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 Research and Projects







This is a listing of projects undertaken in 2013 and 2014 which are not mentioned substantively elsewhere in this report. They were implemented by the staff of the School of Public Health (SOPH), often in collaboration with partners whose organisations are named wherever this is the case. Only the names of the SOPH staff and the School’s extraordinary professors are given here, however.

A phase III double-blind placebo/controlled trial of the efficacy and safety of infant periexposure prophylaxis with lamivudine to prevent HIV-1 transmission by breastfeeding (PROMISE-PEP trial)

Debra Jackson, Justus Hofmeyr, Mandisa Singata

The PROMISE PEP study, completed in April 2013, was a randomised double-blind placebo-controlled multicentre trial that measured the efficacy of prolonged periexposure prophylaxis with lamivudine (3TC) or Kalitrato prevent HIV-1-transmission through breast milk and death in children born to HIV-1-infected mothers not eligible for HAART.

Funded by the European & Developing Countries Clinical Trials Partnership, this project was a collaboration between the SOPH and ECRU; the universities of Bergen, Montpellier 1 and Zambia; Centre Muraz; and Makerere University.

Effectiveness of the national Prevention of Motherto-Child Transmission (PMTCT) Programme in South Africa

Debra Jackson, Tanya Doherty

The aim of this evaluation was to conduct a national facility-based survey to monitor the population level effectiveness of the South African national PMTCT programme. The primary objective was to measure rates of early mother-to-child-transmission (MTCT) of HIV at six weeks postpartum in 2010, 2011 and 2012, along with 18 month HIV transmission and HIV-free survival in a cohort of HIV-exposed infants in 2012 to 2014 . The early MTCT was 3.5% and 2.7% in 2010 and 2011, respectively. 2012 data is pending release in 2015.

This project was undertaken in collaboration with the National Health Laboratory Service, the University of the Witwatersrand and the Medical Research Council, who also contributed to funding it along with the National Department of Health, the National Research Foundation, CDC/PEPFAR and UNICEF.

Rwanda Mother-to-Child Transmission (PMTCT) Evaluation

Debra Jackson

The aim of this evaluation, completed in 2013, was to conduct a national facility-based survey to monitor the population level effectiveness of the Rwandan national PMTCT programme. The primary objective was to measurerates of early mother-to-child-transmission of HIV at six weeks postpartum in 2012.

Funded by UNICEF, the evaluation was undertaken in collaboration with the South African Medical Research Council, the Rwanda Biomedical Council, the National University of Rwanda, and UNICEF Rwanda.

External evaluation of the Catalytic Initiative (CI)/Integrated Health Systems Strengthening (IHSS)Programme in Ethiopia, Mali, Mozambique, Ghana, Malawi and Niger.

Debra Jackson, Tanya Doherty, David Sanders

The purpose of this external evaluation was to evaluate the effect of the Canadian DFATD/UNICEF-sponsored Integrated Health Systems Strengthening (IHSS) programme on the coverage of a limited package of proven, high impact, and low cost maternal and child health interventions in Ethiopia, Ghana, Malawi, Mali, Mozambique and Niger.

Completed in 2014, it did this by assessing the effect of the IHSS programme on

  • coverage of selected maternal, newborn and child health and nutrition interventions, particularly integrated community case management of diarrhoea, malaria and pneumonia, which were supported by the IHSS programme;

  • the number of additional lives saved by the IHSS programme; strengthening the health system (workforce, servicedelivery, information, supplies, financing and leadership/governance);

  • the capacity of government and/or civil society organisations to train, equip, deploy, and supervise front-line health workers to deliver this limited package of interventions.

The project provided data for future decision making, recommendations for improvements to the programmes as it scales up, as well as lessons for other countries.

The study was undertaken between July 2012 and July 2014 by the SOPH, the Medical Research Council and Save the Children Fund. The reports are available at: http://www.mrc.ac.za/healthsystems/publications.htm.

Accessing Medicines in Africa and South Asia (AMASA)

David Sanders, Bvudzai Magadzire, Kim Ward, Henry Leng 

Completed in 2013, the main aim of this project was to investigate how the interplay of patent regimes, pharmaceutical regulation, availability of drug production facilities, health care infrastructure and service provision, and engagement by foreign donors influence appropriate, affordable access to medicines in South Asia and sub-Saharan Africa.

