Current Projects

PI: Dr. Marian Loveday

Aim
To document the treatment, pregnancy and outcomes of women treated for DR-TB during their pregnancy. 

Study methods

A descriptive cohort analysis

Status
Data collection ongoing

Collaboration

• Dr. Jennifer Hughes from the Desmond Tutu TB Centre (DTCC)
• Dr. James Seddon from Imperial College London and the Desmond Tutu TB Centre (DTCC)
• Clinicians at King Dinuzulu Hospital, eThekweni, KwaZulu-Natal.

Study outcomes

• Loveday M, Hughes J, Sunkari B, Master I, Hlangu S, Reddy T, Chotoo S, Green N, Seddon JA. Maternal and infant outcomes among pregnant women treated for multidrug/rifampicin-resistant tuberculosis in South Africa. 2020. https://doi.org/10.1093/cid/ciaa189.
• Presented pregnancy findings as WHO Guideline Development Group meeting. These findings have been included in the latest WHO guidelines on how pregnant women with RR-TB should be managed.

Nested study within the DR-TB during pregnancy study:

Title: To explore plasma concentrations of second-line TB drugs in pregnant women and their infants

PI: Dr. Gary Maartens (UCT)

PI MRC: Marian Loveday

Aim
To explore plasma concentrations of the second-line TB drugs in these women and their infants.

Study methods

All recruited participants who have not yet delivered will be screened for eligibility into the pharmacokinetic (PK) analysis to enhance the understanding of drug exposure in pregnant women on therapy for DR-TB. Two PK sampling occasions will be scheduled, the first will be prior to delivery preferably in the third trimester, on a date, which is convenient for the mother and the second at 6 weeks post-delivery to compare drug levels in the pregnant and non-pregnant state.

Status
Recruitment has started and is ongoing.

Collaboration

Prof Gary Maartens, Prof Helen Mclleron, Dr Richard Court: UCT

Second nested study within the DR-TB during pregnancy study:

PI: Dr Grant Theron (US)

PI MRC: Dr. Marian Loveday

Aim

To explore whether microbiomes of mothers (airways, breastmilk, vagina, gut) and babies (gut) are potentially affected by treatment, and if so, are any microbiome changes associated with infant outcomes and drug exposure?

Study methods

All recruited participants who have not yet delivered will be screened for eligibility into the microbiome study. Vaginal, gut, breastmilk and sputum samples will be collected from the mother in the 3^rd trimester and 6 weeks, 6 months and 12 months after delivery. Microbiome estimates in each specimen type will be correlated with PK data and clinical outcomes (in mothers and babies).

Status

Recruitment has started and is ongoing. .

MRC PI: Dr. Marian Loveday

PI: Prof Helen Cox (UCT)

Aim
To document survival and the recurrence of TB after successful drug-susceptible- and rifampicin-resistant TB treatment

Study methods

A mixed methods cohort study design: We will identify a similar number of patients with TB in Umzinyathi and Khayelitsha, matching for age and gender with MDR-TB patients in the same area.  Patients co-infected with HIV and with co-morbid conditions (eg. Diabetes) will be included.

Status
Data collection for Umzinyathi is complete. The qualitative data component has been analysed and submitted for publication. We have been unable to extract quantitative data for Khayelitsha from the PDSA.

Collaboration
Mr Johnny Daniels and Dr. Erika Mohr from Medicins san Frontier (Khayelitsha, South Africa)
Dr. Helen Cox and Dr. Andrew Boulle from UCT

PI: Dr. Marian Loveday

Aims
The aims of the implementation component are:

• To develop and implement a targeted screening approach for diabetes, hypertension, and other diseases and conditions utilizing existing community-based and facility-based health service infrastructure in eThekwini, using an improved diagnostic algorithm aligned with national guidelines. This builds on existing screening efforts against other diseases such as tuberculosis.
• To develop an algorithm alongside our partners that is based on peer-reviewed evidence and in line national guidelines. Subsequently, implement it for treatment, support, and education for these patients and their families. Work with public health and where appropriate private health delivery partners to implement and improve this program in subsequent years in a large, targeted area of the municipality.
• To support the National health services integration initiative by sharing practical operational research in a timely manner, avoiding duplication or parallel, “vertical” disease efforts (HIV, TB, hypertension, diabetes, etc.), improving existing and new health worker capacity in public and private sectors, and implementing a clear sustainability plan at the end of the grant period

