Articles tagged as "National responses"

Monitoring for positive and negative consequences of service integration

Evaluation of using Routine Infant Immunization Visits to Identify and Follow-up HIV-exposed Infants and their Mothers in Tanzania.

Goodson JL, Finkbeiner T, Davis NL, Lyimo D, Rwebembera A, Swartzendruber AL, Wallace AS, Kimambo S, Kimario CJ, Wiktor SZ, Luman ET. J Acquir Immune Defic Syndr. 2013 Feb 12. [Epub ahead of print]

Without treatment, approximately half of HIV-infected infants die by age two years, and 80% die before age five years. Early identification of HIV-infected and -exposed infants provides opportunities for life-saving interventions. We evaluated integration of HIV-related services with routine infant immunization in Tanzania.  During April 2009-March 2010, at 4 urban and 4 rural sites, mothers' HIV status was determined at first-month immunization using antenatal cards. HIV-exposed infants were offered HIV testing and follow-up care. Impact of integrated service delivery was assessed by comparing average monthly vaccine doses administered during the study period and a two-year baseline period; acceptance was assessed by interviewing mothers and service providers. During 7569 visits, 308 HIV-exposed infants were identified and registered; of these, 290 (94%) were tested, 15 (5%) were HIV-infected. At urban sites, first-month vaccine doses remained stable (+2% for pentavalent vaccine and -4% for polio vaccine), and vaccine doses given later in life (pentavalent, polio, and measles) increased 12%, 8%, and 11%, respectively. At rural sites, first-month vaccine doses decreased 33% and 35% and vaccine doses given later in life decreased 23%, 28% and 28%. Mothers and service providers generally favored integrated services; however, HIV-related stigma and inadequate confidentiality controls of HIV testing were identified, particularly at rural sites.  Integration of HIV-related services at immunization visits identified HIV-exposed infants, HIV-infected infants, and HIV-infected mothers; however, decreases in vaccine doses administered at rural sites were concerning. HIV-related service integration with immunization visits needs careful monitoring to ensure optimum vaccine delivery.

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Editor’s notes: This study raises some concerns about service integration: the numbers of first month and later vaccine doses decreased significantly at rural (as opposed to urban sites where vaccination dose numbers remained stable) when HIV status of mothers documented in the clinic card was utilized to identify HIV-exposed infants. Quite high percentages of women did have evidence of HIV testing during antenatal care – an indication of good coverage of this essential service. It is important that this study not be over-interpreted – while no immediate other causes for decreases in numbers of infants vaccinated at rural sites were evident, it does highlight that efforts to promote service integration must evaluate a number of service variables as part of its monitoring for success.

Africa
United Republic of Tanzania
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Keeping health care workers well

Workplace wellness for HIV/AIDS-affected nurses in South Africa.

Basson HA, Roets L. Br J Nurs. 2013 Jan 9;22(1):38-44

Registered nurses and midwives, enrolled staff nurses and auxiliary nurses (referred to as nurses) in the South African nursing workforce are confronted daily with HIV in the workplace due to the high HIV prevalence rate among sexually and economically active adult women between 15-49 years of age. Components for a framework of a workplace wellness programme for HIV infected and/or affected nurses in South Africa, who comprise registered nurses and midwives, enrolled staff nurses and auxiliary nurses, were identified and described. Health and wellness could be promoted by instituting a workplace wellness programme. The nurses emphasized the threat of HIV and considered a workplace wellness programme a priority.

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Editor’s notes: Health care worker shortages are pervasive in Africa. Nurses are the backbone of primary care provision in most countries, and increasingly are asked to initiate or maintain people living with HIV on antiretroviral treatment and other HIV primary care services. While the size of the available nursing workforce is impacted by enrollment rates in nursing schools, emigration to wealthier countries, and salary levels, there has been great concern about nursing ‘burn-out’. HIV treatment has reduced HIV-related in-patient occupancy, but the burden on understaffed out-patient departments has increased.  As the authors note, HIV prevalence in nurses and other members of the health care work force mirror national HIV prevalence, and these nurses who are themselves living with and affected by HIV, have their own health care and psychosocial needs. Workplace wellness programs can be a meaningful response to caring for the caregiver.

