Rural South Africa Research Articles

Associations of history of intimate partner violence with mental ill-health and lifestyle factors in middle-aged and older men and women in South Africa

ObjectivesThe aim of this study was to assess the association between history of intimate partner violence (IPV) exposure and mental and lifestyle factors among middle-aged and older men and women in rural South Africa. MethodsThe analysis utilized data from wave 3 of the longitudinal Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) (n = 3,707, median age 66 years, range 46–118 years). History of IPV was assessed with five questions on physical, sexual, psychological, and economic IPV. Logistic regression was used to assess the association between history of IPV exposure and mental and lifestyle factors. ResultsAmong men 7.8% and among women 10.9% reported a history of IPV. In terms of mental health outcomes, in the final adjusted model, among men, exposure to 1 and/or 2–4 types of IPV were associated with depressive symptoms, insomnia symptoms, PTSD, and loneliness, while among women, exposure to 1 and/or 2–4 types of IPV was associated with insomnia symptoms and PTSD. In terms of lifestyle outcomes, in the final adjusted model, among men, 2–4 types of IPV were associated current tobacco use, current heavy alcohol use, inadequate fruit intake, and food insecurity, and among women, 1 and/or 2–4 types of IPV were associated with soft drink intake, and food insecurity. ConclusionWe found that lifetime exposure to IPV was associated with several mental and lifestyle factors in middle-aged and older men and women. Enhanced screening and treatment of IPV may reduce poor mental and health risk behavior among this aging male and female population in South Africa.

The medicine in the circle: A case example of embodied arts-based community practice to address intergenerational trauma in rural South Africa

This article shares extracts from an arts-based community model of mental healthcare that works with family and social systems to develop collective resilience and address intergenerational trauma in a culturally informed manner. The practice is situated in an African philosophy of collectivism, where the group is a resource and source of support. It invites arts therapists to engage with psychological practices outside of an individualistic focus with a practical approach to considering the ecosystem which influences health and well-being. Theories such as embodiment and polyvagal theory, community and collective resilience and intergenerational trauma are explored and translated to practise with an example of implementation in a remote farming community in the Western Cape of South Africa. The authors focus on practice elements derived from Dramatherapy and Applied Drama, which highlights embodied practices as they are applied to address intergenerational trauma and develop collective resilience.

Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort

BackgroundStudies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease.MethodsOur exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes.ResultsVirally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes.ConclusionsOur results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.

Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa

Background. Progressive interventions have recently improved programmatic outcomes in drug-resistant tuberculosis (DR-TB) care in South Africa (SA). Amidst these, a shorter regimen was introduced in 2017 with weak evidence, and has shown mixed results. Outcomes still fall short of national targets, and the coronavirus disease 2019 pandemic has undermined progress to date. Objectives. To describe the outcomes of participants treated for DR-TB using a shorter, compared with a longer, regimen in a deeply rural SA setting, and to explore other factors affecting these outcomes. Methods. This retrospective cohort study describes outcomes in short and long DR-TB treatment regimens, over 5 years, at two rural treatment sites in SA. Characteristics were analysed for outcome correlates using multivariable logistic regression models. Results. Of 282 treatment episodes, 62% were successful, with higher success in shorter (69%) compared with longer regimens (58%). Mortality was approximately 21% in both groups. Characteristics included high proportions of HIV co-infection (61%). Injectables (adjusted odds ratio (aOR) 3.00, 95% confidence interval (CI) 1.48 - 6.09), bedaquiline (aOR 3.16, 95% CI 1.36 - 7.35), increasing age (aOR 0.97, 95% CI 0.95 - 0.99) and HIV viraemia defined as final HIV-RNA viral load >1 000 copies/mL (aOR 0.16, 95% CI 0.07 - 0.37) were all significantly and independently associated with treatment success. Injectables (aOR 0.22, 95% CI 0.08 - 0.57), bedaquiline (aOR 0.05, 95% CI 0.01 - 0.19), increasing age (aOR 1.09, 95% CI 1.05 - 1.13), extra-pulmonary TB (aOR 8.15, 95% CI 1.62 - 41.03) and HIV viraemia (aOR 9.20, 95% CI 3.22 - 26.24) were all significantly and independently associated with mortality. Conclusion. In a rural context, treating DR-TB amid limited resources and a high burden of HIV co-infection, we found that after considering controls, a short regimen was no different to a longer regimen in terms of success or mortality. Therefore, by alleviating burdens on multiple stakeholders, a short regimen is likely to be favourable for rural patients, clinicians, and healthcare systems. Besides other previously described correlates of outcomes, HIV viraemia emerged as a novel marker for reliably predicting poor outcomes in DR-TB with HIV co-infection, and a pragmatic target for intervention.

