Research Articles (Family Medicine)

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A complexity theory-informed COPC approach to evaluation of mining health programmes
Renkin, Wayne; Hugo, Johannes F.M. (AOSIS, 2025-11-25)
BACKGROUND : Conventional evaluation approaches are often designed for predictable, linear systems and fail to capture the non-linear dynamics of complex community health interventions. Health projects in mining-affected communities are typically fragmented, with limited coordination or responsiveness to socio-ecological realities. This study applied complexity theory, community-oriented primary care (COPC) principles, and used a transdisciplinary approach to assess a health and wellness project in such a setting. AIM : To describe and reflect on the methodology of a complexity-informed assessment of the coherence and contextual alignment of a health and wellness project in mining-affected communities. SETTING : Health and wellness projects funded by the Sishen Iron Ore Company Community Development Trust (SIOC-CDT) and implemented across five municipalities in the Northern Cape and Limpopo provinces, South Africa. METHODS : A complexity-informed, mixed-methods design was used. Data were gathered through document review, field observation, and 12 key informant interviews with implementing agents, health officials and traditional healers. Community-oriented primary care principles and complexity theory guided iterative analysis and were supported by digital tools. RESULTS : The study identified fragmented implementation, limited household engagement and weak data systems. Despite widespread activity, the lack of integration and adaptive strategy limited systemic effectiveness. However, transdisciplinary engagement, adaptive iteration and co-production of knowledge and reflection facilitated institutional learning and practical proposals for change that are integrated and context sensitive, responding to complexities. CONCLUSION : Sustainable health system change in complex settings requires integrated, reflexive and locally grounded approaches that move beyond project-based interventions. CONTRIBUTION : This study demonstrated how complexity theory, transdisciplinarity, and community-oriented primary care principles offer a viable methodological framework for adaptive evaluation and systemic learning in community health and development, contributing to the journal’s focus on primary care and community health systems in dynamic contexts.
Beyond compliance : evaluating AfriMEDS competencies in South African medical education
Mofolo, Nathaniel; Jama, Priscilla Mpho; Wisker, Gina (Springer, 2025-09-20)
South African medical education confronts systemic challenges rooted in colonial legacies, demanding transformative pedagogies that redress inequities and integrate community health through culturally responsive frameworks. This convergent mixed-methods study, guided by a transformative paradigm emphasizing ethical engagement and social justice, evaluated the implementation of the AfriMEDS framework, a local adaptation of CanMEDS incorporating community-based education (CBE) and community-oriented primary care (COPC) at the University of the Free State (UFS). Methods included curriculum mapping, document analysis, 15 educator interviews, and surveys of 71 medical interns. Document review revealed that health advocate, leader and manager, and scholar roles were minimally featured in phase guides and that existing assessment tools diverged from CanMEDS recommendations. Educator interviews identified three principal barriers: insufficient faculty development (87% of participants), resource constraints, and misaligned assessment practices. Intern surveys showed only 63% felt leadership training was adequate, 71% felt prepared for CBE, and 72% felt competent in collaboration. These findings expose critical gaps in embedding AfriMEDS competencies, particularly intrinsic roles, within undergraduate training. Our methodological framework highlights how CBE and COPC can serve as catalysts for meaningful curricular reform by fostering sustained collaboration between learners, educators, and communities. We recommend systemic reforms including decolonial pedagogical strategies, robust faculty development in cultural competency, alignment of curricula with national health priorities, and the creation of benchmarked assessment tools that reflect African healthcare contexts and community needs. Failure to implement these reforms risks perpetuating inequity and undermining South Africa’s health transformation agenda.
Artificial intelligence for HIV care : a global systematic review of current studies and emerging trends
Ngcobo, Sanele; Madela-Mntla, Edith; Shock, Jonathan; Louw, Murray; Mbonambi, Linda; Serite, Thato; Rossouw, Theresa M. (Wiley, 2025-09)
INTRODUCTION : Artificial intelligence (AI) and, in particular, machine learning (ML) have emerged as transformative tools in HIV care, driving advancements in diagnostics, treatment monitoring and patient management. The present review aimed to systematically identify, map and synthesize studies on the use of AI methods across the HIV care continuum, including applications in HIV testing and linkage to care, treatment monitoring, retention in care, and management of clinical and immunological outcomes. METHODS : A comprehensive literature search was conducted across databases, including PubMed and ProQuest Central, Scopus and Web of Science, covering studies published between 2014 and 2024. The review followed PRISMA guidelines, screening 3185 records, of which 47 studies were included in the final analysis. RESULTS : Forty-seven studies were grouped into four thematic areas: (1) HIV testing, AI models improved diagnostic accuracy, with ML achieving up to 100% sensitivity and 98.8% specificity in self-testing and outperforming human interpretation of rapid tests; (2) Retention in care and virological response, ML predicted clinic attendance, viral suppression and virological failure (72-97% accuracy; area under the curve up to 0.76), enabling early identification of high-risk patients; (3) Clinical and immunological outcomes, AI predicted disease progression, immune recovery, comorbidities and HIV complications, achieving up to 97% CD4 status accuracy and outperforming clinicians in tuberculosis diagnosis; (4) Testing and treatment support, AI chatbots improved self-testing uptake, linkage to care and adherence support. Methods included random forests, neural networks, support vector machines, deep learning and many others. DISCUSSION : AI has the potential to transform HIV care by improving early diagnosis, treatment adherence and retention in care. However, challenges such as data quality, infrastructure limitations and ethical considerations must be addressed to ensure successful implementation. CONCLUSIONS : AI has demonstrated immense potential to address gaps in HIV care, improving diagnostic accuracy, enhancing retention strategies and supporting effective treatment monitoring. These advancements contribute towards achieving the UNAIDS 95-95-95 targets. However, challenges such as data quality and integration into healthcare systems remain. Future research should prioritize scalable AI solutions tailored to high-burden, resource-limited settings to maximize their impact on global HIV care.
