Dataset Information

The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from oMakoti in uMgungundlovu District, South Africa.

ABSTRACT:

Introduction

In response to revisions in global and national policy in 2011, six-month isoniazid preventive therapy (IPT) became freely available as a preventive measure for people living with HIV in the uMgungundlovu District of KwaZulu-Natal province, South Africa. Given a difference in uptake and completion by sex, we sought to explore the reasons why Zulu women were more likely to accept and complete IPT compared to men in an effort to inform future implementation.

Methods

Utilising a community-based participatory research approach and ethnographic methods, we undertook 17 individual and group interviews, and met regularly with grassroots community advisory teams in three Zulu communities located in uMgungundlovu District between March 2012-December 2016.

Findings & discussion

Three categories described women's willingness to initiate IPT: women are caregivers, women are obedient, and appearance is important. The findings suggest that the success of IPT implementation amongst clinic-utilising women of uMgungundlovu is related to the cultural gender norms of uMakoti, isiZulu for "the bride" or "the wife." We invoke the cultural concept of inhlonipho, meaning "to show respect," to discuss how the cultural values of uMakoti may conflict with biomedical expectations of adherence. Such conflict can result in misinterpretations by healthcare providers or patients, and lead some patients to fear the repercussions of asking questions or contemplating discontinuation with the provider, preferring instead to appear obedient. We propose a shift in emphasis from adherence-focussed strategies, characteristic of the current biomedical approach, to practices that promote patient agency in an effort to offer IPT more appropriately.

Implications

Building on existing tools, namely the harm reduction model and the use of mini-ethnography, we provide guidance on how to support women to participate as agents in the decision to initiate or continue IPT, decisions which may also impact the health and choices of the family.

SUBMITTER: Boffa J

PROVIDER: S-EPMC5841771 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Publications

The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from oMakoti in uMgungundlovu District, South Africa.

Boffa Jody J Boffa Jody J Mayan Maria M Ndlovu Sithembile S Mhlaba Tsholofelo T Williamson Tyler T Sauve Reginald R Fisher Dina D

PloS one 20180307 3

<h4>Introduction</h4>In response to revisions in global and national policy in 2011, six-month isoniazid preventive therapy (IPT) became freely available as a preventive measure for people living with HIV in the uMgungundlovu District of KwaZulu-Natal province, South Africa. Given a difference in uptake and completion by sex, we sought to explore the reasons why Zulu women were more likely to accept and complete IPT compared to men in an effort to inform future implementation.<h4>Methods</h4>Uti ...[more]

PMID: 29513719

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Project description:BackgroundThe World Health Organization recommends isoniazid preventive therapy (IPT) for people living with HIV (PLHIV) to prevent tuberculosis (TB), including pregnant women. Recent trial results suggest increased adverse pregnancy outcomes associated with IPT during pregnancy. Data are limited regarding programmatic IPT use in pregnant PLHIV.MethodsWe assessed previous programmatic IPT during pregnancy among HIV-infected mothers on enrollment to an infant TB prevention trial in Kenya. Pregnancy IPT use was assessed by the estimated conception date assuming 38 weeks of gestation. Correlates of initiation and completion were analyzed by relative risk regression, using generalized linear models with log link and Poisson family adjusted for IPT initiation year.ResultsBetween August 15, 2016, to June 6, 2018, 300 HIV-infected women enrolled at 6 weeks postpartum. Two hundred twenty-four (74.7%) women reported previous IPT, of whom 155/224 (69.2%) had any pregnancy IPT use. Forty-five (29.0%) initiated preconception extending into early pregnancy, 41 (26.5%) initiated and completed during pregnancy, and 69 (44.5%) initiated in pregnancy and extended into early postpartum. The median gestational age at IPT pregnancy initiation was 15.1 weeks (interquartile range 8.3-28.4). Pregnancy/early postpartum IPT initiation was associated with new pregnancy HIV diagnosis [adjusted relative risk 1.9 95% confidence interval (CI): 1.6 to 2.2, P < 0.001]. Six-month IPT completion rates were high [147/160 (91.9%)] among women with sufficient time to complete before trial enrollment and similar among preconception or during pregnancy initiators [adjusted relative risk 0.93 (95% confidence interval: 0.83 to 1.04, P = 0.19)].ConclusionsProgrammatic IPT use was high in pregnant PLHIV, with frequent periconception and early pregnancy initiation. Programmatic surveillance could provide further insights on pregnancy IPT implementation and maternal and infant safety outcomes.