The project mapped patterns of production, distribution, supply and consumption of medicines within five health

care areas – HIV/AIDS, malaria, reproductive health, TB control, and mental health. It also investigated the strategies and influence of selected Indian, Chinese and Brazilian producers who are active in the study countries as exporters, partners in joint ventures, or as direct producers.

Using a case study approach, we followed specific drugs to explore these issues, employing a multi-disciplinary approach, bringing together public health scientists and clinicians, political economists, sociologists and anthropologists.

Thus far, analysis of the South African data reveals stark inequities in distribution of drug outlets across different sites, and the role played by nurses as ‘brokers’ in assisting clients to overcome medicine supply chain obstacles in their local facilities. Additional findings will soon be available.Funded by the European Commission, this project was a collaboration between the SOPH, the universities of Edinburgh and Ghent, the Swiss Tropical and Public Health Institute, Mbarara University of Science andTechnology and Makerere University in Uganda, and the Foundation for Research in Community Health, India.

Mid-term review of the National Strategic Plan for Maternal, Newborn, Child and Women’s Health and Nutrition (MNCWH&N) 2012 – 2016 and implementation of the CARMMA in South Africa

David Sanders, Thuba Mathole

South Africa is committed to achieving Millennium Development Goals 4 and 5 to reduce maternal, newborn and child mortality. The national MNCWH&N strategy 2012-2016 and the Campaign on Accelerated Reduction of Maternal, newborn and child Mortality in Africa (CARMMA) outline key strategies and targets for the country – and there have been substantial advances in addressing maternal and child health outcomes over the last few years.

To assess the mid-term implementation of the MNCWH&N strategy 2012-2016, the National Department of Health commissioned a review to assess progress made against specific targets, identify challenges, lessons and best practices for potential replicability and scale-up as well as identify approaches to support delivery of integrated quality care to improve MNCWH&N outcomes. An additional function was to assess whether the monitoring and evaluation (M&E) framework had been implemented and to identify additional M&E requirements to maximise learning during on-going implementation. The review also assessed the stewardship of the plan and key institutional supporting structures at sub-national levels, including promotive approaches to address the broader determinants of health.

Funded by UNICEF, the project utilised technical expertise and financial resources from multiple development partners, locally and globally. 

Source country perspectives on the migration of highly trained health personnel: Causes, consequences and responses

Thuba Mathole, David Sanders

This study, funded by the Canadian Institutes of Health Research, aimed to better understand the causes, consequences and responses of four countries regarding the migration of highly skilled health personnel to Canada and other countries. The purpose was to provide new evidence regarding the implications of this migration for the Philippines, India, Jamaica and South Africa. The SOPH worked on the South African study with the University of Limpopo and Ottawa University, Canada.

While the South African government has tried to respond to human resources for health (HRH) challenges through a number of initiatives, initial findings of this study indicate that the South African experience clearly demonstrates the complexity involved in addressing these issues. Increased pay for health professionals by itself is not sufficient. The problem requires interventions in management and more broadly in working conditions - and even apparently positive steps can have unintended negative consequences. Perhaps most critically, the policy terrain is contested.

To implement actions intended to address HRH problems there is a needto engage a wide range of stakeholders with a range of perspectives and interests. Political sensitivity and strategic skills are essential in fashioning appropriate policies.

Building capacity for health in South Africa and the African continent through multi-disciplinary research, teaching and networking

Helen Schneider, Wim van Damme

As part of our broader collaboration with the Institute of Tropical Medicine (ITM), the SOPH is a beneficiary of the Belgian government funding under the Third Framework Agreement between Belgian Development Co-operation and ITM. The programme runs for a three-year period (2014-16), with the objective of increasing the capacity of SOPH to provide, and support others in providing, postgraduate public health training.

