HIV and SRH healthcare delivery experiences of South African healthcare workers and adolescents and young people during COVID-19.

Kelly J ，Gittings L ，Laurenzi C ，Glinski CD ，Mangqalaza H ，Ralayo N ，Langwenya N ，Sidloyi L ，Mbiko A ，Taleni B ，Saliwe B ，Toska E ... -  《-》

Sexual and reproductive health services during outbreaks, epidemics, and pandemics in sub-Saharan Africa: a literature scoping review.

The COVID-19 pandemic could worsen adolescent sexual and reproductive health (ASRH). We sought evidence on the indirect impacts of previous infectious disease epidemics and the current COVID-19 pandemic on the uptake of ASRH in sub-Saharan Africa (SSA) to design relevant digital solutions. We undertook a literature scoping review to synthesize evidence on the indirect impacts of COVID-19 on ASRH in SSA per the Arksey and O'Malley framework and PRISMA reporting guidelines. We conducted the search on PubMed, Embase, Google Scholar, and ResearchGate in June and November 2020. We included all peer-reviewed, English-language primary studies on the indirect impacts of infectious disease epidemics on the uptake of sexual and reproductive health (SRH) in SSA. We included 21 of 42 identified studies. Sixteen studies (76.2%) quantitatively assessed utilization and access to SRH during epidemics. Five studies (2 [9.6%] qualitative and 3 [14.3%] mixed methods) explored factors affecting SRH services. All studies focused on adult populations, most often on labor and delivery (n = 13 [61.9%]) and family planning (n = 8 [38.1%]) outcomes. Although we sought out to assess all outbreaks, epidemics, and pandemics, the only relevant studies took place during the West African Ebola pandemic (n = 17 [80.9%]) and COVID-19 pandemic (n = 4 [19.0%]). One study (4.8%) highlighted adolescent-specific outcomes and condom use. Most studies found declined access to and utilization of facility delivery, antenatal care, family planning, and HIV care. One study noted an increase in adolescent pregnancies. However, other studies noted similar, or even increasing trends in access to and utilization of other SRH services (family planning visits; HIV diagnosis; ART initiation) during epidemics. Barriers to SRH uptake included factors such as a reduced ability to pay for care due to lost income, travel restrictions, and fear of infection. Supply-side barriers included lack of open facilities, workers, commodities, and services. Community-based peer delivery systems, telemedicine, and transport services improved SRH uptake. Access to SRH services during epidemics among adolescents and young people in SSA is understudied. We found that no studies focused on SRH outcomes of abortion, emergency contraception, sexually transmitted infections, or cervical cancer. To improve access to and utilization of SRH during pandemics, we recommend the following; in terms of research, key standardized SRH indicators should be included in routine data collection, routine data should be disaggregated by age, gender, and geography to understand gaps in ASRH service delivery, and additional rigorous epidemiological and social-behavioral studies should be conducted. On implementation, community-based peer delivery systems and telemedicine, internet-based, and other technological solutions may better reach adolescent and young people in SSA.

Ng'andu M ，Mesic A ，Pry J ，Mwamba C ，Roff F ，Chipungu J ，Azgad Y ，Sharma A ... -  《Systematic Reviews》

Adapting community-based sexual and reproductive health services for adolescents and young people aged 15-24 years in response to COVID-19 in Lusaka, Zambia: the implications on the uptake of HIV testing services.

Across Sub-Saharan Africa, adolescents and young people (AYP) aged 15-24 have limited access to sexual and reproductive health (SRH) services, including HIV testing services (HTS). In response, the Yathu Yathu study was implemented in two high-density communities in Lusaka, Zambia. Yathu Yathu provides comprehensive, community-based, peer-led SRH services, including differentiated HTS (finger-prick and HIV self-testing) and comprehensive sexuality education (CSE). We describe adaptations to the Yathu Yathu intervention in response to the COVID-19 epidemic, and implications on uptake of HTS among AYP. Yathu Yathu provides SRH services through community-based peer-led spaces. AYP in study communities were offered prevention points cards (PPC), which incentivizes and tracks service use. Social media (WhatsApp©/Facebook©) is used to engage and inform AYP about SRH. Due to COVID-19, hubs closed from April-June 2020. We describe adaptations in response to COVID-19 and, using routinely collected PPC data, describe uptake of HTS before (September 2019-March 2020) and after (July-December 2020) adaptations in response to COVID-19. We describe reach of the Yathu Yathu Facebook page and use qualitative data to describe AYP experiences of SRH service access. During hub closures, CSE was delivered via video on social media, resulting in an increase in Facebook page followers from 539(April) to 891(June). WhatsApp groups evolved as a platform to deliver CSE and COVID-19 information, with higher participation among young people aged 20-24. Key service delivery adaptations included: reducing the number of participants in hubs, mandatory handwashing before entry, use of personal protective equipment by staff and provision of facemasks to AYP. HTS were provided as normal. Adaptations led to fewer AYP attending hubs. Uptake of HTS among AYP visiting hubs for the first time after COVID-19-related closures was higher (73.2%) compared to uptake before adaptations (65.9%; adjOR=1.24 95%CI 0.99, 1.56, p=0.06). Despite disappointments with some aspects of service delivery, AYP expressed happiness that hubs had reopened. Social media can be a useful additional platform to reach AYP with HIV prevention information during COVID-19. With proper infection control in place, HTS can safely be provided to, accessed and accepted by AYP in community-based settings during COVID-19. National Clinical Trials NCT04060420,19th August 2019. Current Controlled Trials ISRCTN75609016 , 14th September 2021, retrospectively registered.