Project description:Wastewater treatment plants (WWTPs) are major reservoirs of antibiotic-resistant bacteria (ARB), favouring antibiotic resistance genes (ARGs) interchange among bacteria and they can provide valuable information on ARB circulating in a community. This study characterised extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli from the influent and effluent of four WWTPs in uMgungundlovu District, KwaZulu-Natal, South Africa. E. coli was enumerated using the membrane filtration method and confirmed using the API 20E test and real-time polymerase chain reaction. ESBL-producers were phenotypically identified by their susceptibility to the third-generation cephalosporins using the disc diffusion and the double-disc synergy methods against cefotaxime (30 µg) with and without 10 µg clavulanic acid. Genotypic verification was by PCR of the TEM, SHV, and CTX-M genes. The clonality of isolates was assessed by ERIC-PCR. The highest E. coli count ranged between 1.1 × 105 (influent) and 4.3 × 103 CFU/mL (effluent). Eighty pure isolates were randomly selected, ten from the influent and effluent of each of the four WWTP. ESBLs were phenotypically confirmed in 49% (n = 39) of the isolates, of which 77% (n = 30) were genotypically confirmed. Seventy-three percent of the total isolates were multidrug-resistant (MDR). Only two isolates were susceptible to all antibiotics. Overall, resistance to first and second-generation cephalosporins was higher than to third and fourth generation cephalosporins. Also, 15% of the isolates were resistant to carbapenems. The CTX-M-type ESBL (67%; n = 20) was the most common ESBL antibiotic resistance gene (ARG) followed by TEM (57%; n = 17) and SHV-types (27%; n = 8). Also, a substantial number of isolates simultaneously carried all three ESBL genes. ERIC-PCR revealed a high diversity of isolates. The diversity of the isolates observed in the influent samples suggest the potential circulation of different ESBL-producing strains within the studied district, requiring a more comprehensive epidemiological study to prevent the spread of ESBL-producing bacteria within impoverished communities.

Project description:Coagulase-negative staphylococci (CoNS) are increasingly associated with nosocomial infections, especially among the immunocompromised and those with invasive medical devices, posing a significant concern. We report on clinical multidrug-resistant CoNS from the uMgungundlovu District, KwaZulu-Natal Province, South Africa, as emerging pathogens. One hundred and thirty presumptive CoNS were obtained from blood cultures. Culture, biochemical tests, and the Staphaurex™ Latex Agglutination Test were used for the initial identification of CoNS isolates; confirmation and speciation were undertaken by the VITEK 2 system. Susceptibilities of isolates against a panel of 20 antibiotics were determined using the Kirby-Bauer disk diffusion method, and the multiple antibiotic resistance (MAR) indices of the isolates were determined. The polymerase chain reaction (PCR) was used to amplify the mecA gene to confirm methicillin resistance. Overall, 89/130 presumptive CoNS isolates were confirmed as CoNS by the VITEK 2 system. Of these, 68 (76.4%) isolates were putatively methicillin-resistant by the phenotypic cefoxitin screen test and 63 (92.6%) were mecA positive. Staphylococcus epidermidis (19.1%), S. hominis ssp. hominis (15.7%), and S. haemolyticus (16.9%) were the most common CoNS species. Isolates showed high percentage resistance against penicillin (100.0%), erythromycin (74.2%), and azithromycin (74.2%) while displaying high susceptibilities to linezolid (95.5%), gentamicin (95.5%), and tigecycline (94.4%). Multidrug resistance (MDR) was observed in 76.4% of isolates. MAR index calculation revealed 71.9% of isolates with MAR index >0.2 and 20.2% >0.5. Isolates with the highest MAR indices (0.7 and 0.8) were recovered from the neonatal intensive care unit. Fifty-one MDR antibiograms were observed. The high prevalence of methicillin resistance and multidrug resistance in several species of CoNS necessitates surveillance of this emerging pathogen, currently considered a contaminant of microbial cultures.