The funding specifically supports the development of open-access distance learning materials (such as the new on-line Pharmaceutical Public Health courses), enabling the sharing of experiences in flexible, distance and on-line modes of delivery for postgraduate programmes in our partner institutions across the continent, including exchanges around e-learning with ITM’s other major partner in South Africa, the Faculty of Veterinary Sciences at University of Pretoria. It also provides PhD scholarship funding for non-South African students wishing to study at UWC, and supports regular exchanges between SOPH and ITM.

Policy review and development of a framework for home and community-based (HCBC) services

Helen Schneider, Nikki Schaay

In 2012/3 the SOPH led a collaborative project with the universities of Cape Town and Stellenbosch to review home- and community-based services in the province. This was commissioned by the Western Cape Provincial Health Department and followed a prior review of intermediate care services in the province a year earlier.

During a period of eight months a team of nine researchers, in close collaboration with their provincial counterparts, completed an in-depth review of home- and community based services. Drawing on the newly-developed provincial strategic framework, Healthcare2030, and the national Primary Health Care Re-engineering proposals, the review mapped the arrangements regarding the roles and service delivery, human resource, financing and governance of an extensive NGO-contracted service delivery infrastructure, based on community health workers – and analysed the challenges of re-orienting this towards new goals.

The findings were compiled in a comprehensive report and have contributed to a new phase of thinking and policy development around community-based services in the Western Cape.

District Innovation, Action and Learning for Health Systems (DIALHS)

Uta Lehmann and Lucy Gilson, Vera Scott, Nikki Schaay

The DIAHLS project is an action research and learning collaboration between the City of Cape Town, the Western Cape Provincial Department of Health, and the schools of public health at the universities of the Western Cape and Cape Town. It aims to strengthen district health systems in South Africa by understanding the key restrainers and enablers at local (sub-district, programme and facility) levels.

DIAHLS’ specific objectives are to:

  • develop and test strategies for strengthening the district system through improved implementation of existing policies and programmatic innovation;

  • identify both key restrainers and enablers of district health system development, and appropriate actions to overcome or enhance these, respectively;

  • guide the development and distil practical examples of the leadership and management strategies needed across levels to support effective policy implementation and strengthen the district health system;

  • provide support for postgraduate public health and health management training programmes that draw on such experience.

The specific areas of focus within activities are evolving over time. In the past two years a particular focus has been on supporting and strengthening relationships between sub-district management teams, primary care facility managers, environmental health practitioners and community members. Project activities are not only jointly conceptualised with local health officials, but also jointly written up and presented at conferences.

DIAHLS is funded by The Atlantic Philanthropies.

Increasing access to TB case finding and treatment in Sisonke district, South Africa

Christina Zarowsky, Thuba Mathole, Jeannine Uwimana, Harry Hausler

The aim of this WHO-funded project was to increase access to early TB diagnosis and treatment in Sisonke, a poor rural district in South Africa. The objectives were:

  • to increase TB case finding and treatment through mobile HIV counselling and testing linked with TB symptom screening;

  • to diagnose TB with the Gene Xpert in health facilities;

  • to intensify TB contact tracing and household TB screening at community level; and

  • to evaluate through operational research

  • the feasibility of a facility-community continuous quality improvement (CQI) approach with an initial focus on improving HIV/TB services for pregnant women; and

  • the feasibility and acceptability of a cellphonebased (m-Health) system to enhance TB/HIV case finding, treatment adherence and linkage to care.

The SOPH undertook the operational research. In the CQI component, cohort tracking tools were developed and implemented in seven facilities organised into a Learning Network – which then worked together to achieve clear aims for each step in PMTCT. Improving TB care was integrated with improving the complete antenatal PMTCT process. CQI teams were formed in all participating facilities, where they were mentored and met regularly to review the data, to identify gaps and work together to close them. The mHealth component developed and piloted mobile phone applications to enable community care workers to capture and upload household data and to enhance their supervision.