Optimising insulin use in people living with type 2 diabetes at primary healthcare facilities : the Tshwane insulin project
Rheeder, Paul; Botha, G.; Mohlala, Maryangela G.; Eales, Owen; Van Zyl, Danie G.; Ngassa Piotie, Patrick (South african Medical Association, 2025-07)
BACKGROUND : In South Africa (SA), glucose control for individuals with type 2 diabetes follows a stepwise approach. According to the guidelines, insulin therapy is started after using two oral agents. However, various challenges may delay the initiation of insulin. OBJECTIVES : To implement a nurse-led, telehealth-assisted programme to address these challenges, aiming to transition patients to insulin safely to achieve better glycaemic control. METHODS : From 2021 to 2023, we conducted a single-arm, unblinded before-and-after study in primary care facilities in Tshwane District, Gauteng Province, SA. Participants were on insulin or two oral agents at maximum doses. Study nurses monitored glycated haemoglobin (HbA1c) results, and participants with HbA1c levels of ≥8% (≥10% during the COVID‑19 pandemic) were counselled about insulin use. During an initiation visit, participants received demonstrations and education on using insulin and glucose meters. The participants then tested their glucose levels at home according to a fixed schedule. Over 14 weeks, we implemented monthly clinic visits supplemented by home visits facilitated by community healthcare worker teams. During these visits, glucose results were communicated to the clinic physician via the Vula mobile app, allowing timely adjustments to insulin therapy. RESULTS : Of the 293 participants, 65% (n=192) were women and 35% (n=101) were men. The mean (standard deviation (SD)) age was 53 (10) years, with a baseline mean (SD) HbA1c level of 12.1% (1.7%). Of those initiated, 169 (58%) were on oral agents and 124 (42%) were on insulin. Biphasic mixed human insulin was prescribed to 185 participants (63%) and intermediate human neutral protamine Hagedorn (NPH) insulin to 108 (37%). Immediately after baseline assessment and during the 14-week study period, 72 participants (23%) were lost to follow-up, and seven were hospitalised during the study period. Glucose values decreased over 14 weeks, with approximately one-third of participants having no insulin adjustments, one-third having one adjustment, and one-third having more than one adjustment. The mean (SD) HbA1c level decreased from 12.1% (1.6%) to 8.8% (1.6%) over the 14 weeks in 240 paired samples (p<0.001). Ten percent of these participants achieved HbA1c levels <7%, and 34% had levels <8%. CONCLUSION : The nurse-led, telehealth-supported intervention successfully transitioned participants onto twice-daily mixed insulin or night-time intermediate NPH insulin, resulting in a significant decrease in HbA1c from 12.1% to 8.8%. However, clinics will require additional resources to initiate or intensify insulin therapy in primary care settings.