Africa
South Africa
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Integrating HIV care and treatment into primary health care centers

Integration of HIV Care and Treatment in Primary Health Care Centers and Patient Retention in Central Mozambique: A Retrospective Cohort Study.

Lambdin BH, Micek MA, Sherr K, Gimbel S, Karagianis M, Lara J, Gloyd SS, Pfeiffer J. J Acquir Immune Defic Syndr. 2013 Jan 2. [Epub ahead of print]

In 2004, the Mozambican Ministry of Health began a national scale-up of antiretroviral therapy (ART) using a vertical model of HIV clinics co-located within large, urban hospitals. In 2006, the ministry expanded access by integrating ART into primary health care clinics. The authors conducted a retrospective cohort study including adult, ART-naive patients initiating ART between January 2006 and June 2008 in public sector clinics in Manica and Sofala provinces. Cox proportional hazards models with robust variances were used to estimate the association between clinic model (vertical/integrated), clinic location (urban/rural) and clinic experience (1st 6 months/post-1st 6 months) and attrition occurring in early patient follow-up (≤6 months) and attrition occurring in late patient follow-up (>6 months), while controlling for age, sex, education, pre-ART CD4 count, WHO stage and pharmacy staff burden. A total of 11,775 patients from 17 clinics were studied. The overall attrition rate was 37 per 100 person-years. Patients attending integrated clinics had a higher risk of attrition in late follow-up (HR=1.75 (95%CI: 1.04-2.94)), and patients attending urban clinics (HR=0.57 (95%CI: 0.35-0.91)) had a lower risk of attrition in late follow-up. Though not statistically significant, clinics open for longer than 6 months (HR=0.72 (95%CI: 0.51 - 1.02)) had a lower risk of attrition in early follow-up. Patients attending vertical clinics had a lower risk of attrition. Utilizing primary health clinics to implement ART is necessary to reach higher levels of coverage; however, further implementation strategies should be developed to improve patient retention in these settings.

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Editor’s notes: There is no single service delivery strategy that is most appropriate for HIV primary care and provision of antiretroviral treatment. The strategies chosen in generalized epidemics may be quite different from countries with highly concentrated epidemics. High prevalence countries are often choosing to integrate HIV treatment into other primary health care services. As countries move towards universal access, earlier approaches to the delivery of HIV treatment benefit from review – vertical structures for antiretroviral therapy services may not be sustainable as increasing numbers of people living with HIV come into care.  The provision of HIV primary health care does need to respond to the comprehensive service needs of people living with HIV, and the impact of a changeover to a new system of care must be implemented and monitored carefully.  Strategies to minimize loss to follow up and to support retention must be included when these changes occur.

Africa
Mozambique
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Decentralizing pediatric HIV care and treatment into primary care centers

Decentralization of pediatric HIV Care and Treatment in Five sub-Saharan African Countries.

Fayorsey RN, Saito S, Carter RJ, Gusmao E, Frederix K, Koech-Keter E, Tene G, Panya M, Abrams EJ. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHF) versus secondary/tertiary health facilities (SHFs). Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania from January 2008- March 2010 trends were examined in the number of children < 15 years of age initiating antiretroviral treatment (ART) by facility type. Clinic-level lost to follow-up (LTFU) and mortality per 100 person years (PYs) on ART during the period by facility type were compared. During the two year period, 17,155 children enrolled in HIV care and 8,475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, while SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100PYs and 5.2/100PYs, respectively at PHFs and 20.2/100PYs and 6.0/100PYs at SHFs. Adjusted models show PHFs associated with lower LTFU (Adjusted Rate Ratio, ARR=0.55; p=0.022) and lower mortality (ARR=0.66; p=0.028). The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

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Editor’s notes: Early during treatment scale up pediatric ART remained a referral clinic intervention, limiting the enrollment of children and disrupting efforts to provide ‘one-stop’ visits for families with adults and children living with HIV. Barriers such as provider discomfort with pediatric ART have been addressed by increased training efforts as well as a public health approach of algorithm-based treatment. Increasingly pediatric ART is being provided in the same sites and by the same providers as other primary health services.

