Africa Health Research Institute

This cluster examines how peer-led, decentralised, and digital strategies can increase HIV testing, prevention, and linkage to care among adolescents, young adults, and men in rural KwaZulu-Natal. Using factorial and stepped-wedge cluster randomised designs, studies tested peer navigators who mobilise youth into nurse-led mobile sexual and reproductive health services, integration of STI/contraception with serostatus-neutral HIV prevention, HIV self-testing (including peer-to-peer distribution), small financial incentives, and a male-targeted decision-support app grounded in self-determination theory. Home-based and community distributions consistently reached men - many first-time testers - and facilitated confirmatory testing and PrEP/ART initiation when youth-friendly services and referral tools were available. Financial incentives increased testing uptake, but linkage to care remained weak, especially among young men; the digital app was acceptable yet hampered by privacy, usability, and fidelity challenges, with limited impact on linkage. Process evaluations highlighted stigma, “feminised” clinics, and negative clinic experiences as enduring barriers. Operational lessons emphasise pairing peer support with convenient, confidential services, strengthening implementation quality, and measuring population-level outcomes such as transmissible HIV and viral suppression.

This cluster synthesises population-based cohorts from rural KwaZulu-Natal and regional analyses across East, Central, and Southern Africa to track HIV incidence, age shifts, and spatial concentration amid expanding antiretroviral therapy, male circumcision, and prevention programmes. Prospective surveillance with repeated testing, G-imputation for interval-censored seroconversion, Bayesian and catalytic reconstructions, and fine-scale geospatial modelling consistently show substantial recent incidence declines, earlier and steeper in men, accompanied by a shift of new infections to older ages. Yet incidence remains high among adolescent girls and young women and female sex workers and varies sharply across small areas. UNAIDS epidemic control metrics indicate progress but uneven and off target in hyperendemic settings. Modified population viral load measures that incorporate local prevalence, and risk models using only age and geospatial covariates, accurately identify high-incidence places, outperforming behaviour-only models. Studies also document increased survival with ART before incidence fell and find youth HIV testing protective. Operational lessons emphasise targeting underserved high-burden clusters, scaling men’s treatment to reduce women’s risk, and deploying cost-effective sex worker programmes.

This cluster examines how expanding antiretroviral therapy (ART) and universal test-and-treat (UTT) affect HIV incidence, survival, and care engagement in resource-limited settings, with a focus on rural KwaZulu-Natal, South Africa. Using cluster-randomised trials (ANRS 12249 TasP; DO ART), population-based cohorts linked to clinic records, regression discontinuity at CD4 thresholds, interrupted time series around UTT rollout, programme evaluations, and a global review of Undetectable = Untransmittable (U=U)/TasP knowledge, studies show that ART scale-up substantially increased adult life expectancy and that higher community ART coverage reduces HIV acquisition risk. UTT achieved very high testing coverage and, when paired with rapid linkage and patient-centred care, raised population viral suppression and lowered incidence and mortality, though elimination targets were not met. Persistent challenges include poor linkage and initiation among people with higher CD4 counts, men and youth lagging in suppression, and only modest, transient increases in CD4 at initiation after UTT. Immediate eligibility improves retention, and community-based initiation and refill models outperform clinic-based care on viral suppression. Longitudinal cascades reveal major pre-linkage losses, and awareness of U=U remains low in Africa, underscoring the need for sustained, decentralised, gender-tailored services and vigilant viral load monitoring.