The Sociocultural Influences on Breast Cancer Screening among Rural African Women in South Africa.

The incidence of breast cancer in South Africa is increasing, with rural South African women presenting with advanced stages of the disease. A woman's breasts are a symbol of her womanhood; they also constitute a social definition of her femininity. Women with breast cancer in rural South Africa are heavily stigmatized and suffer from various sociocultural interpretations of the disease. Breast cancer is frequently interpreted in rural South Africa as a symbol of witchcraft, sin, and punishment, and traditionally, it is treated by offering animal sacrifices, consumption of herbs, and prayer to ancestors. Using care-seeking behaviour theory as the theoretical framework, we intend to explore the sociocultural factors influencing breast cancer screening practices among rural South African women. A qualitative exploratory study was conducted using semi-structured interviews with 22 rural South African women selected by purposive sampling. Thematic analysis was used to analyse the data. The study identified four sociocultural factors influencing women's practices of breast cancer screening in rural South Africa, including psychological factors, habits, beliefs, and perceptions of healthcare. Women in rural South African communities have deep-rooted traditional beliefs and practices regarding breast cancer. Consequently, this influences women's preventative health behaviours regarding breast cancer screening. The development of culturally appropriate health education programs involving traditional healers and influential community leaders is essential to increasing the number of women being screened for breast cancer in rural South Africa.

HIV, hypertension and diabetes care and all-cause mortality in rural South Africa in the HIV antiretroviral therapy era: a longitudinal cohort study

IntroductionSouth Africa is in the midst of rapid epidemiological transition from extremely high HIV and tuberculosis (TB) mortality to one characterised increasingly non-communicable disease-related deaths. However, longitudinal data linking modifiable...

Exploring Information Needs and Diverse Sources for the Growth and Sustainability of the South African Honeybush Industry

Honeybush is an indigenous fynbos shrub with the potential to contribute significantly to socio-economic development in rural South Africa. However, there exists a knowledge gap on the types of information that role players in this emerging agricultural sector need to produce quality honeybush tea efficiently, as well as their preferences for obtaining information and guidance materials. A survey of 44 role players along the Honeybushsh value chain was conducted to determine the nature of the information they require and their preferred communication formats. The results show that the most pressing need is information about general honeybush cultivation, followed by detailed guidance on cultivating different species and implementing quality management systems, such as organic certification. Respondents also highlighted the urgency of improving consumer awareness of honeybush tea. Other information related to sustainable cultivation practices, enhancing the industry’s sustainability and helping with marketing. Respondents preferred information from research institutions and wanted to receive the information in a face-to-face (interpersonal) format. These findings could help to improve agricultural extension and fill knowledge gaps in the South African honeybush industry.

Norovirus-Associated Gastroenteritis Vesikari Score and Pre-Existing Salivary IgA in Young Children from Rural South Africa.