Symposium showcasing a collaborative initiative on health workforce development

Uta Lehmann, Woldekidan Amde

A two-day mini-symposium was held in March 2013 to showcase contributions of the WHO-funded collaboration on health workforce development which exists between the SOPH, the Department of Community Health, University of Eduardo Mondlane, Mozambique; School of Public Health, Addis Ababa University, Ethiopia; and School of Public Health, University of Rwanda. At the symposium, attended by 26 participants drawn from the partner institutions/countries, and the WHO,

  • leadership and delegates from collaborating institutions engaged in systematic reflections on the progress and challenges of embedding UWC’s MPH programme/courses focusing on Health Workforce Development, in their respective contexts; graduates from the programme shared their research findings, networked with academic staff and other graduates of the School; and

  • students reflected on their experiences, including key factors which facilitated and impeded their study, learning and progress.

The symposium also provided the opportunity to plan the way ahead regarding consolidating the programme locally, and advancing the development of a joint teaching platform among the institutions, as well as the wider sharing of developed materials.

Strengthening human capacity development to address HIV/AIDS in South Africa

Christina Zarowsky, David Sanders, Debra Jackson, Uta Lehmann, Harry Hausler, Verona Mathews, Helen Schneider, Patricia Struthers

A major challenge in addressing HIV is how to strengthen the capacity of individuals, organisations and systems to integrate curative and preventive activities related to HIV and TB with existing health, education, and community services and programmes – whilst adapting to changing epidemiological, scientific, social and policy contexts.

This multi-facetted five-year programme – implemented through the School’s Centre for Research in HIV and AIDS (CRHA) – addressed this challenge by expanding the delivery of HIV and AIDS treatment and care, strengthening systems, and improving the quality of care in South Africa. It focused specifically on managers and practitioners working in health, education and in community-based structures. Referring to several sub-projects, the CRHA’s review panel noted that: ‘The work also had an impact far beyond the University.

Both provincial and national government departments adopted models developed [in these projects] as part of their policies: it is not an exaggeration to say that [this] work developed government policy.’

Funded by the CDC through PEPFAR – and ending in 2014 – this programme comprised ten discrete sub-projects (listed below). In addition, the programme also had a ‘Core, synergies and sustainability’ component, which promoted and funded activities to enhance synergies and exchange across UWC projects; and strengthened capacity for research and teaching related to the project’s themes. This value-adding component, led by the CRHA’s director, was realised through symposia, writing retreats, seminars, networking, conference presentations and the development and dissemination of publications and products. 

Half of the sub-projects did not directly involve staff from the SOPH – being

  • Training health care providers and traditional health care practitioners on collaboration for HIV & AIDS prevention and care

  • HIV & AIDS prevention through sports participation

  • Training nurse -midwives in community-based PMTCT & HIV/AIDS prevention and management skills and competencies

  • Provide management and leadership training for new HIV programme managers and HR managers at the provincial and district levels

  • Molecular surveillance by accurate detection of HIV-1 drug resistance mutations in patients on antiviral treatment in Southern Africa: An informatics approach.

The remaining five involved SOPH staff and extraordinary professors, as follows:

  • Addressing TB and HIV through the development of health promoting schools

Patricia Struthers

Health promoting schools (HPS) have been developed internationally and championed by various bodies, including the WHO. Growing a school environment that provides a healthy setting for learning and working is an intensive process, including the capacity development of individuals and the organisation. Creating a healthy setting in

South African schools includes the development of school TB and HIV policies, skills development, addressing challenges in the school physical and psycho-social environment, developing the schoolcommunity network, and facilitating links to appropriate support services.

This project worked with school management, staff, learners and parents, as well as the district education and health departments – to promote collaboration between sectors; to provide training and consultation to stakeholders working with schools; and to promote policy engagement.

Implemented in three Western Cape secondary schools, this was the first application of HPS approaches to the secondary school setting in South Africa.

  • A web-based HIV/TB educational programme for South African school learners

Patricia Struthers

This project aimed to develop the capacity of teachers and learners with a view to preventing the spread of HIV/AIDS and TB. Through interactive materials which foregrounded perspectives and voices of teachers and learners in poorly-resourced local schools, it aimed to engage and educate teenagers about TB in particular, within the context of HIV, supporting them in making decisions about their lives that will mitigate some of the risks of infection.

