Health Systems Research Unit
Current projects
Evaluation of the effectiveness of the Prevention of Mother - to - Child Transmission of HIV (PMTCT) Programme on Infant HIV until 18 months postpartum in South Africa (SAPMTCTE)
Within seven years of implementing the national PMTCT program, South Africa has been successfully scaling up its PMTCT services. Interventions to prevent mother-to-child transmission of HIV are now offered in more than 95% of antenatal clinics and maternity institutions country-wide. In 2008 and again in 2010, the South African NDOH updated its PMTCT policy to include more efficacious interventions to reduce mother-to-child transmission of HIV. These efforts are to meet the National Strategic Plan (NSP 2012-2016) targets of reducing the MTCT rate of HIV to less than 2% by six weeks and < 5% by 18-months. However no system has been set in place to monitor MTCT, and to track progress towards this NSP target. Furthermore, until 2010, population-based effectiveness and impact of the South African PMTCT programme on MTCT rate of HIV is not known; evaluations have thus far been restricted to a few selected sites. Therefore, these periodic evaluations are crucial as they aim to track impact of the national PMTCT programme over time. These data are of primary importance as South Africa works towards meeting the NSP target (of reducing vertical transmission to less than 5% by 2011), and towards meeting the 4th and 6th millennium development goals (i.e. ‘reduce by two thirds, between 1990 and 2015, the under-five mortality rate’ and ’have halted by 2015 and begun to reverse the spread of HIV/AIDS’).
Aim
To periodically conduct facility-based surveys to monitor the effectiveness of the South African National PMTCT programme until 18 months postpartum.
Objectives
Primary Objective
- To periodically measure rates of early mother-to-child transmission (MTCT) of HIV at 6-weeks postpartum
- To periodically measure rates of MTCT at 6 months, 9 months, 12 months and 18 months postpartum
- To periodically measure rates of infant HIV free survival at 6 months, 9 months, 12 months and 18 months postpartum
Secondary Objectives
- To periodically estimate coverage of key PMTCT (prevention of mother-to-child transmission of HIV) interventions and services (e.g. HIV testing, CD4 cell count testing, infant ARV prophylaxis, counselling on infant feeding)
- To estimate the association between MTCT rate and ARV regimen, maternal background characteristics including CD4 cell count, maternal health care services and maternal and infant health status
- To periodically measure uptake of HIV care-and-treatment referral services for HIV-infected pregnant women, infant post-test counselling and HIV-infected children who are diagnosed at primary health care settings.
Study design
A cross-sectional survey was conducted in 2010 and 2011 and will be conducted in 2012 to measure perinatal HIV transmission at six weeks postpartum (SAPMTCTE-6weeks). Multi stage, probability proportional to size (PPS) and systematic sampling methods were used to select a representative national and provincial study sample of infants aged 4-8 weeks attending public health facilities for their six weeks immunisation, and their caregivers. In 2011 and 2012 all HIV-exposed consented infants identified at 6 weeks (during SAPMTCTE-6 weeks) will be followed up (closed cohort) until 18 months of age or their HIV-infection is confirmed - whichever comes first (SAPMTCTE – follow-up).
Study sites
The survey is conducted at 580 public health facilities (primary health care clinics and community health centres) offering immunization services across all nine provinces of SA
Data collection and Analysis
Data are collected by MRC study nurses. Each survey round (2010, 2011, 2012) includes caregivers’ interviews to ascertain basic demographic data and selected programme indicators and a target of 12 200 DBS drawn from eligible infants of consenting mothers/caregivers during SAPMTCTE-6weeks Participating HIV-exposed infants enrolled in SAPMTCTE-follow-up are tested for HIV at 6, 9, 12and 18 months. In 2012 two further testing points may be added, viz. 3 and 15 months. All analysis are adjusted for population live births and sample attainment to yield population-based estimates for transmission.
Collaboration
The survey is a collaborative effort between the Medical Research Council, National Department of Health, Centers for Disease Control and Prevention, Atlanta, University of the Western Cape, NICD/NHLS, Wits Infant HIV Diagnostics, UNICEF and Provincial Departments of Health. All findings are reported to all stakeholders to improve implementation of the national PMTCT programme. A Steering Committee Comprising all collaborative organisations drives the survey and meets at least twice a year.