Africa
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Task shifting from doctors to nurses results in comparable outcomes

Task shifting HIV care in rural district hospitals in Cameroon: evidence of comparable antiretroviral treatment related outcomes between nurses and physicians in the Stratall ANRS/ESTHER trial.

Boullé C, Kouanfack C, Laborde-Balen G, Carrieri MP, Dontsop M, Boyer S, Aghokeng AF, Spire B, Koulla-Shiro S, Delaporte E, Laurent C; for the Stratall ANRS/ESTHER Study Group. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

Task shifting to nurses for antiretroviral therapy (ART) is promoted by WHO to compensate for the severe shortage of physicians in Africa. The effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon was assessed through a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed-up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. The associations between the consultant ratio (i.e. the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to WHO clinical stage 4 in multivariate analyses were assessed. Of the 4,141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success (odds ratio 1.00, 95%CI 0.59-1.72, p=0.990), CD4 recovery (coefficient -3.6, 95%CI -35.6; 28.5, p=0.827), mortality (time ratio 1.39, 95%CI 0.27-7.06, p=0.693) or disease progression (time ratio 1.60, 95%CI 0.35-7.37, p=0.543). This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of non-complex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, as well as for other health interventions.

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Editor’s notes: Most health services in primary health facilities are provided by nurses or clinical officers, with few PHC having physician cadre staffing. The evidence is strong that nurses can ably prescribe and refill ART for adults and children living with HIV, further supporting universal access to HIV treatment. The strategies described in the accompanying articles for decentralization to primary health clinics for adults and children require task shifting in many settings – decentralization and integration of HIV services into primary care will inevitably benefit from an increased reliance on nurses as providers of primary care.

Africa
Cameroon
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Cost-effectiveness

Expanding ART for treatment and prevention of HIV in South Africa: Estimated cost and cost-effectiveness 2011-2050

Granich R, Kahn JG, Bennett R, Holmes CB, Garg N, Serenata C, Sabin ML, Makhlouf-Obermeyer C, De Filippo Mack C, Williams P, Jones L, Smyth C, Kutch KA, Ying-Ru L, Vitoria M, Souteyrand Y, Crowley S, Korenromp EL, Williams BG. PLoS One. 2012;7(2):e30216. Epub 2012 Feb 13

Antiretroviral treatment (ART) significantly reduces HIV transmission. Granich and colleagues conducted a cost-effectiveness analysis of the impact of expanded antiretroviral treatment in South Africa. The authors modelled a best case scenario of 90% annual HIV testing coverage in adults 15-49 years old and four antiretroviral treatment eligibility scenarios: CD4 count <200 cells/mm(3) (current practice), CD4 count <350, CD4 count <500, all CD4 levels. 2011-2050 outcomes include deaths, disability adjusted life years (DALYs), HIV infections, cost, and cost per DALY averted. Service and antiretroviral treatment costs reflect South African data and international generic prices. Antiretroviral treatment reduces transmission by 92%. The authors conducted sensitivity analyses. Expanding antiretroviral treatment to CD4 count <350 cells/mm(3) prevents an estimated 265,000 (17%) and 1.3 million (15%) new HIV infections over 5 and 40 years, respectively. Cumulative deaths decline 15%, from 12.5 to 10.6 million; DALYs by 14% from 109 to 93 million over 40 years. Costs drop $504 million over 5 years and $3.9 billion over 40 years with breakeven by 2013. Compared with the current scenario, expanding to <500 prevents an additional 585,000 and 3 million new HIV infections over 5 and 40 years, respectively. Expanding to all CD4 levels decreases HIV infections by 3.3 million (45%) and costs by $10 billion over 40 years, with breakeven by 2023. By 2050, using higher antiretroviral treatment and monitoring costs, all CD4 levels saves $0.6 billion versus current; other antiretroviral treatment scenarios cost $9-194 per DALY averted. If antiretroviral treatment reduces transmission by 99%, savings from all CD4 levels reach $17.5 billion. Sensitivity analyses suggest that poor retention and predominant acute phase transmission reduce DALYs averted by 26% and savings by 7%. Increasing the provision of antiretroviral treatment to <350 cells/mm3 may significantly reduce costs while reducing the HIV burden. Feasibility including HIV testing and ART uptake, retention, and adherence should be evaluated.