This cluster examines how HIV and social determinants shape maternal, child, and adult mortality in rural South Africa and multi-country HDSS sites across eastern and southern Africa during the ART era. Studies use population-based cohorts with verbal autopsies interpreted by probabilistic algorithms (InterVA, InSilicoVA), linked HIV/ART records, spatial clustering, and Cox or interrupted time-series analyses. Consistently, HIV/TB dominated mortality but declined with ART scale-up; however, HIV remained strongly associated with direct maternal deaths and with late postpartum mortality alongside other infections and rising noncommunicable causes, often amid health-system failures. Maternal ART improves under-five survival, while a mother’s death triggers a sharp, early hazard for her child. Combined wasting and stunting greatly elevate infant mortality, and pervasive stunting underlies later deaths. Offspring schooling is linked to parental survival; migration heightens postpartum risk; and Covid-19 lockdowns reduced paediatric admissions, likely constraining access. Priorities include embedding verbal autopsy in CRVS, targeting spatial hotspots, ensuring quality maternity and HIV care across mobility and postpartum, safeguarding services during shocks, and addressing mental health and socioeconomic drivers.

Drawing on a long‑running demographic surveillance platform in rural South Africa, this cluster examines how to detect, link, and deliver care for HIV, tuberculosis and related conditions. Community and clinic‑based surveys show that many culture‑confirmed TB cases lack symptoms, indicating symptom screening alone misses disease; computer‑aided chest radiography and deep‑learning interpretation of HIV rapid tests improve diagnosis and quality assurance. Modelling attributes a share of TB to transmission in primary care clinics, with infection‑prevention measures yielding moderate community benefits, while a systems‑focused review highlights persistent implementation barriers from space, staffing, equipment, and norms. Qualitative studies reveal stigma, provider attitudes, clinic design, and inconvenient hours restrict youth access; drought‑related livelihood shocks undermine antiretroviral adherence, and hepatitis B awareness and care pathways are weak. During Covid‑19, phone surveillance tracked household impacts; adult HIV care was resilient, but child visits dipped. Consistent lessons include integrating community screening, digital diagnostics, and data linkages, investing in stigma reduction, youth‑friendly, climate‑resilient services, and TB IPC; gaps include under‑addressed mental health needs and strategies for radiologically subtle TB.

This cluster examines multimorbidity in rural South Africa - especially KwaZulu-Natal - through population-based surveillance, mobile health camps (Vukuzazi), WHO STEPS surveys, longitudinal cohorts with verbal autopsy, and modelling, alongside a randomised trial of home-based hypertension care. Across studies, hypertension, elevated glucose, HIV, and TB co-occur frequently, with disease control consistently better for HIV than for hypertension or diabetes. Screening alone is insufficient: few individuals link to care after home-based blood pressure screening, particularly younger adults and men, and half of those with chronic conditions have unmet needs spanning diagnosis, engagement, and treatment optimisation. A community health worker– and nurse-supported, app-enabled home model improves blood pressure control over clinic-based care. HIV care platforms appear to bolster the hypertension cascade but less so diabetes. Risk profiles differ by sex and socioeconomic context, with obesity concentrated among women, higher TB and mortality in men, and geospatial clustering of unmet need. ART and HIV status shape adiposity and blood pressure trajectories, and overweight relates to lower mortality risk. Operational priorities include integrated, decentralised chronic care, targeted linkage strategies, and treatment control as a mortality-critical outcome.

This cluster examines how HIV intersects with pregnancy, breastfeeding, and maternal and child health in high-prevalence rural and peri-urban South Africa, particularly KwaZulu-Natal. Using longitudinal cohorts (e.g., Vertical Transmission Study), population-based surveillance, clinic-based retrospective cohorts, and nested case–control virology studies, it addresses maternal morbidity and mental health, HIV acquisition during pregnancy and postpartum, infant feeding practices, and biological cofactors of transmission. Consistently, women living with HIV face greater postpartum morbidity and mortality and higher risks of adverse pregnancy outcomes, modulated by immune status. Postnatal HIV transmission is driven by breast milk viral burden and is amplified by co-infections (notably cytomegalovirus) and inflammatory breast conditions, while antiretroviral prophylaxis and sustained therapy reduce risk. Exclusive breastfeeding, supported by lay counsellor programmes, is achievable and confers survival and diarrheal benefits versus mixed or no breastfeeding, without clear harm from common efavirenz-based regimens; mixed feeding increases transmission. Longer-term child benefits are modest but include less behavioural problems and lower adiposity with sustained breastfeeding. Gaps include integrating depression care into PMTCT, targeted prevention for young multiparous women, and operational strategies to detect and manage breast infections and milk-borne co-pathogens.