The prject was implemented in several Western Cape secondary schools, where the materials were developed in consultation with teachers and learners as well as through provincial and national consultations with experts, stakeholders and Departments of Education. While the initial distribution of the Resource Kit reached 4,000 learners and teachers in five schools in the Western Cape, many more grade 7 to grade 9 learners were reached through making this material available to teachers – through formally mainstreaming the material in the curricula for these grades. In addition, there is access through an interactive website (www.skills4life.org).

Building capacity to monitor and evaluate HIV care in KwaZulu-Natal

Harry Hausler

This project sought to improve the capturing and use of HIV- and TB-related data through supporting the secondment of three monitoring and evaluation (M&E) officers to the KwaZulu-Natal provincial Department of Health – with a view to improving the capacity of the health system.

The M&E officers were often involved in building the capacity of district-level information teams and HIV/AIDS/STI/TB (HAST) co-ordinators to monitor and evaluate integrated TB and HIV care, both at facility and community levels. This also included training community care givers, supervisors and community health facilitators involved in the home communit based care programme in M&E generally, and in the use of data collection tools in particular.

The project also supported the implementation of the electronic HIV care and antiretroviral treatment register (TIER.net) to replace paper-based registers, following a mandate from the National Department of Health.

  • Improving the quality of community health worker programmes for delivery of HIV/AIDS services

Helen Schneider, Busi Nkosi

Initially intended to develop and implement a training programme for community health workers (CHWs), this project responded to the rapidly changing policy environment and government priorities by shifting focus to enhancing capacities for policy dialogue and policy development. The implementing team created spaces for often difficult policy dialogue and provided technical and expert support to the provincial and national departmentsof Health and to civil society organisations. The focus was on integrating community-based activities with each other and with the formal health system, as well as on formalising and regulating the status of CHWs.

In addition, working closely with the National Department of Health, a monitoring and evaluation (M&E) strategy for ward-based outreach teams was designed and tested through an extensive consultative process – and piloted in the North West Province. One component of this was an mHealth system of M&E for outreach teams.

  • Human Resource Information System

Verona Matthews

This project was completed in 2012 – so is not reported here.

Transforming health and education policies and systems for improved HIV prevention and care

Christina Zarowsky

The aim of this long-term academic collaboration between UWC and Flemish universities through VLIR – the Flemish Inter-University Council – was to develop and strengthen capacity and engage in joint research collaboration and supervision of PhD students. This initiative was integrated into the wider Dynamics to Build a Better Society (DBBS) Programme at UWC.

In the SOPH, VLIR provided foundational five-year funding for the Centre for Research in HIV and AIDS (CRHA), which ended in 2014. The overall development objective was to transform health and education policies and systems with the aims of decreasing the burden of HIV/AIDS and TB; improving the impact of education on HIV/AIDS prevention; and developing proper responses for the prevention of, and response to, gender-based violence.

While the overall academic objective was to develop sustainable HIV-related research capacity, the specific academic objective was to build research capacity and strengthen partnerships in the areas of integrated HIV/AIDS prevention and care, with a specific focus on HIV/AIDS and TB, education and gender-based violence.

The VLIR project provided funding for three PhD scholarships and the Centre’s first post-doctoral fellows, core funding for five annual HIV-in-Context research symposia and assistance with funding additional activities in the Centre.

THE HARICCI COLLABORATION - HIV and AIDS Research in Complex Contexts of Inequality

The HARICCI Collaboration is an interconnected body of work which addresses HIV from a social determinants of health perspective, and which links community, policy and health systems interventions on the structural drivers and social impacts of HIV. Migration, inequality, violence (interpersonal, gender-based, political and structural) and resilience are the key entry points and cross-cutting themes.

HARICCI comprises an evolving set of research studies, symposia, fellowships, and participatory interventions that build on existing research and partnerships across and beyond UWC.

The following two research projects were undertaken in 2013 and 2014:

  • Irregular migration, human trafficking and HIV/AIDS in South Africa

Joshua Aransiola

A baseline situational analysis on irregular migration, human trafficking and HIV/AIDS in South Africa was conducted by post-doctoral fellow Joshua Aransiola.