Longitudinal patterns and predictors of opioid and stimulant use initiation and cessation among female sex workers living with HIV in South Africa
Schluth, Catherine G.; Rosen, Joseph G.; Mcingana, Mfezi; Rucinski, Katherine B.; Knox, Justin R.; Comins, Carly A.; Steingo, Joel; Shipp, Lillian; Makama, Siyanda; Phetlhu, Deliwe R.; Mishra, Sharmistha; Hausler, Harry; Baral, Stefan D.; Schwartz, Sheree R. (Elsevier, 2025-04)
Female sex workers (FSW) are disproportionately impacted by HIV and substance use. Substance use has been linked to poor HIV treatment outcomes, necessitating exploration of substance use patterns — including polysubstance use — and predictors among FSW living with HIV. Data were obtained for 777 FSW living with HIV who were not virally suppressed and previously randomized to Siyaphambili, a trial of HIV treatment support strategies implemented through TB HIV Care in eThekwini, South Africa. FSW were asked about recent marijuana, opioid, stimulant, and hazardous alcohol use at enrollment and semi-annually for 18 months from June 2018-January 2022. We estimated incidence of substance use initiation/cessation post-enrollment and used Kaplan-Meier plots and lasagna plots to visualize trends. Cox proportional hazards models assessed baseline predictors of substance use initiation/cessation. Overall, 454 FSW (58.4 %) reported any opioid and/or stimulant use. Prior visit hazardous alcohol use (aHR: 0.20, 95 % CI 0.09–0.41) and prior-visit stimulant use (aHR: 2.80, 95 % CI 1.23–6.37) were negatively and positively associated with opioid initiation, respectively. Prior visit marijuana use (aHR: 1.75, 95 % CI 1.11–2.75) and opioid use (aHR: 5.31, 95 % CI 3.32–8.51) were positively associated with stimulant initiation. We found a high prevalence of substance use among FSW living with HIV that was dynamic over time, including a shared relationship between opioid and stimulant use that suggests intertwined substance use. Further investigation into the impact of polysubstance use patterns on success of HIV support strategies is needed to inform HIV treatment and harm reduction programming. HIGHLIGHTS • Opioid and stimulant use are prevalent among female sex workers in South Africa. • Opioid use at prior study visit predicts stimulant initiation and vice versa. • Psychosocial factors (e.g. stigma) predict substance use changes over time.
Performance management and development system in South Africa, a necessary evil : qualitative study
Ibeziako, Ozoemena Joan (Public Library of Science, 2025-07-01)
Performance management focused on development enhances individual and organisational performance and enables improved services. Achieving performance management objectives is vital for addressing healthcare worker shortages and ensuring equitable, quality healthcare. A weakened South African district-based primary health care system links to inadequate leadership and governance. This study aimed to explore how doctors in primary health care perceive performance management and development systems. The objectives examined what medical officers understand about it and their experiences. Emerging themes may provide insights into enhancing implementation. This study used a qualitative, interpretive, and phenomenological research design. Stratified purposive sampling based on PMDS completion and employment duration led to four focus group discussions with 17 participants. A thematic analysis was performed. The overarching theme was the Performance Management and Development System as a necessary evil, with benefits and challenges. The subthemes included understanding components, comprehending clinic systems to improve outcomes, nurturing employee-supervisor interactions, fostering performance and learning culture, and facilitating personal and professional growth. Additional subthemes included ambiguity in fairness, lack of management capacity, and need for a bottom-up approach and realistic implementation. Effective implementation of a Performance Management and Development System requires managers and supervisors to drive this process strategically. Those responsible for clinical governance should invest in personal development to understand the process and consider appropriate implementation tools.
Treatment outcomes of short-regimen multi-drug resistant tuberculosis in uMkhanyakude district (2018-2022) South Africa : a retrospective, cross-sectional study
Mtolo, Lucky; Ngoma, Nqobile; Naidoo, Saloshini (BioMed Central, 2025-10)
BACKGROUND : Rifampicin-resistant / Multidrug-resistant tuberculosis (RR/MDR-TB), remains a major global health challenge, exacerbated by socioeconomic factors, poor treatment outcomes, and rising drug resistance. In response, RR/MDR-TB care has been decentralised to district hospitals in uMkhanyakude Health District to improve treatment access. This study aimed to assess treatment outcomes of patients receiving the nine-month short regimen for RR/MDR-TB in uMkhanyakude District from 2018 to 2022, and to identify socio-demographic and clinical factors associated with treatment success or failure. METHODS : A retrospective cross-sectional study was conducted among patients aged 18 years and older who received a nine-month short-course RR/MDR-TB treatment regimen at decentralised facilities in KwaZulu-Natal’s uMkhanyakude District from 2018 to 2022. Data were collected through clinical chart reviews, and descriptive statistics and multivariable regression analysis were used to identify predictors of treatment outcome. RESULTS : Among 375 RR/MDR-TB patients on nine-month short-course therapy, 50.1% (n = 188) were Males. Most patients 39.5%, (n = 148) were aged 35–51 years. The treatment success rate was 81.3% (n = 305), with 48.8% (n = 183) cured and 32.5% (n = 122) completing treatment without a confirmed bacteriological cure. Unsuccessful treatment outcomes occurred in 18.7% (n = 70) of patients, including deaths 3.2% (n = 12), treatment failures 3.7% (n = 14), loss to follow-up was 6.7% (n = 25) and treatment interruption leading to unsuccessful outcomes in 5.1% (n = 19). Occupational status, treatment interruption, and adverse drug reactions (ADRs) were significant predictors of treatment failure. Employed patients had higher odds of failure (aOR = 10.5, p = 0.001). Shorter treatment interruption (1 month) was protective (OR = 0.02, p = 0.001). ADRs increased the risk of failure (OR = 4.2, p = 0.001). CONCLUSION : The treatment success rate for patients on the RR/MDR-TB nine-month short-course in uMkhanyakude District was high. Being employed was identified as a significant predictor of treatment failure, emphasising the need for targeted interventions for employed individuals. Further research is needed to explore Directly Observed Treatment (DOT) options for employed patients.
