a b s t r a c tThe study sought to determine the prevalence and predictors of being at risk of an alcohol-exposed pregnancy (AEP) among women of child-bearing age in an urban and rural location in South Africa. We conducted a cross-sectional household survey of 1018 women aged 18-44 years in one urban (n ¼ 606) and one rural (n ¼ 412) site. The women were interviewed using a structured questionnaire. We defined the primary dependent variable, being at risk of having an AEP, as current alcohol use, not being pregnant, being fertile, and no effective use of contraceptives. The independent variables included demographic, substance use, health perceptions, psycho-social, and partner characteristics. The rural women (21.84%) were more likely than their urban counterparts (11.22%) to be at risk of an AEP. In multiple logistic regression analyses, significant predictors of being in the ''at risk'' group for the urban women were (a) being 'white' as opposed to 'black/African', and being 'coloured' as opposed to 'black/African'; and (b) current smoking. For the rural women, significant risk factors were (a) current smoking and (b) early onset of alcohol use. The significant protective factors were (a) education; (b) knowledge about Fetal Alcohol Syndrome; (c) parity. Use of stricter alcohol use criteria (i.e., three or more drinks and five or more drinks per sitting) in the definition of risk of an AEP yielded slightly different patterns of significant predictors. The results revealed high levels of risk of an alcohol-exposed pregnancy, especially amongst the rural women, and a need for location-specific prevention programmes. The high burden of AEP in South Africa calls for the establishment of national AEP prevention strategies and programmes as a matter of urgency.

BackgroundTwo thirds of the world’s new HIV infections are in sub-Saharan Africa. Acute HIV infection (AHI) is the time of virus acquisition until the appearance of HIV antibodies. Early HIV infection, which includes AHI, is the interval between virus acquisition and establishment of viral load set-point. This study aimed to detect acute and early HIV infections in a hyper-endemic setting.MethodsThis was a cross-sectional diagnostic study that enrolled individuals who had negative rapid HIV results in five clinics in South Africa. Pooled nucleic acid amplification testing (NAAT) was performed, followed by individual sample testing in positive pools. NAAT-positive participants were recalled to the clinics for confirmatory testing and appropriate management. HIV antibody, p24 antigen, Western Blot and avidity tests were performed for characterization of NAAT-positive samples.ResultsThe study enrolled 6910 individuals with negative rapid HIV results. Median age was 27 years (interquartile range {IQR}: 23–31). NAAT was positive in 55 samples, resulting in 0.8% newly diagnosed HIV-infected individuals (95% confidence interval {CI}: 0.6–1.0). The negative predictive value for rapid HIV testing was 99.2% (95% CI: 99.0–99.4). Characterization of NAAT-positive samples revealed that 0.04% (95% CI: 0.000–0.001) had AHI, 0.3% (95% CI: 0.1–0.4) had early HIV infection, and 0.5% (95% CI: 0.5–0.7) had chronic HIV infection. Forty-seven (86%) of NAAT-positive participants returned for follow-up at a median of 4 weeks (IQR: 2–8). Follow-up rapid tests were positive in 96% of these participants.ConclusionsNAAT demonstrated that a substantial number of HIV-infected individuals are misdiagnosed at South African points-of-care. Follow-up rapid tests done within a 4 week interval detected early and chronic HIV infections initially missed by rapid HIV testing. This may be a practical and affordable strategy for earlier detection of these infections in resource-constrained settings. Newer molecular tests that can be used at the points-of-care should be evaluated for routine diagnosis of HIV in hyper-endemic settings.

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Interventions that appeal to adolescents and initiate sexual and reproductive health care early should be tested in low- and middle-income settings to reduce differential service uptake and infant outcomes between adolescent and adult mothers.

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