Norovirus (NoV) is the leading cause of viral gastroenteritis, mostly affecting young children worldwide. However, limited data are available to determine the severity of norovirus-associated AGE (acute gastroenteritis) and to correlate it with the NoV-specific IgA antibodies' level. Between October 2019 and September 2021, two hundred stool samples were randomly collected from symptomatic cases for the vesikari score and NoV-specific IgA assessment in young children from rural South Africa. Additionally, one hundred saliva specimens were concomitantly sampled within the same cohort to evaluate the NoV-specific salivary IgA levels. In addition, 50 paired saliva and stool samples were simultaneously collected from asymptomatic children to serve as controls. NoV strains in stool samples were detected using real-time RT-PCR, amplified, and genotyped with RT-PCR and Sanger sequencing. ELISA using NoV VLP (virus-like particles) GII.4 as antigens was performed on the saliva specimens. Dehydrated children were predominantly those with NoV infections (65/74, 88%; p < 0.0001). NoV-positive infections were significantly associated with the severe diarrhea cases having a high vesikari score (55%, 33/60) when compared to the non-severe diarrheal score (29.3%, 41/140; p < 0.0308). NoV of the GII genogroup was mainly detected in severe diarrhea cases (50.9%, 30/59; p = 0.0036). The geometric means of the NoV-specific IgA level were higher in the asymptomatic NoV-infected group (0.286) as compared to the symptomatic group (0.174). This finding suggests that mucosal immunity may not protect the children from the NoV infection. However, the findings indicated the contribution of the pre-existing NoV-specific IgA immune response in reducing the severity of diarrheal disease. A high vesikari score of AGE associated with the NoV GII genogroup circulating in the study area underscores the need for an appropriate treatment of AGE based on the severity level of NoV-associated clinical symptoms in young children.

Identifying sex-specific anthropometric measures and thresholds for dysglycemia screening in an HIV-endemic rural South African population.

Valid screening and diagnostic algorithms are needed to achieve 2030 targets proposed by the WHO's Global Diabetes Compact. We explored anthropometric thresholds to optimally screen and refer individuals for diabetes testing in rural South Africa. We evaluated screening thresholds for waist circumference (WC), body mass index (BMI), and waist-hip ratio (WHR) to detect dysglycemia based on a glycated hemoglobin (HbA1C) ≥6.5% among adults in a population-based study in South Africa using weighted, non-parametric ROC regression analyses. We then assessed the diagnostic validity of traditional obesity thresholds, explored optimal thresholds for this population, and fit models stratified by sex, age, and HIV status. The prevalence of dysglycemia in the total study population (n = 17,846) was 7.7%. WC had greater discriminatory capacity than WHR to detect dysglycemia in men (p-value<0.001) and women (p<0.001). WC had greater discriminatory capacity than BMI to detect dysglycemia in women (p<0.001). However, BMI and WC performed similarly for men (p = 0.589). Whereas traditional WC thresholds for women (>81cm) performed well (sensitivity 91%, positive predictive value [PPV] 14.9%), substantially lower thresholds were needed to achieve acceptable sensitivity and PPV among men (traditional >94cm, derived >79.5cm). WC outperforms BMI as an anthropometric screening measure for dysglycemia in rural South Africa. Whereas WC guideline thresholds are appropriate for women, male-derived WC cutoffs performed better at lower thresholds. In this rural South African population, thresholds that maximize specificity and PPV for efficient resource allocation may be preferred.

Prevalence and associated factors of probable depression amongst pregnant and parenting young females: a comparison of adolescents and young adults in rural South Africa

BackgroundPregnant teenagers have been reported to have an increased likelihood of experiencing depression than their non-pregnant peers. There is little research on the risk factors for depression in rural Black adolescents and young adults, especially after the Covid-19 pandemic. Therefore, the current study aimed to identify the prevalence of probable depression and associated factors amongst pregnant and parenting young females.MethodThe study was a cross-sectional design, consisting of 362 pregnant and parenting adolescents and young adults aged 14–22. The study used the Edinburgh Postnatal Depression Scale (EPDS) to measure probable depression. Data were analyzed using Statistical Package for Social Sciences SPSS, version 27.0.ResultsThe study found that the overall prevalence of probable depression was 42.8%. The study also found a relationship between alcohol consumption, lack of financial support, unplanned pregnancy, and probable depression in pregnant and parenting adolescents. The prevalence of unplanned pregnancy in the present study was 81.8%.ConclusionFurthermore, the present study indicated that participants from low socio-economic status families and those who were HIV positive were at a greater risk of depression in both groups. Therefore, we recommend that measures be put in place for early detection and treatment of depression and that social support be given to adolescent mothers.