Funding
The SAPMTCTE is funded predominantly by the Centers for Disease Control and Prevention, Atlanta, with contributions from the National Department of Health, NICD/NHS and UNICEF.
Current Status
The 2010 survey has been completed and results were presented at numerous conferences including SAAIDS 2011, IAS 2011, APHA 2011 and Perinatal priorities 2011. The details 2010 survey report can be found at the following link.
The 2011 SAPMTCTE-6weeks has been completed and results were released by the Minister of Health and at the International AIDS Conference 2012. The Executive Summary with preliminary 2011 results can be found at the following link.
The 2011 follow-up component was stopped after 9 months follow-up. The report on the 2011 follow-up can be found at the following link.
The 2012 survey will start in September 2012 and results will be available by September 2013.
Appraising the use of mHealth to support community-based maternal and child outreach services in South Africa to improve demand creation, increase communication with families and improve retention in care
The enthusiasm for the use of new mobile technologies in healthcare services (mHealth) is not met by sound evidence on the effectiveness of such technologies. HSRU recently submitted a comprehensive report on mHealth to the Western Cape Department of Health, and is currently piloting mobile phone management systems to support health services and analysed the health systems challenges of upscaling mHealth for community based services in SA. These pilots are conducted in two districts in the North West and Western Cape provinces respectively. Both districts are also pilot-sites for the Re-engineering of Primary Healthcare in South Africa, and thus provide opportunities to assess mHealth in the context of the imminent changes to primary healthcare.
Aim
The primary aim is to field test a mobile phone-based management system for monitoring activities and performance of community-based maternal and child health workers (LHWs) as well as using SMS messages to mothers, an adaptation of the USA’S ‘text4baby’ initiative, for conveying important health messages, reminders and adherence support. Secondary to this, is assessing the integration of lay community healthcare workers’ data with patient-management systems maintained at facilities.
Objectives
- To increase demand for, and improve retention in care for mothers and children through improved supervision and monitoring of community based workers and improved communication with mothers with the aim of improving coverage of care and child survival.
- To assist LHWs to adhere to service protocols for chronic disease management.
Innovation
This will be the first project to assess the feasibility of introducing mobile phone technology into the national community worker programme to improve supervision and monitoring as well as health outcomes for women, children, and chronically ill patients.
Current status
Implementation commenced in August 2012 and is expected to be completed in April 2013.
The routine use of monitoring and evaluation data in the Western Cape and Kwa Zulu Natal (KZN) Departments of Health
Optimal service delivery and appropriate allocation of resources are dependent on the quality, and timeous collection, of monitoring and evaluation data on all levels of the public health system. Our unit has provided technical and logistical support to the Information Directorates in the Western Cape and KZN since 2009.
Objectives
- To provide technical and logistical support in assessing information management and data use at all levels of the public healthcare system to improve strategic and operational decisions regarding service delivery.
- To improve the ability for related information systems to interface, to assess program outputs and outcomes across the systems, including the quality of interventions and the efficiency by which those interventions are provided.
Milestones
The Joint Information Management Initiative (JIMI) is one of the flagship programmes in the Western Cape that has contributed to unqualified Auditor General reports in the Province. At present work is underway to support the uptake of the JIMI project on a national scale. Extensive reviews were conducted in KZN that have resulted in improved routine data collection protocols and tools.
Current status
This is an on-going project, funded by the Centres for Diseases Control.
Implementing decentralised treatment for MDR-TB in KwaZulu-Natal: Evaluation of a pilot project
Aim
The research aims to compare the effectiveness of decentralised treatment of MDR TB with treatment administered at a specialised centralised hospital. The effect of health systems performance on treatment outcomes in the decentralised and centralised model will be determined.
Objectives
- To evaluate the implementation of the decentralised model of MDR TB treatment.
- To determine the impact of the decentralised model of treatment by comparing the treatment outcomes of decentralised management of MDR TB patients with the treatment outcomes of patients managed at a specialist centralised hospital.
