BackgroundSouth Africa has high rates of HIV and HPV and high incidence and mortality from cervical cancer. However, cervical cancer is largely preventable when early screening and treatment are available. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV-infected women currently taking antiretroviral treatment at a public HIV clinic in Johannesburg, South Africa.MethodsMethod effectiveness was derived from a validation study completed at the clinic. Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered. Threshold analysis was used to explore the potential for reducing the cost of HPV DNA testing.ResultsVIA was least costly in both scenarios. In the higher volume scenario, the average cost per procedure was US$ 3.67 for VIA, US$ 8.17 for Pap and US$ 54.34 for HPV DNA. Colposcopic biopsies cost on average US$ 67.71 per procedure. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. HPV DNA testing was US$ 320.09 per case detected. Colposcopic biopsy costs largely drove the total and per case costs. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition.ConclusionsWomen need access to services which meet their needs and address the burden of cervical dysplasia and cancer in this region. Although most cost-effective, VIA may require more frequent screening due to low sensitivity, an important consideration for an HIV-positive population with increased risk for disease progression.

BackgroundAccess to adequate health services that is of acceptable quality is important in the move towards universal health coverage. However, previous studies have revealed inequities in health care utilisation in the favour of the rich. Further, those with the greatest need for health services are not getting a fair share. In Zambia, though equity in access is extolled in government documents, there is evidence suggesting that those needing health services are not receiving their fair share. This study seeks therefore, to assess if socioeconomic related inequalities/inequities in public health service utilisation in Zambia still persist.MethodsThe 2010 nationally representative Zambia Living Conditions and Monitoring Survey data are used. Inequality is assessed using concentration curves and concentrations indices while inequity is assessed using a horizontal equity index: an index of inequity across socioeconomic status groups, based on standardizing health service utilisation for health care need. Public health services considered include public health post visits, public clinic visits, public hospital visits and total public facility visits.ResultsThere is evidence of pro-poor inequality in public primary health care utilisation but a pro-rich inequality in hospital visits. The concentration indices for public health post visits and public clinic visits are −0.28 and −0.09 respectively while that of public hospitals is 0.06. After controlling for need, the pro-poor distribution is maintained at primary facilities and with a pro-rich distribution at hospitals. The horizontal equity indices for health post and clinic are estimated at −0.23 and −0.04 respectively while that of public hospitals is estimated at 0.11. A pro-rich inequity is observed when all the public facilities are combined (horizontal equity index = 0.01) though statistically insignificant.ConclusionThe results of the paper point to areas of focus in ensuring equitable access to health services especially for the poor and needy. This includes strengthening primary facilities that serve the poor and reducing access barriers to ensure that health care utilisation at higher-level facilities is distributed in accordance with need for it. These initiatives may well reduce the observed inequities and accelerate the move towards universal health coverage in Zambia.

IntroductionHIV self-testing (HIVST) presents a convenient, private approach that removes barriers to providing HIV testing services. The Self-Testing Africa (STAR) Initiative aims to scale up HIVST among priority and undertested populations. HIVST has the potential to help maintain testing services during the social distancing restrictions implemented to prevent the spread of COVID-19. This project evaluates linkage to confirmatory testing and treatment for HIV-positive clients for the STAR South Africa site.Methods and analysisThis secondary data analysis protocol aims to evaluate different HIVST distribution models from a prospective study implemented during November 2017 and December 2020 by Ezintsha, a subdivision of Wits Reproductive Health and HIV Institute. Routinely collected distribution and self-reported HIVST outcomes data will be deidentified and analysed. The main outcomes of interest are linkage to care and treatment among HIVST users who report a reactive HIVST result. Additionally, we plan to determine sociodemographic factors associated with linkage to care and treatment among HIVST users. Descriptive statistics will be used to describe the variables of interest, and modified Poisson regression with robust variance estimation will be performed to identify factors associated with linkage to care and treatment among HIVST users who report a reactive HIVST result. Risk ratios and 95% CIs for the risk ratios will be reported.Ethics and disseminationThe study protocol has been approved by the University of Witwatersrand Human Research Ethics Committee. The dissemination plan for the study findings will include presentations to local and international health authorities, international conferences and publications in open access journals.

Introduction With over 500 000 infections and nearly 12 000 deaths, South Africa (SA) is the African epicenter of the current Coronavirus (COVID-19) pandemic. SA has implemented a 5-stage Risk-Adjusted Strategy which includes a phased national lockdown, requiring social distancing, frequent hand washing and wearing face masks. Strict adherence to this strategy is crucial to reducing COVID-19 transmission, flattening the curve, and preventing resurgence. As part of the 22-country International Citizens Project COVID-19 (ICPcovid), this study aimed to describe the SA adherence to the Risk-Adjusted Strategy and identify determinants of adherence. Method During 24 April-15 May 2020, people were electronically invited, through social media platforms and a text blast, to complete an online survey, accessible via www.icpcovid.com. The survey investigated COVID-19 testing and preventative adherence measures, then used logistic regression analysis to identify predictors of adherence. Results There were 951 participants, with 731(76.9%) 25 to 54 years. Most (672;70.7%) were female, and 705(74.1%) had a university degree. Since the epidemic started, 529(55.6%) and 436(45.9%) participants stated they were eating healthier and taking more vitamins, respectively. Only 82(8.6%) had been COVID-19 tested, and 1(1.2%) tested positive. In public, 905(95.2%) socially distanced, however 99(10.4%) participants had recently attended meetings with over ten people. Regular hand washing was practiced by 907(95.4%) participants, 774(81.4%) wore face masks and 854(89.8%) stayed home when they experienced flu-like symptoms. The odds of adhering to the guidelines were lower among men versus women (AOR 0.72, 95% confidence interval [CI] = 0.528, 0.971) and those who had flu-like symptoms (AOR 0.42, 95% CI = 0.277, 0.628). In contrast, increased odds were reported for those who reported increased vitamin intake (AOR 1.37, 95% CI = 1.044,1.798), and were either cohabiting or married (AOR 1.39, 95% CI = 1.042,1.847). Conclusion Despite high reported adherence, face mask use and symptomatic individuals not self-isolating, were areas for improvement. However, these factors cannot solely account for SA’s increasing COVID-19 cases. Larger general population studies are needed to identify other adherence predictors for a strengthened SA COVID-19 response. While the government must continue to educate the entire population on preventative measures, provide personal protective equipment and stress the importance of adherence, there also needs to be implementation of prioritised prevention strategies for men and single individuals to address their demonstrated lower adherence.

BackgroundCervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa.MethodsMethod effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women—regardless of their original treatment assignment—received LEEP. “Cure” was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis.ResultsIn total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8–91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4–85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US$ 118.00 (113.91–122.10), and per case “cured” at US$ 140.90 (136.01–145.79). Women in the LEEP group cost US$ 162.56 (157.90–167.22) per patient randomized and US$ 205.59 (199.70–211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses.ConclusionsFor this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the eff...