'Through the drawings…they are able to tell you straight': Using arts-based methods in violence research in South Africa.

Arts-based methods are underutilized in violence research and may offer improved means of understanding these phenomena; but little is known about their value, especially in low-resource settings. A pilot study using a cross sectional sample was conducted in rural South Africa to determine the feasibility and acceptability of using arts-based methods in research with adults and children, in preparation for a longitudinal multigenerational cohort study on mechanisms that underly the intergenerational transmission of violence. Four arts-based methods were piloted with young adults aged 22-30 years (n = 29), children aged 4-7 years (n = 21) and former caregivers of the young adults aged 40-69 years (n = 11). A sample of qualitative interviews were audio recorded and transcribed (child n = 15, adults n = 19). Three focus group discussions (FGDs) were conducted to understand implementation and lessons learnt with the six interviewers on the study team, none of whom had used these methods in research before. Interviews and FGDs were audio recorded, transcribed and reviewed by the investigative team. Using a rapid analytical approach, our pilot study demonstrated that using arts and play-based methods in multigenerational violence research is feasible and acceptable to participants and interviewers. These methods worked well for nearly all participants regardless of age or ability and offered a comfortable and 'fun' way to engage in weighty conversations. They presented benefits in their capability to facilitate disclosure, expanding understanding, particularly around violence that is often a stigmatizing and sensitive experience. Interviewers required increased capacity and sensitivity in using the methods carefully, to maximize their full potential, and ongoing mentorship was indicated. Our study adds to the burgeoning evidence base of the effectiveness of the use of arts-based methods in health research.

Challenges of Women Entrepreneurship and Empowerment in South Africa: Evidence from Rural Areas

This study aims to identify impediments to expanding women-owned businesses in rural areas of South Africa. The study used a quantitative research method to collect data. The study concentrated on 250 female business owners in the rural communities of Hluhluwe, Ulundi, and Eshowe in northern KZN. The study found that the main obstacles to expanding women-owned businesses in rural areas were financial constraints, a lack of education, and inadequate infrastructure. However, these difficulties experienced by women business owners in rural South Africa can be conquered. Overcoming these obstacles could empower women entrepreneurs and stimulate economic growth in rural areas, thus reducing poverty and enhancing the living standards of rural communities. Based on these findings, the study recommends various interventions, such as alternative financing models, targeted education and training programs, and infrastructure development, to support the growth of women-owned enterprises in rural areas. Future research should examine additional issues such as cultural and social hurdles, a lack of access to markets and information, and legal and regulatory restrictions that impede the establishment of women-owned businesses in rural areas.

Patterns and trends in household food security in rural Mpumalanga Province, South Africa

ABSTRACT This study examines patterns and trends in household food security in Bushbuckridge, Mpumalanga Province, South Africa, from 2010 to 2019. We use data from a household panel nested in the Agincourt Health and Socio-Demographic Surveillance System. Findings indicate that there have been improvements in household food security in this rural setting over the last decade. By polychoric principal component analysis, an aggregate food security index was constructed and we observed a small, yet important, proportion of households (7.8%) that remained chronically food insecure. An ordered probit model was used to estimate the determinants of food security. Findings reveal that the observed differences in household food security status are as a result of differences in socioeconomic status. We therefore recommend that focus must be placed on identifying economic opportunities and empowering the chronically food insecure households if universal household food security is to be attained in rural South Africa and beyond.

Home-based HIV testing strategies for middle-aged and older adults in rural South Africa.