This cluster evaluates the multi-sectoral DREAMS package for adolescent girls and young women (AGYW) in Nairobi informal settlements, rural Gem/Siaya, and rural KwaZulu-Natal. Using population-based cohorts randomly drawn from demographic platforms with annual follow-up, cross-sectional surveys, causal analyses, and qualitative studies, researchers asked who was reached, which interventions were layered, and whether knowledge of status, behaviours, violence, empowerment, and HIV incidence changed. Awareness and invitations increased over time, especially among younger and in-school AGYW. HIV testing, school-based education, and social asset building were commonly accessed, yet few received the full primary package; parenting, community mobilisation, and services engaging male partners were underused. DREAMS increased knowledge of HIV status - most strongly in Kenya and among younger AGYW - and modestly improved social support and some behavioural outcomes, but PrEP use remained low, and there was no consistent reduction in gender-based violence or HIV/HSV-2 incidence. Persistent gender norms, poverty, mental health needs, and household power dynamics constrained impact. Operational lessons emphasise adaptable, youth-engaged delivery; stronger links to PrEP and condoms; integration of mental health; meaningful male partner and caregiver engagement; and building on local infrastructure to achieve true layering.

This cluster examines how age, partnership patterns, and mobility shape HIV and sexual health in hyperendemic rural KwaZulu-Natal. Population-based surveillance cohorts, Cox and additive models, and nested biomarker surveys assess HIV incidence by partner age pairings, migration predictors, and STI/BV prevalence; mixed-methods and modelling studies explore social gradients and programme responses. Evidence converges that specific age pairings drive risk: young women partnering with men in their late twenties to early thirties face elevated incidence, while for women over 30, older male partners may confer lower risk. Partner age effects are independent of one’s own age, and HIV-seroconcordant coupling exceeds random mixing, suggesting assortativity. Non-resident and newly migrant youth report more risk behaviours; community ART coverage is associated with reduced out-migration. STI/BV burden among adolescents and young adults is high and frequently asymptomatic. Alcohol-attributable mortality disproportionately affects lower socioeconomic groups. Findings challenge simple concurrency narratives and highlight operational needs: age- and mobility-tailored prevention, integrated PrEP within routine SRH (including for young women who sell sex), youth-friendly nonjudgmental services, asymptomatic STI screening, and edutainment-delivered safe spaces engaging families.

This cluster examines HIV viral load monitoring, drug resistance, and antiretroviral therapy performance in hyperendemic rural South Africa, chiefly KwaZulu-Natal and the Eastern Cape, using population-based surveillance, clinic registries (including TIER.Net), national laboratory databases, genotypic/sequencing studies, programme case studies, and a planned cluster-randomised quality-improvement trial. Consistent findings are that pretreatment drug resistance, especially to NNRTIs, rose to levels that undermine efavirenz-based first-line therapy, while integrase inhibitor resistance remains rare, supporting the transition to dolutegravir. Unsuppressed viral load is concentrated among young, mobile women and residents of geographic hotspots; high viral load is linked to pregnancy loss. Routine care shows gaps: suboptimal viral load monitoring, slow failure management, and frequent second-line protease inhibitor failures, exacerbated by tuberculosis treatment, though many patients resuppress with monitoring. After dolutegravir rollout, overall viral loads declined, yet moderate viremia and spatial hotspots persist, and declines among people with HIV did not translate into lower population-level viremia. Operational lessons emphasise strengthening monitoring via electronic data integration, result triage “champions,” and dashboards; accelerating the failure cascade; geotargeted and youth-focused interventions; resistance surveillance (including rilpivirine screening before long-acting CAB/RPV); and tracking viremia in the whole population.