For abstract access click here. 

Editor’s note: The 2010 WHO recommendations for antiretroviral treatment initiation increased the CD4 count eligibility level from under 200 cells/uL to under 350 cells/uL, after expert review of the scientific evidence concluded that the benefits of earlier HIV treatment are tangible and valuable. This expanded the numbers of those eligible for treatment globally by 50%, with the result that countries adopting the new Guidelines  - and many did - saw their per cent achievement towards universal access for antiretroviral treatment drop. South Africa opted to expand treatment at CD4 350 first to pregnant women and tuberculosis-coinfected patients and then, in August 2011, to all those with CD4 counts at or below 350. This economic analysis provides a vision of the potential costs of earlier treatment balanced against the savings from lowered future treatment demand as a result of infections averted with this policy decision. The analysis also examines the options of treatment initiation at 500 cells/uL and treatment initiation regardless of CD4 count. Some of parameters seem unrealistic (e.g.1.5% annual programme drop-out, 5-year scale-up horizon to 90% for sustained annual HIV testing and sustained 90% antiretroviral treatment coverage [regardless of gender or HIV exposure risk], no consideration of the potential impact of antiretroviral drug resistance, and no viral load testing to inform adherence counselling and the need for switching regimens in the base case scenario. However, the case for front-loaded investment in earlier antiretroviral therapy is compelling nonetheless. This model predicts that South Africa’s change to 350 cells/uL will pay for itself in 4 to 12 years as care shifts from inpatient to ambulatory HIV care and disease burden declines through both direct health benefits and collateral prevention spin-offs of expanded treatment scale-up.

National responses
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Research conduct

Applying the principles of knowledge translation and exchange to inform dissemination of HIV survey results to adolescent participants in South Africa

Nixon SA, Casale M, Flicker S, Rogan M. Health Promot Int. 2012 Jan 10. [Epub ahead of print]

It is widely accepted that researchers have an obligation to inform survey participants of research results. However, there is little evidence on the effectiveness of various dissemination strategies. The emerging field of knowledge transfer and exchange (KTE) may offer insight given its focus on techniques to enhance the effectiveness of communicating evidence-based information. To date, knowledge translation and exchange has focused primarily on information exchange between researchers and policy-makers as opposed to study participants; however, there are principles that may be relevant in this new context. This gap in the literature becomes even more salient in the context of public health research where research results can reveal particular misunderstandings or shortcomings in knowledge that threaten to severely compromise participants' health. The objective of this article is to describe how knowledge translation and exchange principles were used to inform dissemination of results of a self-administered sexual health survey to adolescent study participants in a resource-deprived, peri-urban area of South Africa. Strategies for enhancing two-way information exchange included constructing interactive dissemination sessions led by young, isiZulu fieldworkers. Nixon and colleagues also employed techniques to create a safe space for dialogue, encouraged the shared ownership of results and crafted targeted messages. Particularly noteworthy was the benefit accrued by the research team through this process of exchange, including novel explanations for study findings and new ideas for future research.

For abstract access click here.

Editor’s note: This thoughtful article provides a brief overview of the field of knowledge translation and exchange between research producers and research users. This process, based on collaborative engagement, begins with identifying what research questions are relevant, what study design is most appropriate, and how study conduct is proceeding. It goes through to analysis of results, dissemination of findings, and application of the knowledge gained. The example provided here is intriguing. How best do you share survey results with adolescents who have participated in a study and will that process, if successful, promote not only ownership of the results and produce plausible explanations for quantitative survey findings, but will it also promote healthy behaviour itself? What was done here could be considered a best practice for establishing ground rules for a respectful, interactive space for results dissemination. But during the dissemination process qualitative data, in the form of explanations emerging from the adolescents, was not well captured because this component of the research process had been planned as sharing of results. However, reflecting back school-based findings through guessing games, posters, and booklets that could be taken home, and valuing youth expertise in explaining the results went a long way to creating ownership.