More than one in four adults over 40 years with HIV in South Africa are unaware of their status and not receiving antiretroviral therapy (ART). HIV self-testing may offer a powerful approach to closing this gap for aging adults. Here, we report the results of a randomized comparative effectiveness trial of three different home-based HIV testing strategies for middle-aged and older adults in rural South Africa. Two thousand nine hundred and sixty-three individuals in the 'Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI)' cohort study were randomized 1 : 1 : 1 to one of three types of home-based and home-delivered HIV testing modalities: rapid testing with counseling; self-testing, and both rapid testing with counselling and self-testing. In OLS regression analyses, we estimated the treatment effects on HIV testing and HIV testing frequency at about 1 year after delivery. Finally, we assessed the potential adverse effects of these strategies on the secondary outcomes of depressive symptom as assessed by the CESD-20, linkage to care, and risky sexual behavior. There were no significant differences in HIV testing uptake or testing frequency across groups. However, respondents in the self-testing treatment arms were more likely to shift from testing at home and a facility [self-testing (HIVST), -8 percentage points (pp); 95% confidence interval (CI) -14 to -2 pp; self-testing plus rapid testing and counselling (ST+RT+C); -9 pp, 95% CI -15 to -3 pp] to testing only at home (HIVST 5 pp; 95% CI 2 to 9 pp; ST+RT+C: 5 pp, 95% CI 1 to 9 pp) - suggesting a revealed preference for self-testing in this population. We also found no adverse effects of this strategy on linkage to care for HIV and common comorbidities, recent sexual partners, or condom use. Finally, those in the self-testing only arm had significantly decreased depressive symptom scores by 0.58 points (95% CI -1.16 to -0.01). We find HIV self-testing to be a well tolerated and seemingly preferred home-based testing option for middle-aged and older adults in rural South Africa. This approach should be expanded to achieve the UNAIDS 95-95-95 targets.

Culture-Led Smart Villages: A Critical Cultural Policy Analysis in South Africa

South Africa is rapidly obliterating its cultural resources and indigenous values. Particularly, this is the case in rural South Africa where manifestations of socio-economic declensions are evident. However, a number of the policies that are meant to enhance rural development lack a cohesive strategy that is based on culture-based theoretical frameworks. The paper argues that the conspicuous disregard to address rural development and its concomitant socio-economic challenges in the Revised White Paper on Arts, Culture, and Heritage, 2017, by the Department of Arts and Culture (DAC), now (DSAC); poses a great threat to sustainable rural development

Healthcare worker perceived barriers and facilitators to implementing a tuberculosis preventive therapy program in rural South Africa: a content analysis using the consolidated framework for implementation research

BackgroundSouth African national tuberculosis (TB) guidelines, in accordance with the World Health Organization, recommend conducting routine household TB contact investigation with provision of TB preventive therapy (TPT) for those who qualify. However, implementation of TPT has been suboptimal in rural South Africa. We sought to identify barriers and facilitators to TB contact investigations and TPT management in rural Eastern Cape, South Africa, to inform the development of an implementation strategy to launch a comprehensive TB program.MethodsWe collected qualitative data through individual semi-structured interviews with 19 healthcare workers at a district hospital and four surrounding primary-care clinics referring to the hospital. The consolidated framework for implementation research (CFIR) was used to develop interview questions as well as guide deductive content analysis to determine potential drivers of implementation success or failure.ResultsA total of 19 healthcare workers were interviewed. Identified common barriers included lack of provider knowledge regarding efficacy of TPT, lack of TPT documentation workflows for clinicians, and widespread community resource constraints. Facilitators identified included healthcare workers high interest to learn more about the effectiveness of TPT, interest in problem-solving logistical barriers in provision of comprehensive TB care (including TPT), and desire for clinic and nurse-led TB prevention efforts.ConclusionThe use of the CFIR, a validated implementation determinants framework, provided a systematic approach to identify barriers and facilitators to TB household contact investigation, specifically the provision and management of TPT in this rural, high TB burden setting. Specific resources—time, trainings, and evidence—are necessary to ensure healthcare providers feel knowledgeable and competent about TPT prior to prescribing it more broadly. Tangible resources such as improved data systems coupled with political coordination and funding for TPT programming are essential for sustainability.