The epidemiology of human schistosomiasis in Gauteng Province, South Africa, 2017-2022
Makhubele, Nchucheko; Ngoma, Nqobile; Matjokotja, Tebogo; Nyasulu, Peter S.; Neti, Mzimasi; Mokgetle, Refilwe (AOSIS, 2025-08)
BACKGROUND : Schistosimiasis affects over 250 million people globally. It is considered a moderately endemic condition in South Africa, with 36 people per 100 000 infected annually between 2011 and 2018. Despite its ability to cause long-term complications, it remains under-studied in Gauteng Province, and its epidemiological patterns are poorly understood. AIM : To describe the prevalence and trends of human schistosomiasis from 2017 to 2022. SETTING : Gauteng Province, South Africa. METHODS : A descriptive cross-sectional study was conducted using all clinical and laboratory human schistosomiasis cases in Gauteng Province from 2017 to 2022. Descriptive statistics summarised cases. Annual trends, seasonal patterns, and geographic distribution were assessed. Yearly incidence rates and overall provincial prevalence were estimated per 100 000 population. RESULTS : There were 2526 human schistosomiasis cases recorded. The median age was 28 years (interquartile range [IQR]: 19–42), and men aged 10–19 years were most affected (15%). Cases declined by 37 per year over the study period, with seasonal peaks in February–March and August–September. The highest incidence occurred in 2019 (3.83 cases per 100 000). City of Tshwane Metropolitan and Mogale City had region-specific prevalence of > 25 cases per 100 000; overall provincial prevalence was 15 cases per 100 000. CONCLUSION : Enhanced surveillance, strengthened reporting, targeted awareness and preventative measures in vulnerable communities are recommended to reduce transmission. Ongoing research is crucial to inform evidence-based interventions in Gauteng Province and South Africa. CONTRIBUTION : The study identified key demographic patterns, geographic hotspots, and temporal trends of human schistosomiasis cases in Gauteng Province.
Knowledge, attitudes and practices on hypertension among patients in a district hospital
Ahmed, Esla H.H.; Maphasha, Olga M.; Okeke, Sunday O. (AOSIS, 2025-05-15)
BACKGROUND : Hypertension is a major global public health issue, with effective management relying heavily on patient adherence to lifestyle changes and medication. Understanding demographic influences on these behaviours is vital for targeted intervention. This study assessed knowledge, attitudes, and practices related to hypertension among patients at a district hospital in Tshwane, South Africa. METHODS : A descriptive cross-sectional study used a structured, piloted questionnaire adapted from previous studies with 283 participants at a Tshwane district hospital. RESULTS : The mean knowledge score was 55.2%, with gaps in understanding normal blood pressure (BP) values (46.29%) and risk factors (18.02%). Attitudes were positive, with 97.6% endorsing regular BP checks and 93.3% supporting salt reduction. Practices were moderate, with 70% never missing medication and 58% regularly monitoring weight. Higher education correlated with better knowledge and attitudes (p < 0.001, p = 0.001, respectively). Non-smokers and non-drinkers exhibited better health practices (p < 0.001). Age negatively correlated with knowledge (r = –0.15, p = 0.010) and attitudes (r = –0.19, p = 0.002). CONCLUSION : While attitudes towards hypertension are generally positive, knowledge and practices remain suboptimal. Targeted educational interventions, tailored to diverse socio-demographic factors, are essential to enhancing adherence. CONTRIBUTION : This study identified gaps in hypertension management in Tshwane, aiding in the development of more effective, patient-centred educational programmes.
Characteristics of paediatric burn injuries seen in the tertiary emergency centre, South Africa
Mugwena, Ntsovelo; Human, Rule; Geyser, M.M. (Mimi) (AOSIS, 2025-01-08)
BACKGROUND : Burn injuries cause significant morbidity and mortality, with prevalence in developing countries such as South Africa. This study aimed to determine the characteristics and referral patterns of burn injuries. METHODS : A retrospective observational study was conducted in a single emergency centre, Kalafong Provincial Tertiary Hospital, from 01 January 2021 to 31 December 2021. The study included patients < 13 years with burn injuries. RESULTS : A total of 266 patients were identified. Males (n = 144, 54.1%) had a higher prevalence of incurring burn injuries. The majority of injuries were secondary to scald burns (n = 237, 89.1%). A total of 208 (78.2%) patients had a percentage of total body surface area (%TBSA) of < 10%, and 257 (96.6%) had superficial partial-thickness burns. Only 77 (28.9%) cases were from referral centres and there was no relationship between referral pattern and %TBSA. Majority (n = 248, 93.2%) received no pre-hospital wound care. Only 108 (40.6%) patients were admitted and the median length of hospital stay (interquartile range [IQR]) was 7 days (2 to 9). There was a significant relationship between the length of hospital stay and %TBSA burns (p < 0.001). CONCLUSION : The pattern of burn injuries in patients is similar to previous studies carried out predominantly in townships in South Africa. Most referrals were found to be appropriate and complied with institutional burn injury admission protocol, although pre-hospital wound care was inadequate. CONTRIBUTION : Primary burn injury care is vital to reduce morbidity and mortality, and development of programmes for public awareness of burn injuries remains crucial.