- To pilot two different approaches to adherence monitoring in MDR-TB patients being treated in the community.
- To pilot two different approaches to monitoring the incidence and management of side effects in MDR-TB patients being treated in the community.
- To determine health systems performance in the decentralised model of treatment and its impact on programme processes and outcomes and compare this with health systems performance and the impact on programme processes and outcomes in the centralised model of treatment.
Study design and sites
This is a mixed method observational epidemiological study with an analytic and descriptive component. There will be five study sites. King George V hospital in Durban is the specialist centralized hospital for drug resistant TB in KwaZulu-Natal province. The four sites where decentralised MDR TB management is being piloted are Greytown, Manguzi, Murchison and Thulasizwe hospitals.
Current status
This project is a collaboration with the KwaZulu-Natal provincial department of health.
Evaluation of UNICEF’s Catalytic Initiative in 6 African countries
An external evaluation of the IHSS program in Ethiopia, Ghana, Malawi, Mali, Mozambique, Niger, and one overall evaluation of the IHSS program across these six countries.
The Catalytic Initiative to Save a Million Lives (CI) is “an international partnership with the goal of strengthening health systems to accelerate progress on the health-related Millennium Development Goals (MDGs)” To achieve this objective, the CI seeks to “strengthen health systems by delivering life-saving health and nutritional services to disadvantaged children and pregnant women to dramatically reduce child and maternal mortality” in Africa and Asia.
Barriers to ARV adherence at 6 Facilities in Cape Town: A Needs Assessment
Adherence support is a critical component of antiretroviral treatment (ART) programmes. Any programme aimed at ameliorating a problem needs to respond to the circumstances of those in need in order to be effective. This study aims to determine prevalent barriers to ARV adherence among people attending public healthcare facilities in Cape Town in order to inform strategies for adherence support.
Study objectives
Study design and sites
This study is descriptive, and has a cross-sectional design. The study is conducted at the following sites: Dr Ivan Toms Clinic; Kuyasa Clinic; Albow Gardens Clinic; Delft South Clinic; Retreat Community Health Center; Inzame Zabantu Community Health Center.
Current status
This project is a collaboration between researchers at the Medical Research Council, University of Cape Town, Brown University and Stellenbosch University. The project is funded by the Centers for Disease Control and Prevention (CDC).
Options for Health: Western Cape
Options for Health is an evidence-based HIV-transmission risk reduction intervention designed for use within busy clinic settings. Lay antiretroviral (ARV) adherence counsellors from 21 public healthcare facilities were trained to use the Options interventionto help their clients to reduce sexual risk behaviour and optimise their ARV adherence.
Implementation evaluation objectives were to determine:
- The number of patients who should have received the intervention who actually did receive the intervention over 13 months of implementation;
- Barriers to the implementation of Options in this setting;
- The ability of lay counsellors to deliver the intervention as intended following training and,
- The impact of on-going training and supervision on counsellors’ ability to deliver the intervention and their basic counselling communication skills.
Study design
The studies conducted as a part of this evaluation employed a number of designs and methods.
Current status
The implementation and evaluation of Options for Health: Western Cape was a collaboration between researchers from at Medical Research Council, University of Cape Town, University of the Western Cape and the Human Sciences Research Council. Implementation of the intervention was funded by the Centers for Disease Control and Prevention (CDC).
More information can be found on the project website: http://www.sahealthinfo.org/motivational/healthoptions.htm
Conducting regular HIV behavioural and biological surveillance among hard-to-reach, high risk populations in the Western Cape
The current survey targets another hard-to-reach, high risk population: female foreign migrants residing in Cape Town. Bio-behavioural surveillance (BBS) among female migrants builds upon previous work with the Center for Disease Control and Prevention (CDC) and the Western Cape Department of Health since 2006 that used Respondent Driven Sampling (RDS) in BBS studies among men and women with multiple sex partners in the province.