Ubuntu as a mediator in coping with multimorbidity treatment burden in a disadvantaged rural and urban setting in South Africa

BackgroundPeople living with multimorbidity in economically precarious circumstances in low- and middle-income countries (LMICs) experience a high workload trying to meet self-management demands. However, in countries such as South Africa, the availability of social networks and support structures may improve patient capacity, especially when networks are governed by cultural patterns linked to the Pan-African philosophy of Ubuntu, which promotes solidarity through humanness and human dignity. We explore the mediating role Ubuntu plays in people's ability to self-manage HIV/NCD multimorbidity in underprivileged settings in urban and rural South Africa. MethodsWe conducted semi-structured interviews with 30 patients living with HIV/NCD multimorbidity between February–April 2022. Patients attended public health clinics in Gugulethu, Cape Town and Bulungula, Eastern Cape. We analysed interviews using framework analysis, using the Cumulative Complexity Model (CuCoM) and Burden of Treatment Theory (BoTT) as frameworks through which to conceptualise the data. ResultsDespite facing economic hardship, people with multimorbidity in South Africa were able to cope with their workload. They actively used and mobilized family relations and external networks that supported them financially, practically, and emotionally, allowing them to better self-manage their chronic conditions. Embedded in their everyday life, patients, often unconsciously, embraced Ubuntu and its core values, including togetherness, solidarity, and receiving Imbeko (respect) from health workers. This enabled participants to share their treatment workload and increase self-management capacity. ConclusionUbuntu is an important mediator for people living with multimorbidity in South Africa, as it allows them to navigate their treatment workload and increase their social capital and structural resilience, which is key to self-management capacity. Incorporating Ubuntu and linked African support theories into current treatment burden models will enable better understandings of patients’ collective support and can inform the development of context-specific social health interventions that fit the needs of people living with chronic conditions in African settings.

Forgotten but not gone in rural South Africa: Urinary schistosomiasis and implications for chronic kidney disease screening in endemic countries.

Background: Urinary schistosomiasis caused by infection with Schistosoma haematobium ( S. haematobium) remains endemic in Africa and is associated with haematuria and albuminuria/proteinuria. Kidney Disease Improving Global Outcomes clinical guidelines recommend evaluating proteinuria/albuminuria and glomerular filtration rate for chronic kidney disease (CKD) diagnosis. The guidelines are informed by population data outside of Africa but have been adopted in many African countries with little validation. Our study aimed to characterise the burden of urinary schistosomiasis in rural South Africa (SA) and evaluate its relationship with markers of kidney dysfunction with implications for CKD screening. Methods: In this population-based cohort study, we recruited 2021 adults aged 20 - 79 years in the Mpumalanga Province, SA. Sociodemographic data were recorded, urinalysis performed, and serum creatinine and urine albumin and creatinine measured. Kidney dysfunction was defined as an estimated glomerular filtration rate (eGFR) <60ml/min/1.73m 2 and/or urine albumin-creatinine ratio >3.0mg/mmol. S . haematobium infection was determined by urine microscopy. Multivariable analyses were performed to determine relationships between S. haematobium and markers of kidney dysfunction. Results: Data were available for 1226 of 2021 participants. 717 (58.5%) were female and the median age was 35 years (IQR 27 - 47). Prevalence of kidney dysfunction and S. haematobium was 20.2% and 5.1% respectively. S. haematobium was strongly associated with kidney dysfunction (OR 8.66; 95% CI 4.10 - 18.3) and related to albuminuria alone (OR 8.69; 95% CI 4.11 - 18.8), with no evidence of an association with eGFR <90ml/min/1.73m 2 (OR 0.43; 95% CI 0.05 - 3.59). Discussion: The strong association between urinary schistosomiasis and albuminuria requires careful consideration when screening for CKD. Screening for, and treatment of, schistosomiasis should be a routine part of initial work-up for CKD in S. haematobium endemic areas. Urinary schistosomiasis, a neglected tropical disease, remains a public health concern in the Mpumulanga province of SA.