Mastering your fellowship : Part 4, 2025
Naidoo, Mergan; Von Pressentin, Klaus; Musonda, John M.; Rangiah, Selvandran; Torlutter, Michele; Musonda, Joyce Sikwese (AOSIS, 2025-04)
The ‘Mastering your Fellowship’ series provides examples of the question format encountered in the written and clinical examinations for the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series aims to help family medicine registrars prepare for this examination.
Causes of delayed antenatal care at an urban community health centre in Gauteng, South Africa
Mlambo, Siphesihle P.; Ibeziako, Ozoemena Joan (AOSIS, 2025-04-23)
BACKGROUND : Maternal and perinatal deaths remain significant despite various strategies that have been implemented. Antenatal care (ANC) for pregnant women is crucial in reducing maternal and child mortality. Delayed ANC is associated with several maternal and foetal complications, which can be prevented through timely intervention. Previous studies have identified various factors contributing to the late initiation of ANC, and although recommendations have been made and implemented, there has been no impact. Objectives were to determine and rank the factors contributing to the delayed initiation of ANC among pregnant women attending a community health centre in the Tembisa township and to explore potential strategies for the early initiation of ANC. METHODS : A cross-sectional survey was conducted using a validated questionnaire on pregnant women attending their first ANC after 20 weeks of gestation. RESULTS : Multiple variables affecting the early initiation of ANC were identified, namely healthcare workers’ behaviour, negative attitude, operational management factors and participants’ socio-economic standing. Staff counselling, support and training in holistic maternal healthcare, as well as accurate, uniform and consistent health educational information that recognises and addresses cultural beliefs, could encourage early initiation of ANC. CONCLUSION : Staff empowerment and support for maternal health care through wellness services are crucial. Clinic operational management should adopt best practices to address prolonged time spent accessing services. Relevant health educational information for change should be provided. CONTRIBUTION : The study‘s findings offer insights into the factors that delay the timely initiation of ANC and strategies to mitigate these delays.
Ten-year outcomes of antiretroviral therapy : a retrospective cohort study in Tshwane district, South Africa
Mhlongo, Kateko; Louw, Murray; Ngcobo, Sanele (BioMed Central, 2025-10)
BACKGROUND : South Africa continues to face one of the world’s highest HIV burdens, with 7.7 million people living with HIV (PLWHIV) in 2023. Despite progress toward UNAIDS 95–95–95 targets, challenges in long-term retention and treatment outcomes persist. This study aimed to evaluate 10-year antiretroviral therapy (ART) outcomes among PLWHIV initiated on treatment in 2013 within Tshwane District, South Africa. METHODS : Retrospective cohort using Tier.Net data from 1,337 adults across 10 randomly selected facilities (clinics and community health centres [CHCs]). Outcomes were retention, loss to follow‑up (LTFU), mortality, viral suppression, and CD4 recovery. We used Kaplan–Meier methods and multivariable models (Cox for LTFU and mortality, logistic for viral suppression, linear for CD4 change). Mortality analyses were limited to participants with complete ascertainment (n = 640). RESULTS : At 10 years, 47.7% were retained, 30.4% LTFU, 20.1% transferred out, and 3.3% died. Attrition was steepest early and most pronounced among 18–24-year-olds. Advanced WHO stage strongly predicted death (Stage III/IV vs. I/II: aHR 3.06, 95% CI 1.26–7.44), and younger age was protective (≤ 34 vs. > 34 years: aHR 0.28, 95% CI 0.09–0.86). Care at CHCs was associated with lower mortality (aHR 0.33, 95% CI 0.13–0.83) and greater CD4 gains (clinic care: −74.35 cells/µL vs. CHCs; p < 0.001). Female sex was associated with larger CD4 recovery (+ 90.06 cells/µL vs. males; p < 0.001). Only baseline CD4 > 200 cells/µL independently predicted viral suppression (aOR for being suppressed ≈ 1.89, derived from aOR 0.53 for non-suppression; p < 0.001). No baseline covariates were significant predictors of time to LTFU (clinic type borderline: HR 0.80, p = 0.086). CONCLUSION : A decade after initiation, fewer than half remained in care. Mortality clustered among older adults and those presenting with advanced disease, while CHC-based care conferred survival and immunologic advantages. Programme priorities should include earlier diagnosis and ART start, youth-friendly retention strategies, and scaling CHC-style differentiated service delivery to improve long-term outcomes.