Migration is an important risk factor for many sexual health issues that are related to HIV infection, and female migrants are disproportionally affected by these risks. South Africa has a large foreign migrant population, and it is estimated that 1-3 million Zimbabwean migrants alone are currently living in the county. Foreign migrants are able to self-settle in any area of their choosing in South Africa and are thus diversely distributed throughout the general population making them hard-to-reach by conventional HIV surveillance methods such as household surveys and/or sentinel surveillance systems that are designed to track infection in the general population.
Aim
The aim of the current BBSS will be to conduct robust surveillance to measure key risk behaviours, and HIV prevalence in hard-to-reach, high-risk population of female migrants in Cape Town, South Africa.
Objectives
- To determine the prevalence of key behavioural factors associated with HIV among populations already at elevated risk such as:
- having more than one sexual partner in the last 3 months,
- engaging in unsafe sex practices, including transactional sex, sex work, or inconsistent condom use;
- To determine the seroprevalence of HIV infection in these high-risk populations;
- To determine the prevalence of gender-based physical and sexual abuse; and
- To determine the nature of migration and post-migration experiences, levels of alcohol consumption; and social support and experiences with xenophobia and depression
Study design and sites
RDS is a chain-referral sampling approach that gains access to hard-to-reach, vulnerable groups and is used to obtain unbiased HIV prevalence rates and risk behaviours among these sub-groups.
Current status
The BBS studies have been and are funded by the Centers for Disease Control and Prevention (CDC).
Promoting sexual and reproductive health among adolescents in southern and eastern Africa - mobilizing schools, parents and communities (PREPARE project)
Adolescents who have their sexual debut at a young age constitute a high risk group because they are less likely to use condoms and more likely to have multiple and casual sexual partners and to be involved in other risk behaviours such as substance use and interpersonal violence. In sub-Saharan Africa sexual debut at age 14 or younger is common and the burden of HIV and AIDS is highest in the world, indicating the importance of sexual risk reduction interventions in early adolescence. Four recent randomised controlled trials of HIV prevention interventions among adolescents and youth in sub-Saharan Africa have had minimal effects on sexual risk behaviour. Adolescent sexual relationships are marked by a high incidence of violence, particularly in first sexual encounters. Adolescents in violent relationships are more likely to have an early sexual debut than those who do not experience such violence, and to be coerced into sex. There is overwhelming evidence in South Africa and elsewhere that IPV is a leading cause of reproductive health problems including HIV, sexually transmitted infections and unwanted pregnancy.
Objectives
- Conduct formative studies to investigate the factors contributing to and mitigating against gender-based and intimate partner violence and HIV risk-related behavior among young adolescents and review interventions to address these problems;
- Develop an intervention aimed at reducing intimate partner violence (IPV), other forms of violence and sexual risk behavior;
- Assess the impact of the intervention on a range of behavioral outcome variables and the long term impact on live births and terminations of pregnancy.
Study design and sites
A cluster RCT and process evaluation in 40 schools in and around Cape Town, in rural and urban areas
Current status
The intervention is in the process of being finalised and the baseline data collection phase starts in January 2013. The final follow-up data collection will be conducted in February 2014. The PREPARE study is funded by the EC Health research program (under the 7th Framework Program). Grant Agreement number: 241945. The partners and principal investigators include: University of Cape Town, Muhimbili University College of Health Sciences, University of Limpopo, Makerere University, Maastricht University, University of Exeter, University of Oslo and the University of Bergen.
See also the project homepage: http://prepare.b.uib.no/
The development and implementation of an intervention to reduce gender based violence among young women aged 16-24, in a peri-urban community in South Africa: A community participation model
South Africa has made great strides in the struggle to reduce gender inequality and its associated outcomes in the country. However, these strides are only limited to the policy and legislative arena, where laws and action plans have been passed. Both in the public and private sphere of women’s lived experiences, gender inequality is rife and the country boasts one of the highest prevalence rates of gender based violence (GBV) in the world. Among the challenges that undermine the success of the country’s legislative efforts to curb gender based violence, is the lack of community-based responses that address the social risk factors, such as attitudes towards gender based violence, cultural norms that uphold male dominance and local systems of gender inequality. The GBV-Community Participation Intervention plans to collaborate with a peri-urban community in the Western Cape to co-develop, co-implement and co-evaluate a home grown intervention to reduce the prevalence of GBV among young women aged 16-24.