National responses
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Young people

A tale of two countries: rethinking sexual risk for HIV among young people in South Africa and the United States

Pettifor AE, Levandowski BA, Macphail C, Miller WC, Tabor J, Ford C, Stein CR, Rees H, Cohen M. J Adolesc Health. 2011 Sep;49(3):237-243.e1.

Pettifor and colleagues compared the sexual behaviours of young people in South Africa and the United States of America with the aim to better understand the potential role of sexual behaviour in HIV transmission in these two countries that have strikingly different HIV epidemics. Nationally representative, population-based surveys of young people aged 18-24 years from South Africa (n = 7548) and the USA (n = 13,451) were used for the present study. The prevalence of HIV was 10.2% in South Africa and <1% in the USA. Young women and men in the USA reported an earlier age of first sex than those in South Africa (mean age of coital debut for women: USA [16.5], South Africa [17.4]; for men: USA [16.4], SA [16.7]). The median number of lifetime partners is higher in the USA than in South Africa: women: USA (4), South Africa (2); men: USA (4), South Africa (3). The use of condom at last sex is reported to be lower in the USA than in South Africa: women: USA (36.1%), South Africa (45.4%); men: USA (48%), South Africa (58%). On average, young women in South Africa report greater age differences with their sex partners than young women in the USA. Young people in the USA report riskier sexual behaviours than young people in South Africa, despite the much higher prevalence of HIV infection in South Africa. Factors above and beyond sexual behaviour likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies.

For abstract access click here

Editor’s note: This comparison of two nationally representative surveys of young people starkly underscores that behaviour is not the sole determinant of HIV risk. South African young people had their first sex at a later age, have fewer sexual partners, and practise more safer sex than their American counterparts. How can the more than 10-fold difference in HIV prevalence be explained?  The first thought goes to larger age gaps between sexual partners. This means sexual mixing with older partners who can act as a bridge population to younger cohorts…. but there has to be more to it than that. In South Africa, male circumcision levels are far lower, herpes simplex 2 infection levels are higher, genital tract inflammation is higher, co-infections (tuberculosis, helminths) that can increase viral set points are more common, and the prevalence of the CCR5Δ32 coreceptor is lower. But social determinants, such as gender power imbalances, poverty, coerced sex and rape, lack of youth friendly services, and stigma are likely playing important roles. Although these surveys were conducted in 2003 (South Africa) and 2001-2 (USA) using somewhat different methodologies, the finding that ‘ordinary’ sexual behaviour can place young people, particularly young women, in South Africa at such high risk should galvanise leaders at all levels to call for urgent action. Advocates are calling out ‘where the hell is the gel’ and researchers are testing microfinance and conditional cash transfers, but it will take a paradigm shift at all levels to prioritise investment in protecting young people from what is a preventable, chronic, lifelong disease. 

National responses
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Knowledge translation

Using research to influence sexual and reproductive health practice and implementation in sub-Saharan Africa: a case-study analysis

Tulloch O, Mayaud P, Adu-Sarkodie Y, Opoku BK, Lithur No, Sickie E, Delany-Moretlwe S, Wambura M, Changalucha J, Theobald S. Health Res Policy Syst. 2011 Jun 16;9 Suppl 1:S10.

Research institutions and donor organizations are giving growing attention to how research evidence is communicated to influence policy. In the area of sexual and reproductive health and HIV there is less weight given to understanding how evidence is successfully translated into practice. Policy issues in sexual and reproductive health can be controversial, influenced by political factors and shaped by context such as religion, ethnicity, gender and sexuality. The case-studies presented in this paper analyse findings from sexual and reproductive health and HIV research programmes in sub-Saharan Africa: 1) Maternal syphilis screening in Ghana, 2) Legislative change for sexual violence survivors in Ghana, 3) Male circumcision policy in South Africa, and 4) Male circumcision policy in Tanzania. The authors’ analysis draws on two frameworks: Sumner et al's synthesis approach and Nutley's research use continuum. The analysis emphasises the relationships and communications involved in using research to influence policy and practice and recognises a distinction whereby practice is not necessarily influenced as a result of policy change—especially in sexual and reproductive health where there are complex interactions between policy actors. Both frameworks demonstrate how policy networks, partnership and advocacy are critical in shaping the extent to which research is used and the importance of on-going and continuous links between a range of actors to maximise research impact on policy uptake and implementation. The case-studies illustrate the importance of long-term engagement between researchers and policy makers and how to use evidence to develop policies which are sensitive to context: political, cultural, and practical.