Cascading training model to promote screening, brief intervention, and referral to treatment across South Africa : rollout in an HIV service organization
DiClemente-Bosco, Kira; Kuo, Caroline; Sibeko, Goodman; Allie, Shaheema; Souza, Timothy; Janssen, Tim; Cornelius, Warren; Mkhize, Ayanda; Scheibe, Andrew; Pretorius, Anje; Sterling, Tricia; Becker, Sara J. (Sage, 2025-10)
BACKGROUND : In South Africa, rates of HIV and alcohol use are among the highest globally, with a detrimental synergistic relationship. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, cost-effective approach to identifying people at risk of alcohol-related problems to deliver early intervention. We developed and deployed a cascading train-the-trainer model to promote SBIRT implementation in a large nongovernmental organization offering HIV services across South Africa. METHOD : Between 2021 and 2022, we completed preparatory activities including designing scalable training resources prior to rolling out the train-the-trainer model across two South African provinces. We conducted a comprehensive assessment of outcomes at the trainer- (knowledge, fidelity), provider- (attitudes, confidence, perceived implementation potential, adoption), and client-encounter (reach) levels over approximately one year. RESULTS : We trained 12 novice trainers who then trained 206 providers to implement SBIRT. Trainer SBIRT knowledge increased pre- to posttraining, and fidelity of training delivery was high (99.0% of elements covered across sessions). Provider attitudes, confidence, and perceived implementation potential increased over time, and 64% of providers adopted SBIRT. Reach of the model varied by component, with 41,793 clients screened by trained providers. Of those screening positive for risky alcohol use, 86% received brief intervention (BI) and 53% received referral to treatment (RT). Additionally, 15,353 clients who did not screen as having risky alcohol use received BI and 1,122 received RT. CONCLUSION : Results indicated that the cascading training model was delivered with high fidelity, associated with improvements in all provider outcomes, and reached high numbers of clients for the screening component of the model. Rates of BI and RT delivery were moderate to high, though data suggested over-application of these elements with some clients, highlighting the tension between reach and fidelity. Lessons learned will inform future scale-out of this model in HIV service settings in low- and middle-income countries. PLAIN LANGUAGE SUMMARY Training the HIV-care workforce to deliver screening, brief intervention, and referral to treatment for alcohol use in a non-governmental service organization in South Africa In South Africa, rates of HIV and alcohol use are high, and they negatively impact one another. An approach known as SBIRT—Screening, Brief Intervention, and Referral to Treatment—is an evidence-based and effective way to identify individuals with risky alcohol use and provide them with interventions to reduce alcohol-related risks. The purpose of this research is to test whether a cascading train-the-trainer model can mobilize a large workforce to use SBIRT in HIV service settings. Our research team partnered with a large nongovernmental organization serving populations at high-risk for HIV in South Africa to test this training model. A small group of expert trainers from our team trained 12 novice trainers from the partner organization in how to instruct providers to use SBIRT with their clients. These novice trainers then trained 206 providers within the partner organization covering almost all (99.0%) training elements. Almost two-thirds of these providers used SBIRT, screening 41,793 clients over approximately one year. The reach of brief intervention was very high; 86% of indicated clients who were seen by trained providers received a brief intervention. Reach of referral to treatment was moderate, with 53% of indicated clients seen by trained providers receiving a referral to treatment. We also found that many clients received either a brief intervention or a referral to treatment when they did not screen positive for risky alcohol use. Our results are encouraging with respect to the feasibility of the cascading training model and its ability to mobilize a large workforce to reach clients with SBIRT, yet the fidelity of the application of brief intervention and referral to treatment warrants further research. This work highlights the tension between reaching large numbers of clients and maintaining fidelity.
Clinical trial methods for family medicine and primary care
Mash, Robert; Fatusin, Bolatito B.; Madela-Mntla, Edith; Butler, Christopher (AOSIS, 2025-07)
This article outlines the essential features of clinical trials for doctoral or early career researchers. The World Health Organization has recently emphasised the need for higher quality clinical trials, more trials from low- and middle-income countries, as well as primary care, more engagement with patients and communities and adoption of innovative trial designs. In sub-Saharan Africa, primary care researchers need to move beyond quasi-experimental and before-and-after designs to conduct randomised clinical trials. The article describes the key methodological requirements of a randomised controlled trial: the hypothesis, design, setting, recruitment, randomisation, sample size, intervention, assessment, results, interpretation and extrapolation. We also discuss the aspects of ethical and well-organised trials that respect study participants, engage with collaborative processes, have appropriate governance and transparent dissemination of results. Finally, we outline innovative designs such as step-wedge, clinical trial networks and adaptive platform designs.