STI Partner Notification Monitoring System in Khayelitsha Health Clinics
A project designed to optimise the partner notification monitoring systems.
A national quality assurance Human Resources audit of public health facilities in South Africa
Providing technical expert assistance to the audit of the NDOH (via the HST consortium). The focus is on the analysis of the audit of human resources at health facilities, identifying gaps and advising on improving future audit processes.
Current status
The national level analysis is being finalised.
Long-term evaluation of the impact of child support grants on key childhood outcomes
Cash transfer programs have increasingly become the strategy of choice for poverty alleviation in middle and low-income regions such as Latin America and Caribbean countries (LAC), Asia, and Africa. Many of these cash transfer programs have been found to be effective in improving child outcomes such as learning outcomes, child growth and nutrition. South Africa is unique among developing countries for establishing a large scale cash transfer program, the Child Support Grant (CSG), for children of poor families. The CSG thus presents a unique opportunity to further our understanding of how an unconditional cash transfer works in a developing country context and its impact on key child outcomes. Through a longitudinal analysis of a cohort of families across South Africa, our study evaluates the impact of the CSG on child health outcomes namely child growth, dietary diversity and health care utilisation. We also assess barriers to accessing the CSG, as well as exploring the experiences of recipients and non-recipients of the grant.
Objectives
- To compare growth and dietary diversity of children in households where child support grants are received and in those where they are not received;
- To assess the effect of the child support grant on household food security, and health care utilization;
- To explore barriers and facilitators of successful grant receipt;
- To better understand the pathways and mechanisms through which cash transfers may impact child poverty;
- To add to the existing knowledge base about the suitability of cash transfers to alleviate childhood poverty as measured by child health indicators;
- A secondary and indirect objective is to contribute to knowledge and wider debates about cash transfer programs producing unintended effects, and the design choices underpinning such programs
Current status
We are currently writing up and presenting the results of both the quantitative and qualitative components of the study.
Good Start III/Saving Newborn Lives
Progress towards MDG4 in South Africa will depend largely on scaling up effective prevention against mother to child transmission (PMTCT) of HIV and also addressing neonatal mortality. This imperative drives increasing focus on the neonatal period and particularly on the development and testing of appropriate models of sustainable, community-based care in South Africa in order to reach the poor. We identified three key implementation gaps affecting progress - implementation gaps for HIV prevention in neonates; implementation gaps for neonatal care especially home postnatal care; and implementation gap for maternal mental health support. We have developed and are evaluating and costing an integrated and scaleable home visit package delivered by community health workers targeting pregnant and postnatal women and their newborns to provide essential maternal/newborn care as well as interventions for Prevention of Mother to Child Transmission (PMTCT) of HIV.
Aim
This study aims to test the hypothesis that infants in clusters receiving the intervention, relative to clusters receiving improved health facility care and key information to the mother and family on available social grants and the processes for gaining access to these grants (control clusters) will have significantly improved HIV free survival and higher levels of exclusive appropriate feeding at 12 weeks postnatally.
Objectives
- To assess post-intervention HIV free survival and levels of exclusive and appropriate infant feeding at 12 weeks postnatally in the intervention and control clusters.
- To test the hypotheses that the intervention clusters, relative to control clusters, will at the end of the intervention period report significantly better:
- Uptake of a postnatal clinic visit within 7 days of life
- Coverage of care and behavioural indicators (antenatal HIV testing, uptake of cotrimoxazole mongst HIV exposed infants at 6 weeks, family planning uptake at 6 weeks)
- To assess post intervention levels of maternal depression
- To assess whether the intervention is cost-effective compared to improved health facility care alone. Objective 3 will be evaluated in terms of cost per HIV infection averted and disability-adjusted life years (DALY’s) saved.
