Virginia Zweigenthal

Fertility Intentions and Reproductive Health Care Needs of People Living with HIV in Cape Town, South Africa: Implications for Integrating Reproductive Health and HIV Care Services

Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with women’s fertility intentions. Gender differences were also apparent in participants’ key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations.

Clients’ perspectives on HIV/AIDS care and treatment and reproductive health services in South Africa

Abstract Qualitative research was conducted with HIV-positive women and men of reproductive age attending HIV/AIDS care and treatment services at a public health clinic in Cape Town, South Africa. Focus group discussions were held with women (n = 4) and men (n = 4), and in-depth interviews were held with four men to explore perceptions and experiences of HIV/AIDS care and treatment and sexual and reproductive health (SRH) care. Respondents praised their HIV/AIDS care and treatment, reflected on how it improved their quality of life and contrasted this with suboptimal care at other public health facilities, including SRH services. Women wanted integrated services, especially for contraception and to reduce stigma. HIV-positive mens lack of experience with SRH services and antipathy towards attending “womens” health services were highlighted. Challenges to involving men in HIV/AIDS care and treatment and SRH services and measures to address this were identified.

TB and HIV integration: obstacles and possible solutions to implementation in South Africa

Objectives  To identify key obstacles to operational integration of TB and HIV services and to suggest strategies to promote integration in the prevention, treatment and care of patients with TB and HIV.

Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa

Objective  To assess the quality of pre‐antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART.

Pregnancy intent among a sample of recently diagnosed HIV-positive women and men practicing unprotected sex in Cape Town, South Africa.

Background:Sexual and reproductive health (SRH) services for HIV-positive women and men often neglect their fertility desires. We examined factors associated with pregnancy intent among recently diagnosed HIV-positive women (N = 106) and men (N = 91) who reported inconsistent condom use and were enrolled in an SRH intervention conducted in public sector HIV care clinics in Cape Town. Methods:Participants were recruited when receiving their first CD4+ results at the clinic. All reported unprotected sex in the previous 3 months. Logistic regression identified predictors of pregnancy intent for the total sample and by gender. Results:About three fifths of men and one fifth of women reported intent to conceive in the next 6 months. In the full-sample multiple regression analysis, men [adjusted odds ratio (AOR = 6.62)] and those whose main partner shared intent to conceive (AOR = 3.80) had significantly higher odds of pregnancy intent; those with more years of education (AOR = 0.81) and more biological children (AOR = 0.62) had lower odds of intending pregnancy. In gender-specific analyses, partner sharing pregnancy intent was positively associated with intent among both men (AOR = 3.53) and women (AOR = 13.24). Among men, odds were lower among those having more biological children (AOR = 0.71) and those unemployed (AOR = 0.30). Among women, relying on hormonal contraception was negatively associated with intent (AOR = 0.08), and main partner knowing her HIV status (AOR = 5.80) was positively associated with intent to conceive. Conclusions:Findings underscore the importance of providing integrated SRH services, and we discuss implications for clinical practice and care.

Implementing intimate partner violence care in a rural sub-district of South Africa: a qualitative evaluation

Background Despite a high burden of disease, in South Africa, intimate partner violence (IPV) is known to be poorly recognised and managed. To address this gap, an innovative intersectoral model for the delivery of comprehensive IPV care was piloted in a rural sub-district. Objective To evaluate the initiative from the perspectives of women using the service, service providers, and managers. Design A qualitative evaluation was conducted. Service users were interviewed, focus groups were conducted amongst health care workers (HCW), and a focus group and interviews were conducted with the intersectoral implementation team to explore their experiences of the intervention. A thematic analysis approach was used, triangulating the various sources of data. Results During the pilot, 75 women received the intervention. Study participants described their experience as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For HCW, barriers to inquiry about IPV included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints affected continuity of care, privacy, and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example, high levels of alcohol misuse and socio-economic disempowerment, highlighted the need for a multifaceted approach to addressing IPV. Conclusions This evaluation draws attention to the need to take a systems approach and focus on contextual factors when implementing complex interventions. The results will be used to inform decisions about instituting appropriate IPV care in the rest of the province. In addition, there is a pressing need for clear policies and guidelines framing IPV as a health issue.Background Despite a high burden of disease, in South Africa, intimate partner violence (IPV) is known to be poorly recognised and managed. To address this gap, an innovative intersectoral model for the delivery of comprehensive IPV care was piloted in a rural sub-district. Objective To evaluate the initiative from the perspectives of women using the service, service providers, and managers. Design A qualitative evaluation was conducted. Service users were interviewed, focus groups were conducted amongst health care workers (HCW), and a focus group and interviews were conducted with the intersectoral implementation team to explore their experiences of the intervention. A thematic analysis approach was used, triangulating the various sources of data. Results During the pilot, 75 women received the intervention. Study participants described their experience as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For HCW, barriers to inquiry about IPV included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints affected continuity of care, privacy, and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example, high levels of alcohol misuse and socio-economic disempowerment, highlighted the need for a multifaceted approach to addressing IPV. Conclusions This evaluation draws attention to the need to take a systems approach and focus on contextual factors when implementing complex interventions. The results will be used to inform decisions about instituting appropriate IPV care in the rest of the province. In addition, there is a pressing need for clear policies and guidelines framing IPV as a health issue.