Prevalence and factors associated with HIV testing among women of reproductive age in Liberia : a cross-sectional study from the 2019/20 Demographic and Health Survey
Kolane, Mapei Mary Anna; Tshotetsi, Lumbani (MDPI, 2025-08)
OBJECTIVE : This study explored HIV testing prevalence and its associated factors among reproductive-aged women in Liberia. STUDY DESIGN : A secondary and descriptive cross-sectional study was performed among Liberian women aged 15–49 years using the 2019 Liberia Demographic and Health Survey (LDHS) data set. METHODS : Descriptive statistics were used to describe the characteristics of these women. Bivariate and multivariable logistic regression models were applied to determine factors associated with HIV testing. All analyses were adjusted for unequal probabilities of selection and non-response by use of survey weights. RESULTS : Among the 8065 participants in this survey, 490 women had never had sex and were excluded, leading to the final sample size being 7575 women. The prevalence of HIV testing among Liberian women aged 15 to 49 years in 2020 was 57.17% (95% CI: 56.2 to 60.4). HIV testing among these women is associated with pregnancy history (aOR 6.40, 95% CI:4.99 to 8.22, p < 0.001), STI history (aOR 1.21, 95% CI:1.02 to 3.19, p < 0.001), knowledge of vertical transmission (aOR 1.65, 95% CI:1.23 to 2.21, p = 0.001), and highest educational level (primary (aOR 1.39, 95% CI:1.16 to 1.68, p < 0.001), secondary (aOR 2.10, 95% CI:1.73 to 2.53, p < 0.001), and higher education (aOR 6.80, 95% CI:3.75 to 12.32, p < 0.001)). CONCLUSIONS AND CONTRIBUTION : HIV testing prevalence of 57.17% demonstrates an unmet need for HIV testing among Liberian women aged 15 to 49 years and, thus, it is recommended that HIV testing and counseling services should mostly target these women in rural areas, with limited health services and less educated women.
South African harm reduction guideline for chemsex
Scheibe, Andrew; Andrews, Yolaan; Brown, Ben; Cassim, Naeem; Chidarikire, Thato; Hugo, Johan; Maithufi, Regina; Mjindi, Sive; Nel, Dawie; Shelly, Shaun; Sibeko, Jabulile; Slabbert, Mariette; Xulu, Londeka; Mozalevski, Antons (AOSIS, 2025-09)
The intentional use of psychoactive substances to enhance sexual experiences is known as chemsex. Chemsex is one form of sexualised substance use. Chemsex is primarily, but not exclusively, practised by key population groups including gay, bisexual and other men who have sex with men (GBMSM), transgender people, people who use drugs, and sex workers. The potential harms result from the intersecting stigma and risks relating to substance use, criminalisation of drug use and possession for personal use, sex work, HIV and other sexually transmitted infections (STIs), prolonged and higher-risk sexual practices, substance-use disorders, mental health conditions, and sexual- and gender-based violence. Chemsex is not always problematic, but some people may develop health and/or social issues with this practice. While data on the prevalence of chemsex in South Africa (SA) are limited, HIV and STI programmes for key populations regularly reach people who engage in chemsex. Chemsex sessions are frequently posted on GBMSM social networking and dating applications. This phenomenon is taking place in the context of increasing psychoactive substance use and a high prevalence of HIV and other STIs among key populations in the country. Locally, there is a lack of knowledge, services, and support for people who engage in chemsex. This exacerbates their risk of exposure to HIV and other STIs, heightens barriers to accessing comprehensive care, and intensifies potential harms. This guideline provides recommendations to address the key health and psychosocial aspects relating to chemsex in SA. Box 1 summarises the key components of chemsex harm reduction services. Recommendations are aligned with international evidence and informed by the professional experience of the authors, and research on the values and preferences of South African GBMSM who engage in chemsex. This guideline was thoroughly reviewed by external peer reviewers. This guideline should be viewed within the context of the Southern African HIV Clinicians Guidelines for Harm Reduction. SCOPE AND PURPOSE • Provide an overview of chemsex in SA. • Offer evidence-based clinical guidance for chemsex harm-reduction services. • Provide a directory of useful resources and sensitised providers.