Phiri MM ，Hensen B ，Schaap A ，Sigande L ，Simuyaba M ，Simwinga M ，Floyd S ，Fidler S ，Hayes R ，Ayles H ... -  《-》

The impact of community-based, peer-led sexual and reproductive health services on knowledge of HIV status among adolescents and young people aged 15 to 24 in Lusaka, Zambia: The Yathu Yathu cluster-randomised trial.

The growing population of adolescents and young people (AYP) aged 15 to 24 in sub-Saharan Africa face a high burden of HIV in many settings. Unintended pregnancies among adolescent girls in the region remain high. Nonetheless, the sexual and reproductive health (SRH) service needs of AYP have remained underserved. We conducted a cluster-randomised trial (CRT) to estimate the impact of community-based, peer-led SRH service provision on knowledge of HIV status and other SRH outcomes, including met need for contraceptives. Yathu Yathu was a cluster-randomised trial (CRT) conducted from 2019 to 2021 in 2 urban communities in Lusaka, Zambia. The communities were divided into 20 zones (approximately 2,350 AYP/zone) that were randomly allocated to the Yathu Yathu intervention or control arm. In each intervention zone, a community-based hub, staffed by peer support workers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15 to 24 were given a Yathu Yathu card, which allowed them to accrue points for accessing SRH services at the hub and health facility (intervention arm) or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive to use SRH services in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome: knowledge of HIV status (self-reporting living with HIV or HIV testing in the last 12 months) and secondary outcomes, including use of pre-exposure prophylaxis (PrEP) in the last 12 months, current use of antiretroviral therapy (ART), and met need for contraceptive services. The sampling was stratified on sex and age group, and we analysed data at cluster-level using a two-stage process recommended for CRTs with <15 clusters/arm. A total of 1,989 AYP consented to participate in the survey (50% male); consent was similar across arms (63% consent/arm). Across zones, knowledge of HIV status ranged from 63.6% to 81.2% in intervention zones and 35.4% to 63.0% in control zones. Adjusting for age, sex, and community, knowledge of HIV status was higher in the intervention arm compared to control (73.3% versus 48.4%, respectively, adjusted prevalence ratio (PR) 1.53 95% CI 1.36, 1.72; p < 0.001). By age and sex, results were similar. There was no evidence for impact on any secondary outcomes, including current use of ART and met need for contraceptives. There were no adverse events reported in either arm. A key limitation of our trial is that approximately 35% of the AYP randomly selected for participation in the endline survey could not be reached. Delivering community-based, peer-led SRH services increased knowledge of HIV status among AYP, both males and females, compared with the control arm. Scaling up the highly effective Yathu Yathu strategy has the potential to make a substantial contribution to increasing access to HIV prevention and care services for young people. However, additional implementation research is needed to understand how to improve uptake of broader SRH services, beyond uptake of HIV testing. ISRCTN75609016, clinicaltrials.gov number NCT04060420.

Hensen B ，Floyd S ，Phiri MM ，Schaap A ，Sigande L ，Simuyaba M ，Mwenge L ，Zulu-Phiri R ，Mwape L ，Fidler S ，Hayes R ，Simwinga M ，Ayles H ... -  《-》

Mental health experiences of HIV/TB healthcare workers during the COVID-19 pandemic - lessons for provider well-being and support from a qualitative study in seven South African provinces.

COVID-19 has substantially reshaped health service delivery. Healthcare workers have had to serve more clients, work longer shifts, and operate in conditions of uncertainty. They have experienced multiple stressors related to the additional 'labour of care', including managing the frustration of inadequate therapeutic or symptom relief options, witnessing clients dying, and having to give this news to clients' family members. Ongoing psychological distress among healthcare workers can severely undermine performance, decision-making and well-being. We sought to understand the impact of the COVID-19 pandemic on the mental health experiences of healthcare workers delivering HIV and TB services in South Africa. We used a pragmatic and exploratory design to understand HCWs' mental health experiences with in-depth qualitative data. We implemented the study in ten high HIV/TB burden districts across seven of South Africa's nine provinces among healthcare workers employed by USAID-funded implementing partners. We conducted in-depth interviews (virtual) with 92 healthcare workers across 10 cadres. Healthcare workers reported experiencing a range of extreme and rapidly fluctuating emotions because of COVID-19 that negatively impacted on their well-being. Among these, many healthcare workers report experienced a great deal of guilt at their inability to continue to provide quality care to their clients. In addition, a constant and pervasive fear of contracting COVID-19. Healthcare workers' stress coping mechanisms were limited to begin with, and often further interrupted by COVID-19 and non-pharmaceutical response measures e.g., 'lockdowns'. Healthcare workers reported a need for greater support for managing the everyday burden of work - not only when experiencing a mental well-being 'episode'. Further, that whenever they were exposed to stressor events, e.g., supporting a child living with HIV who reports sexual abuse to the healthcare worker, that this this would trigger additional support interventions and not rely on the healthcare worker seeking this out. Further, that supervisors spend more effort demonstrating appreciation toward staff. The COVID-19 epidemic has added significant mental health burden for healthcare workers in South Africa. Addressing this requires broad and cross-cutting strengthening of everyday support for healthcare workers and centring staff's mental well-being as core to delivering quality health services.

Yang B ，Egg R ，Brahmbhatt H ，Matjeng M ，Doro T ，Mthembu Z ，Muzah B ，Foster B ，Theunissen J ，Frost A ，Peetz A ，Reichert K ，Hoddinott G ... -  《BMC HEALTH SERVICES RESEARCH》