age was the strongest correlate of depressive symptoms with those aged 80 years and older having on average 0.63 (95% confidence interval: 0.40-0.86; p < .001) more depressive symptoms than those aged 40-49 years. Household wealth quintile and education were not significant correlates.
This study provides some evidence that the positive associations of depression with diabetes, HIV, hypertension, and obesity that are commonly reported in high-income settings might not exist in rural South Africa. Our finding that increasing age is strongly associated with depressive symptoms suggests that there is a particularly high need for depression screening and treatment among the elderly adults in rural South Africa.
Adolescent motherhood is common in South Africa and occurs against a backdrop of high HIV risk. While childbearing during adolescence may result in social and economic strain that may negatively ...impact health, there has been limited study of whether adolescent motherhood increases the risk of HIV or herpes simplex virus type 2 (HSV-2) acquisition or engagement in high-risk sexual partnerships.
Data are from HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of adolescent girls and young women (age, 13-23) in rural South Africa.
We used survival analysis to estimate hazard ratios to determine if adolescent motherhood (live birth before 20 years) predicted incident HIV and incident HSV-2 and generalized estimating equations for behavioral risk ratios to determine if adolescent motherhood was associated with transactional sex and age-disparate partnerships.
Of 2452 adolescent girls and young women who were HIV negative at baseline, 5% were adolescent mothers; 16% were adolescent mothers by the end of the study period. After controlling for covariates, adolescent motherhood predicted incident HSV-2 acquisition adjusted hazard ratios, 1.30; 95% confidence interval (CI): 1.01 to 1.95 but not HIV acquisition ( adjusted hazard ratios, 1.19; 95% CI, 0.76 to 1.86). Adolescent motherhood was also associated with being in an age-disparate partnership (adjusted risk ratio, 1.30; 95% CI: 1.07 to 1.58) but not transactional sex.
Adolescent motherhood increased the risk of HSV-2 and engagement in age-disparate partnerships, both known risk factors for HIV infection. Sexually transmitted infection screening and/or tailored combination HIV prevention interventions that account for the context of adolescent motherhood are critical to maximize adolescent mothers' long-term health and to meet UNAIDS 95-95-95 targets by 2030.
The authors assessed the impact of lockdown in response to the COVID-19 pandemic on routine-oriented lifestyle behaviors and symptoms of depression, anxiety, and insomnia in South Africans.
In this ...observational study, 1048 adults (median age = 27 y; n = 767 females; n = 473 students) responded to an online survey on work, exercise, screen, alcohol, caffeine and sleep behaviors, depression, anxiety, and insomnia before and during lockdown. Comparisons were made between males and females, and students and nonstudents.
During lockdown, males reported larger reductions in higher intensity exercise and alcohol use than females, while depressive symptoms increased more among females, more of whom also reported poorer sleep quality. Students demonstrated larger delays in work and sleep timing, greater increases in sitting, screen, sleep duration, napping, depression and insomnia and larger decreases in work hours, exercise time, and sleep regularity compared with nonstudents.
Students experienced more changes in their routine-oriented behaviors than nonstudents, coupled with larger increases in depression and insomnia. The dramatic change in their work and sleep timing suggests habitual routines that are at odds with their chronotype, with their sleep changes during lockdown likely reflecting "catch-up" sleep in response to accumulated sleep debt under usual routines.
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