A realist-informed evaluation of the implementation of complex HIV treatment support strategies for female sex workers living with HIV
Comins, Carly A.; Mcingana, Mfezi; Genberg, Becky; Mulumba, Ntambue; Geng, Elvin; Mishra, Sharmistha; Phetlhu, Deliwe R.; Lujintanon, Sita; Shipp, Lily; Steingo, Joel; Hausler, Harry; Baral, Stefan; Schwartz, Sheree (Elsevier, 2025-09)
PURPOSE : In South Africa, female sex workers (FSW) living with HIV have suboptimal treatment outcomes. The Siyaphambili trial tested two strategies to promote viral suppression. This paper identifies why and under what conditions the strategies were appropriate, feasible, implemented with fidelity, and ultimately effective for FSW living with HIV. METHODS : Guided by the Consolidated Framework for Implementation Research, we conducted in-depth interviews with 36 Siyaphambili participants using maximum variation sampling and purposively selected 12 key informant implementors. We generated ‘Context + Mechanism = Outcome’ configurations using deductive coding and retroductive inference. RESULTS : Overall, strategy appropriateness for FSW reflected how “the needs of innovation recipients” enhanced/challenged the “relative advantage” of the strategies. Feasibility of implementation resulted from the interaction of the “work infrastructure”, “available resources”, and access to “knowledge and resources,” which activated/dampened the “design” of the strategies. Fidelity of implementation relied on how “partnerships”, “relational connections” and “communication” influenced strategy “complexity” and “adaptability.” Strategy effectiveness depended on the influence of FSW “capability” on their “motivation and opportunity.” CONCLUSIONS : Understanding the conditions in which these strategies did or did not work aids in understanding the why this pragmatic trial failed to achieve anticipated results and informs potential success that can be taken forward to better optimize treatment outcomes for FSW.
Longitudinal trajectories of engagement with HIV treatment support strategies among female sex workers living with HIV in South Africa
Comins, Carly A.; Genberg, Becky L.; McIngana, Mfezi; Bandeen-Roche, Karen Bandeen; Phetlhu, René Deliwe; Steingo, Joel; Mishra, Sharmistha; Wang, Linwei; Baral, Stefan David; Hausler, Harry; Schwartz, Sheree (Lippincott, Williams & Wilkins, 2025-12)
BACKGROUND : Tailored implementation strategies to promote the uptake and scale-up of antiretroviral therapy (ART) among female sex workers (FSW) in South Africa are needed, as <50% of FSW living with HIV are on ART and <40% are virally suppressed. SETTING : We conducted a randomized trial testing two HIV treatment support strategies (decentralized treatment provision (DTP); individualized case management (ICM)) among 777 FSW living with HIV and not virally suppressed (≥50 copies/mL) in Durban, South Africa, June 2018 - January 2022. METHODS : We defined strategy engagement in a six-month interval if the monthly strategy session was delivered and the FSW participated. Group-based trajectory modeling with logit response function was used to identify engagement trajectories and describe correlates of trajectories. We used Poisson regression analysis with robust variance estimation to assess the association between assigned trajectory group and 18-month retention and viral suppression (<50 copies/mL). RESULTS : We identified four trajectories: no engagement (12%), late engagement (10%), engagement corresponding with study visits (53%), and consistent engagement (25%). FSW who were older, unmarried, receiving ART at enrollment, and DTP assignment were more likely to be classified in the consistently engaged trajectory compared to the no engagement trajectory. The prevalence of 18-month retention and viral suppression was higher among FSW assigned to the consistent engagement trajectory compared to the no engagement trajectory (prevalence ratio [PR]= 3.2, 95%CI 1.6-6.3). CONCLUSION : Person-centered HIV services that address unmet treatment needs could improve health, viral suppression, and subsequently reduce population-level HIV transmission.
Factors linked to virological failure in people on a dolutegravir-based regimen in Mamelodi
Mmatsoku, Moloko S.; Ngcobo, Sanele (AOSIS, 2024-10-04)
BACKGROUND : Since 2019, the World Health Organization has recommended dolutegravir-containing regimens for HIV in low- and middle-income countries because of its high genetic barriers to resistance, lower drug interactions, fewer side effects, higher viral load (VL) suppression rates and cost-effectiveness compared to efavirenz. OBJECTIVES : This study investigates factors associated with unsuppressed VLs in people living with HIV on tenofovir-lamivudine and dolutegravir (TLD) in South Africa (SA). METHOD : A cross-sectional study was conducted between October 2023 and February 2024 at Mamelodi Regional Hospital’s Ntshembo Clinic. Participants were people living with HIV aged 18 years and older, more than 6 months on TLD, with either suppressed (≤ 50 copies/mL) or unsuppressed (> 50 copies/mL) VLs. RESULTS : Significant associations were found between unsuppressed VL and factors such as sex, marital status, occupation and education level. Male participants were less likely to achieve VL suppression than female participants (odds ratio: 0.45, p = 0.0007). Poor antiretroviral therapy adherence was linked to higher unsuppressed VL (p < 0.05). Newly initiated patients had significantly lower suppression rates (p < 0.05). The use of traditional or herbal and religious products was also linked to unsuppressed VL (p < 0.05). CONCLUSION : The study highlights the importance of addressing adherence factors to improve VL suppression rates among people living with HIV on TLD. CONTRIBUTION : Tailored interventions targeting adherence, especially among newly initiated patients, and addressing the use of traditional or herbal and religious products are warranted to enhance treatment outcomes.

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