Can we find the missing men in clinics? Clinic attendance by sex and HIV status in rural South Africa.

Background: HIV-negative men are over-represented in tuberculosis (TB) prevalence surveys including the first South African national TB prevalence survey in 2018. Traditionally, TB screening is focused in clinics. We aimed to determine the frequency of primary healthcare clinic (PHC) attendance among HIV-negative men in a TB-prevalent setting. Methods: Since January 2017, PHC attendees in a rural South African demographic surveillance area (DSA) were asked their reason for attendance. HIV status was defined as positive if tested positive in a DSA sero-survey or attended clinic for HIV care; negative if tested negative between January 2014-December 2017 and no HIV-related visits; and HIV-unknown otherwise. Results: Among 67124 DSA residents (≥15 years), 27038 (40.3%) were men; 14196 (21.2%) were classified HIV-positive, 18892 (28.1%) HIV-negative and 34036 (50.7%) HIV-unknown. Between April 2017 and March 2018, 24382/67124 (36.3%, 95% confidence interval [CI] 36.0-36.7) adults made ≥1 PHC visit, comprising 9805/40086 (24.5%, 95%CI 23.6-25.3) of HIV-negative or unknown women and 3440/27038 (12.7%, 95%CI 11.6-13.8) of HIV-negative or unknown men. Overall, HIV care accounted for 37556/88109 (42.6%) of adult PHC visits. Conclusion: In this rural population, HIV-negative and -unknown men rarely attend PHCs. Improving TB screening in clinics may not reach a key population with respect to undiagnosed TB. Additional strategies are needed to diagnose and treat TB earlier.

Forgotten but not gone in rural South Africa: Urinary schistosomiasis and implications for chronic kidney disease screening in endemic countries

Background: Urinary schistosomiasis caused by infection with Schistosoma haematobium (S. haematobium) remains endemic in Africa and is associated with haematuria and albuminuria/proteinuria. Kidney Disease Improving Global Outcomes clinical guidelines recommend evaluating proteinuria/albuminuria and glomerular filtration rate for chronic kidney disease (CKD) diagnosis. The guidelines are informed by population data outside of Africa but have been adopted in many African countries with little validation. Our study aimed to characterise the burden of urinary schistosomiasis in rural South Africa (SA) and evaluate its relationship with markers of kidney dysfunction with implications for CKD screening. Methods: In this population-based cohort study, we recruited 2021 adults aged 20 – 79 years in the Mpumalanga Province, SA. Sociodemographic data were recorded, urinalysis performed, and serum creatinine and urine albumin and creatinine measured. Kidney dysfunction was defined as an estimated glomerular filtration rate (eGFR) &lt;60ml/min/1.73m2 and/or urine albumin-creatinine ratio &gt;3.0mg/mmol. S. haematobium infection was determined by urine microscopy. Multivariable analyses were performed to determine relationships between S. haematobium and markers of kidney dysfunction. Results: Data were available for 1226 of 2021 participants. 717 (58.5%) were female and the median age was 35 years (IQR 27 – 47). Prevalence of kidney dysfunction and S. haematobium was 20.2% and 5.1% respectively. S. haematobium was strongly associated with kidney dysfunction (OR 8.66; 95% CI 4.10 – 18.3) and related to albuminuria alone (OR 8.69; 95% CI 4.11 – 18.8), with no evidence of an association with eGFR &lt;90ml/min/1.73m2 (OR 0.43; 95% CI 0.05 – 3.59). Discussion: The strong association between urinary schistosomiasis and albuminuria requires careful consideration when screening for CKD. Screening for, and treatment of, schistosomiasis should be a routine part of initial work-up for CKD in S. haematobium endemic areas. Urinary schistosomiasis, a neglected tropical disease, remains a public health concern in the Mpumulanga province of SA.