For abstract access click here

Editor’s note: The analyses of the case studies of sexual and reproductive health (SRH) policy changes provided here are thought-provoking. Research evidence in this highly politicised field does not simply speak for itself. For research findings to influence SRH policy and programming—sometimes called GRIPP (getting research into policy and practice)—networks of collaborative partnerships, media coverage, knowledge brokers, advocacy, and tailored communication strategies are needed to connect researchers with policy makers and practitioners. Weak public understanding and engagement with science constitutes an initial hurdle that must be overcome to aid stakeholders in understanding the policy implications of new research findings. As described in the male circumcision case study from South Africa, participation of scientists in civil-society government structures facilitated ‘change from within’. In Tanzania, knowledge translation of the male circumcision findings into services is requiring an inclusive, interconnected constructive partnership and continuous communication between policymakers, researchers, advocacy groups, donors, and health practitioners. These case studies demonstrate that the existing policy context is the key pre-condition for research use but policy outcomes can be influenced by concrete actions that increase the probability of research being used by policy actors.

National responses
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National responses

Challenging urban health: towards an improved local government response to migration, informal settlements, and HIV in Johannesburg, South Africa

Vearey J. Glob Health Action. 2011;4. doi: 10.3402/gha.v4i0.5898. Epub 2011 Jun 9

J. Vearey explored local government responses to the urban health challenges of migration, informal settlements, and HIV in Johannesburg, South Africa. Urbanisation in South Africa is a result of natural urban growth and (to a lesser extent) in-migration from within the country and across borders. This has led to the development of informal settlements within and on the periphery of urban areas. The highest HIV prevalence nationally is found within urban informal settlements. South African local government has a 'developmental mandate' that calls for government to work with citizens to develop sustainable interventions to address their social, economic, and material needs. Through a mixed-methods approach, four studies were undertaken within inner-city Johannesburg and a peripheral urban informal settlement. Two cross-sectional surveys - one at a household level and one with migrant antiretroviral clients - were supplemented with semi-structured interviews with multiple stakeholders involved with urban health and HIV in Johannesburg, and participatory photography and film projects undertaken with urban migrant communities. The findings show that local government requires support in developing and implementing appropriate intersectoral responses to address urban health. Existing urban health frameworks do not deal adequately with the complex health and development challenges identified; it is essential that urban public health practitioners and other development professionals in South Africa engage with the complexities of the urban environment. A revised, participatory approach to urban health - 'concept mapping' - is suggested which requires a recommitment to intersectoral action, 'healthy urban governance' and public health advocacy.

For abstract access click here

Editor’s note: Over half the world’s population is now urban and, as a result of rural-urban migration and cross-border migration from other countries into urban areas, almost 60% of the South African population is urban. Urban growth in South Africa is putting pressure on HIV and other health services, on adequate housing, and on basic services such as water, sanitation, and refuse removal. Urban health and development challenges include urban inequalities, migration, informal settlements, urban HIV prevalence, residents with ‘weak rights to the city’, and survivalist livelihood strategies. Applying social determinants of health frameworks, such as the ‘urban living conditions model’, the WHO Commission on Social Determinants of Health conceptual framework for action, and the conceptual framework of the WHO Knowledge Network on Urban Settings, to the interlinked challenges of migration and informal settlements in the urban South Africa setting can be disappointing. By definition such frameworks are intended to provide a guide to understanding a complex reality rather than answers on where and how to intervene. The alternative proposed here is concept mapping, whereby local government officials engage with the diversity of urban populations to create a city-specific concept map, anchored in intersectoral action, healthy urban governance, and public health advocacy, to inform tailored, multi-level responses to urban health challenges.

National responses
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