Project description:BackgroundVancomycin-resistant enterococci (VRE) are important pathogens categorized as high-priority bacteria in the Global Priority List of Antibiotic-Resistant Bacteria to Guide Research, Discovery, and Development of New Antibiotics published by the World Health Organization. The aim of this study was to determine the risk factors, resistance, virulence, mobilomes associated with multidrug-resistant and clonal lineages of Enterococcus faecium and faecalis circulating among hospitalized patients following the health system in South Africa, using whole genome sequencing (WGS).MethodsA cross-sectional study was conducted during a two-month periods among hospitalized patients in 2017. Rectal swabs were collected from patients admitted to medical and surgical wards in an urban tertiary hospital, and a rural district hospital in uMgungundlovu district, South Africa. Enterococci were screened for vancomycin resistance on bile esculin azide agar supplemented with 6 mg/L of vancomycin and confirmation of VRE was done using ROSCO kits. Conventional and real-time PCR methods were used to ascertain the presence of VanA, VanB, VanC-2/3 and VanC-1 genes. All six multidrug-resistant Enterococcus faecalis and faecium selected were identified using multiplexed paired-end libraries (2 × 300 bp) with the Nextera XT DNA sample preparation kit (Illumina, San Diego, CA, USA) and genome sequencing was done using Illumina MiSeq instrument with 100× coverage at the National Institute of Communicable Diseases Sequencing Core Facility, South Africa. Antibiotic resistance genes, virulence factors, plasmids, integrons and CRISPR were characterized using RAST, ResFinder, VirulenceFinder, PlasmidFinder, PHAST and ISFinder respectively.ResultsSequencing analysis revealed that these strains harbouring numerous resistance genes to glycopeptides (vanC[100%], vex3[100%], vex2[83,33%] and vanG[16,66%]), macrolides, lincosamides, sterptogramine B (ermB[33,32%], Isa[16,66%], emeA[16,66%]) and tetracyclines (tetM[33,32%]) in both district and tertiary hospitals. Multidrug efflux pumps including MATE, MFS and pmrA conferring resistance to several classes of antibiotics were also identified. The main transposable elements observed were in the Tn3 family, specifically Tn1546. Four single sequence types (STs) were identified among E. faecium in the district hospital, namely ST822, ST636, ST97 along with a novel ST assigned ST1386, while one lineage, ST29 was detected in the tertiary hospital.ConclusionThe study reveals the genetic diversity and high pathogenicity of multidrug-resistant Enterococcus faecalis and faecium circulating among hospitalized patients. It underlines the necessity to implement routine screening of admitted patients coupled with infection control procedures, antimicrobial stewardship and awareness should be strengthened to prevent and/or contain the carriage and spread of multidrug resistant E. faecium and E. faecalis in hospitals and communities in South Africa.

Project description:IntroductionThe South African public health system plays an important role in the delivery of HIV testing and treatment services. The health system is also an important conduit for targeted behaviour change communication with the expectation that clients who undergo counselling from health personnel, adopt safer sexual practices. Literature remains mixed on the impact these HIV services have on risky sexual behaviour. This analysis examines the sexual behaviour of clients following the utilisation of HIV testing and treatment services in Kwazulu-Natal, South Africa.MethodsData were used from two consecutive cross-sectional household surveys undertaken from June 2014 to June 2015 (2014/2015 survey) and from July 2015 to June 2016 (2015/2016 survey) in the uMgungundlovu District of KwaZulu-Natal, South Africa. Collectively, 20,048 randomly selected individuals aged 15 to 49 years old were interviewed across the two surveys. Utilisation of HIV testing and treatment services were used as independent variables and three sexual risk behaviours were used as dependent variables. Multiple regression models assessed the impact HIV testing and treatment services had on sexual risk behaviour while controlling for socio-demographic characteristics.ResultsHaving tested for HIV had no association with any of the three sexual risk behaviours. However, receiving an HIV positive diagnosis reduced the likelihood of using condoms inconsistently with the respondents' most recent partner (AOR: 0.64; 95% CI 0.54-0.77). Antiretroviral use was negatively associated with inconsistent condom use (AOR: 0.45; 95% CI 0.35-0.58) and number of sexual partners in the previous year (AOR: 0.61; 95% CI 0.46-0.81).ConclusionsResults indicate that HIV testing and treatment services and the assumed exposure of clients to behaviour change communication, had a limited effect in reducing risky sexual behaviour. Data suggests that the engagement between health personnel and individuals accessing HIV testing and treatment services does not necessarily translate into the adoption of safer sexual practices, with the exception of individuals testing positive for HIV and those on ARV treatment, who had adopted safer sexual practices.