General practitioners' perceptions on management of epilepsy in primary care settings in Cape Town, South Africa: An exploratory pilot study

In a context where there are few neurologists, excellent management of patients with epilepsy at a primary care level is imperative. In South Africa, most uninsured patients suffering from epilepsy and other chronic illnesses are managed by general practitioners in state-provided primary care settings. We conducted a qualitative pilot study to explore perceptions of doctors working in primary care settings in Cape Town regarding the quality of epilepsy management. Our analysis revealed that these clinicians believe that epilepsy is poorly managed. Attributing factors were consistent with those found in literature. Although study findings cannot be generalized, we conclude that lack of attention to factors impacting on management of epilepsy is a serious concern and may lead to violations of health rights. Urgent prioritization, advocacy, collaboration, and empowerment of healthcare professionals, patients, lay carers, and the general public are needed to improve the management and quality of care of PWE.

Assessing care for patients with TB/HIV/STI infections in a rural district in KwaZulu-Natal

SETTING Despite the prioritisation of TB, HIV and STI programmes in South Africa, service targets are not achieved, have had little effect, and the magnitude of the epidemics continues to escalate. Objective. To report on a participatory quality improvement intervention designed to evaluate these priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal. METHODS A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. RESULTS We highlight weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. In the 25 facilities audited, 71% of the clinical staff had received no training in TB diagnosis and management, and 46% of the facilities were visited monthly by a PHC supervisor. Eighty per cent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for ART and starting treatment was 47 days. CONCLUSION Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.

Health sector responses to intimate partner violence: A literature review

Abstract Background Intimate partner violence (IPV) is a common and serious public health concern, particularly in South Africa, but it is not well managed in primary care. Aim This review aims to summarise the current state of knowledge regarding health sector-based interventions for IPV, their integration into health systems and services and the perspectives of service users and healthcare workers on IPV care, focusing on the South African context. Method PubMed, CINAHL, PsycINFO and Google Scholar were searched between January 2012 and May 2014. All types of study design were included, critically appraised and summarised. Results Exposure to IPV leads to wide-ranging and serious health effects. There is sufficient evidence that intervening in IPV in primary care can improve outcomes. Women who have experienced IPV have described an appropriate response by healthcare providers to be non-judgmental, understanding and empathetic. IPV interventions that are complex, comprehensive and utilise systems-wide approaches have been most effective, but system- and society-level barriers hamper implementation. Gender inequities should not be overlooked when responding to IPV. Conclusion Further evaluations of health sector responses to IPV are needed, in order to assist health services to determine the most appropriate models of care, how these can be integrated into current systems and how they can be supported in managing IPV. The need for this research should not prevent health services and healthcare providers from implementing IPV care, but rather should guide the development of rigorous contextually-appropriate evaluations.

‘Why do an MPH?’ Motivations and intentions of physicians undertaking postgraduate public health training at the University of Cape Town

Background Public health (PH) approaches underpin the management and transformation of health systems in low- and middle-income countries. Despite the Master of Public Health (MPH) rarely being a prerequisite for health service employment in South Africa, many physicians pursue MPH qualifications. Objectives This study identifies their motivations and career intentions and explored MPH programme strengths and gaps in under- and post-graduate PH training. Design A cross-sectional study using an online questionnaire was completed by physicians graduating with an MPH between 2000 and 2009 and those enrolled in the programme in 2010 at the University of Cape Town. Results Nearly a quarter of MPH students were physicians. Of the 65 contactable physicians, 48% responded. They were mid-career physicians who wished to obtain research training (55%), who wished to gain broader perspectives on health (32%), and who used the MPH to advance careers (90%) as researchers, policy-makers, or managers. The MPH widened professional opportunities, with 62% changing jobs. They believed that inadequate undergraduate exposure should be remedied by applying PH approaches to clinical problems in community settings, which would increase the attractiveness of postgraduate PH training. Conclusions The MPH allows physicians to transition from pure clinical to research, policy and/or management work, preparing them to innovate changes for effective health systems, responsive to the health needs of populations. Limited local job options and incentives are important constraining factors. Advocacy for positions requiring qualifications and benchmarking exit competencies of programmes nationally may promote enrolment.Background Public health (PH) approaches underpin the management and transformation of health systems in low- and middle-income countries. Despite the Master of Public Health (MPH) rarely being a prerequisite for health service employment in South Africa, many physicians pursue MPH qualifications. Objectives This study identifies their motivations and career intentions and explored MPH programme strengths and gaps in under- and post-graduate PH training. Design A cross-sectional study using an online questionnaire was completed by physicians graduating with an MPH between 2000 and 2009 and those enrolled in the programme in 2010 at the University of Cape Town. Results Nearly a quarter of MPH students were physicians. Of the 65 contactable physicians, 48% responded. They were mid-career physicians who wished to obtain research training (55%), who wished to gain broader perspectives on health (32%), and who used the MPH to advance careers (90%) as researchers, policy-makers, or managers. The MPH widened professional opportunities, with 62% changing jobs. They believed that inadequate undergraduate exposure should be remedied by applying PH approaches to clinical problems in community settings, which would increase the attractiveness of postgraduate PH training. Conclusions The MPH allows physicians to transition from pure clinical to research, policy and/or management work, preparing them to innovate changes for effective health systems, responsive to the health needs of populations. Limited local job options and incentives are important constraining factors. Advocacy for positions requiring qualifications and benchmarking exit competencies of programmes nationally may promote enrolment.