Study design
The trial is a cluster randomized controlled trial that is being implemented in Umlazi which is a peri-urban settlement with a total population of 1 million close to Durban in KwaZulu Natal, South Africa. The trial consists of 30 randomized clusters (15 in each arm). A baseline survey established the homogeneity of clusters and neither stratification nor matching was performed. Sample size was based on increasing HIV-free survival from 74% to 84%, and calculated to be 120 pregnant women per cluster. Primary outcome is higher levels of HIV free survival and levels of exclusive and appropriate infant feeding at 12 weeks postnatally. The intervention is home based with community health workers deliver two antenatal visits, a postnatal visit within 48 hours of birth, and a further four visits during the first two months of the infants life. We are undertaking programmatic and cost effectiveness analysis to cost the intervention.
Current status
The trial was completed in July 2011. The team is currently writing up papers and presenting the findings
Good Start Home based HIV counselling and testing trial
Aim
The aim of this study was to develop and implement a culturally appropriate community VCT intervention in a rural community in KwaZulu-Natal province.
Objectives
Primary objectives
- To develop and implement a culturally appropriate community mobilisation strategy to increase acceptability of home based VCT
- To develop and implement a door to door VCT intervention using community lay counsellors
- To increase rates of HIV testing in intervention communities relative to control communities.
Secondary objectives
- To increase rates of disclosure of HIV status within families.
- To increase access to HIV care and treatment for individuals who are HIV positive.
- To increase uptake of AZT and nevirapine amongst HIV positive pregnant women.
- To increased couple counselling and testing
- To decrease HIV risk behaviour
Study hypothesis
Provision of home based human immunodeficiency virus (HIV) testing in intervention communities will result in increased HIV test acceptance, accelerated access to care and treatment for individuals testing HIV positive and reduced HIV risk behaviour compared to control communities.
Study design and sites
Community randomized trial. The study was implemented in one sub district (Umzimkhulu) within Sisonke District in KwaZulu-Natal.
Current status
The trial was completed in June 2011. The team is in the process of writing papers and presenting the findings.
Health economic evaluations
Human Resource for PHC Re-engineering
Aim
The aim of this study is to develop Human Resources norms for the NDoH for the new model of delivery of PHC services.
Objectives
- To develop HR norms for each component of the PHC services: Ward-based PHC Outreach teams, School Health, Clinics, Community Health Centres and District Specialist teams. The focus is on optimal skill mix to ensure quality, efficiency and sustainability.
- To quantify the country PHC HR requirements in the short term and long term in order to inform training needs.
- To identify the HR and financial impact of the implementation of the new category of staff nurse.
- To develop a user friendly tool to assist provinces and districts in the adaptation of the model to the local situation and provide information on priority recruitment and redeployment.
Current status
The draft report has been submitted to the NDoH and consultations are being carried out.
Intermediate Care project for the Provincial Government of the Western Cape (PGWC): Human Resources and Costing
Aim
To develop model to assess HR and costing requirements for Intermediate Care Facilities in the Western Cape, as part of a wider study on Intermediate Care facilities by UWC.
Current status
Model and costing have been finalised.
Save The Children; Saving Newborn Lives: multi-country study on community based interventions to reduce neonatal mortality
Aim
To co-ordinate the economic evaluation of community based interventions to reduce neonatal mortality in 5 African countries (South-Africa, Malawi, Uganda, Ghana,Ethiopia) and 1 Latin-American country, Bolivia.
Objectives
Primary objectives
- To develop a common tool to ensure comparability of results between the different countries
- To assess the additional providers resources requirements of implementing the program
- To assess implications for scale up of the intervention
- To carry out cost-effectiveness analysis in selected countries.
Secondary Objectives
- To analyse time implications of community-based activities
- To assess the possibility of integration of the neonatal package in IMCI community-based programs
- To assess implications of increased efficiency of CHWs on program coverage.
Current status
The analysis of the interventions has been completed in all countries, bar Ethiopia. Papers are currently being written.
Cochrane and Systematic reviews
We are currently leading on the following reviews:
- Clinical effectiveness of school and mixed school/community-based interventions to reduce HIV and STIs in adolescents (Cochrane review)
- LHW and Maternal and Child health (updated Cochrane review)
- Incentives for lay health workers to improve performance, retention in service and patient outcomes in low, middle and high income countries (Cochrane review)
- School-based health clinics for adolescent, sexual and reproductive and mental health (Systematic review)
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