Project description:BackgroundImproving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.MethodsBetween 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.ResultsWe found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.ConclusionRole ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.

Project description:South Africa has implemented a community-based HIV programme (CBHP) in its primary healthcare (PHC) re-engineering strategy that aims to improve public healthcare delivery. This CBHP is delivered by ward-based outreach teams (WBOTs); provision of community HIV services comprises an important component of this programme. We conducted an exploratory study to determine the facilitators and barriers to successful implementation of this CBHP in rural Mopani District, South Africa. Focus group discussions were conducted with the community health workers (CHWs) and PHC nurses; participant interviews were conducted with community members who access these health services, community leaders, and social workers. We conducted a thematic content analysis and based on the key themes reported, we identified the Consolidated Framework for Implementation Research, consisting of five domains, as the most appropriate model to interpret our findings. First, in terms of intervention characteristics, community members generally valued the HIV services provided, but the variable needs impacted on programme implementation. Outer setting challenges include inability to meet the need of patients as a result of stigma, non-disclosure of HIV status and social factors. In terms of the inner setting, CHWs were grateful for the equipment and training received but expressed the need for better support of management and the provision of additional resources. With regard to characteristics of the implementers, the CHWs expressed the desire for further training despite reporting having sufficient knowledge to conduct their HIV work. Finally, in terms of the implementation process, the importance of relationship building between CHWs and community members was emphasised. In conclusion, these data underline the positive receipt and potential of the CBHP in this rural district and identify areas to further strengthen the programme. The success and sustainability of the CBHP requires ongoing commitment of resources, training, supervision, and organisational support in order to operate effectively and efficiently.

Project description:South Africa has over 6,000,000 HIV infected individuals and the province of KwaZulu-Natal (KZN) is the most severely affected. As public health initiatives to better control the HIV epidemic are implemented, timely, detailed and robust surveillance data are needed to monitor, evaluate and inform the programmatic interventions and policies over time. We describe the rationale and design of the HIV Incidence Provincial Surveillance System (HIPSS) to monitor HIV prevalence and incidence.The household-based survey will include a sample of men and women from two sub-districts of the uMgungundlovu municipality (Vulindlela and the Greater Edendale) of KZN, South Africa. The study is designed as two sequential cross-sectional surveys of 10,000 randomly selected individuals aged 15-49 years to be conducted one year apart. From the cross sectional surveys, two sequential cohorts of HIV negative individuals aged 15-35 years will be followed-up one year later to measure the primary outcome of HIV incidence. Secondary outcomes include the laboratory measurements for pulmonary tuberculosis, sexually transmitted infections and evaluating tests for estimating population-level HIV incidence. Antiretroviral therapy (ART) access, HIV-1 RNA viral load, and CD4 cell counts in HIV positive individuals will assess the effectiveness of the HIV treatment cascade. Household and individual-level socio-demographic characteristics, exposure to HIV programmatic interventions and risk behaviours will be assessed as predictors of HIV incidence. The incidence rate ratio of the two cohorts will be calculated to quantify the change in HIV incidence between consecutive samples. In anticipation of better availability of population-level HIV prevention and treatment programmes leading to decreases in HIV incidence, the sample size provides 84% power to detect a reduction of 30% in the HIV incidence rate between surveys.The results from HIPSS will provide critical data regarding HIV prevalence and incidence in this community and will establish whether HIV prevention and treatment efforts in a "real world", non-trial setting have an impact on HIV incidence at a population level. Importantly, the study design and methods will inform future methods for HIV surveillance.

Dataset Information

The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from oMakoti in uMgungundlovu District, South Africa.

Introduction

Methods

Findings & discussion

Implications

Publications

The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from oMakoti in uMgungundlovu District, South Africa.

Similar Datasets

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