Despite increasing efforts at local, national and international levels, human trafficking has proved particularly resilient to remedial action, with desperate and vulnerable individuals continuing to fall into bondage on every continent. While trafficked victims are vulnerable to HIV/AIDS due to their lack of power to negotiate sex, their illegal migrant status and fear of repatriation increases their vulnerability as they do not access medical care. As HIV-infected trafficked victims, they may also try to avoid being stigmatised, as either an illegal migrant or as HIV positive, or both.

Through a desk review, policy analysis and key informant interviews with policy makers and NGOs, this study explored how stakeholders perceive the problems of human trafficking and HIV in South Africa, and what research and interventions are needed.

  • Ethnographic exploration of migration, health and social support in the Cape Metropole

Christina Zarowsky, Sally Guttmacher

The link between migration and increased risk for HIV infection is well established. While this is particularly acute in South Africa, little is known about the distribution of HIV infection among foreign migrants here, making it hard to identify vulnerable groups within this population. 

This study sought to understand how cross-border migrants experience and manage risk, vulnerability and violence – and where they locate HIV amongst the complex set of challenges and priorities they face.

Funded by the CDC as part of a larger quantitative study undertaken by the Medical Research Council (‘Conducting regular HIV behavioural and biological surveillance among hard to reach high risk populations in the Western Cape’), it entailed conducting robust surveillance to measure key risk behaviours and HIV prevalence in hard to reach, high risk population of cross-border migrants in Cape Town, South Africa.

Using respondent driven sampling to gain access to social networks, the interviews explored how the experiences documented in the individual MRC-UCT questionnaires play out within the public social and livelihood contexts of migrant men and women, with a view to developing socially and culturally appropriate interventions.

The findings included starkly varying HIV prevalences amongst different groups of foreign nationals as well as a reluctance among some to engage with the issue, given other survivalist priorities. 

Community-based interventions to improve access to medicines for patients with Chronic Life-Long Conditions (CLLCs) in resource-constrained settings and hard to reach population groups: A scoping review protocol

Bvudzai Magadzire, Hazel Bradley, Brian van Wyk

The dual burden of HIV and non-communicable diseases in low- and middle-income countries gives rise to the emergence of a huge cohort of patients with chronic conditions who need to be managed with limited public health resources. Various service delivery models have been piloted to improve access to medicines. Such models have included community-based distribution of medicines i.e. distribution of medicines outside of health facilities.

Policy makers and researchers have expressed an interest in obtaining systematic evidence to inform policies and service delivery guidelines within the frameworks of pharmaceutical policy and practice.

This systematic scoping review will examine the breadth of evidence on this topic and provide a descriptive account based on studies identified. The primary review question is: What models of community-baseddistribution of medicines are available for CLLCs in low- and middle- income countries and for vulnerable communities in high-income countries? The themes which will guide the description include characteristics of the models; links with the supply chain and management of medicines; policy and regulatory issues; dimension(s) of access to medicines addressed; indicators by which these interventions have been measured; and the types of studies that have generated this evidence.

Family-based counselling and testing

Lucia Knight

This NIH-funded project builds on the successful delivery of an HIV home-based counselling and testing (HBCT) intervention in Vulindlela, South Africa, conducted in collaboration with researchers at the Human Sciences Research Council and the Africa Centre for Health and Population Studies, University of KwaZulu-Natal.

Drawing on lessons from the HBCT model, formative qualitative work and a review of the literature, this familybased counselling and testing project aims to design an intervention to encourage the uptake of HIV testing and counselling by the whole family (including children). It aims to do this through developing a model that facilitates and encourages inter-generational discussions about health and specifically sex and HIV as well as attempting to normalise disclosure at the family level.

AIDS scenario project

Charl Swart

The South African Research Chair Initiative (SARChI) and the SOPH, in collaboration with Stellenbosch University, initiated the HIV/AIDS scenario project in order to explore the future impact of epidemic in South Africa. The project aims to identify emerging challenges and assess implications for ensuring sustainable responses through the national health system by identifying key ‘leverage points’ for sustained responses. The purpose is to inform the considerations, decisions and actions of key stakeholders, including government, civil society and practitioners. In order to achieve this, the project is employing future studies methodology, which has previously been utilised by the United Nations and Metropolitan Holdings to study possible trajectories of the epidemic in Africa and South Africa respectively. 

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