The aims of the evaluation component:

1. Document the opportunities and models for improved integration and health service delivery implemented by AA&D and local partners at PHC facilities, schools and in the community.
2. Through the lens of a non-communicable disease (NCD) diabetes and an infectious disease TB document the functioning of the different levels of the health system, the interface and relationship between these layers and the inputs needed to optimize health system functionality across all levels.
3. Document the strategies and interventions required to improve integration and for effective patient-centered services including active case finding, linkage to care, effective education and quality management of both non-communicable and infectious diseases.
4. Monitor the integration of both non-communicable and infectious disease services at a community level, together with the linkages to PHC facility level care. 
5. Using the platform created for the Zero TB Cities Initiative, pilot a program of decentralized, community-based screening and referral for diabetes, hypertension and other conditions (as the basis for using this approach for integrated PHC delivery).
6. Monitor the impact of the introduction of new, complex interventions at a district level and how these impact on and are integrated into existing services. This may include the provision of MDR-TB services, Test and Treat and adolescent HIV prevention.

Study methods

Implementation research

Status
Ongoing

Collaboration
Advance Access & Delivery (AA&D)

eThekweni Metro Health Services

Provincial TB and NCD directorates

PI: Marian Loveday

Aim

To describe the treatment journeys of PLHIV with sub-optimal retention in care to gain a better understanding of the complexities around HIV disease, its management and the contribution of health system failures to sub-optimal retention in care. (We have defined poor retention in care as a PLHIV who has not taken ART for 30 days in the last two months.)

The specific objectives of the study are:

1. to describe the treatment journey of PLHIV with sub-optimal poor retention in care;
2. to explore the social, structural, economic and cultural factors that influence retention in care;
3. to identify health systems factors which are facilitators or barriers to retention in care. 

Methods

Setting: RK Khan hospital and Don Mackenzie ART clinic for adolescents which are both in eThekwini district in KwaZulu-Natal.

Study design: A mixed methods study design will be used. This will include interviews, participant-generated visual methodologies (PVM) and a review of medical records.

Data collection: Data will be collected using semi-structured interviews in PLHIV ≥ 25 years of age and  PVM in those 16 - 24 years old.

Study outcomes

By describing the treatment journeys of PLHIV with sub-optimal retention in care we will get a better understanding of the complexities around HIV disease, its management and the contribution of health system failures to sub-optimal retention in care. 

Status

The adult component of the study has ethics approval and data collection has commenced. The adolescent component has not commenced as the ethics committee has not approved a waiver of parental consent.

Collaboration

Dr. Jennifer Furin (Department of Global Health and Social Medicine, Harvard Medical School)

Dr Zaynab Essach (Human and Social Development Programme at the Human Sciences Research Council)

PI: Drs Taryn Everton-Barnes and Kerry Holloway (King Dinuzulu Hospital)

SAMRC PI: Marian Loveday

Aim

To conduct a retrospective review of all RR-TB patients screened for Covid-19 at the RR-TB clinic to determine those who were tested for COVID -19 to describe the Covid-19 cascade of care reporting. In the patients with RR-TB from KDH and other RR-TB treatment sites across the province who tested positive for Covid-19, a retrospective record review will be conducted to describe clinical management and outcomes.

Methods

Setting: All RR-TB outpatients at King Dinuzulu Hospital (KDH) and at the RR-TB treatment sites across the province are seen monthly at the RR-TB clinic where they are clinically assessed, their response to treatment monitored and issued with repeat medication. From April 2020, all patients who entered the RR-TB clinics across the province were symptom screened for Covid-19 and if they screened positive, tested for the SARS-2-pathogen.

Study design Case series

Data collection

To determine the proportion of RR-TB patients who screened positive for Covid-19 and who tested positive we will retrospectively review the screening log implemented at the start of the pandemic and completed each day between 1 April 2020 – 30 November 2020. All patients who attended the RR-TB clinic and who were screened will be included. There will be no sampling.

Status

Ethics approval has been granted, but we are awaiting facility level approval

Collaborators

Drs Taryn Everton-Barnes, Kerry Holloway and other clinicians in the MDR-TB utnit in King Dinuzulu Hospital

PI: Nobubelo Ngandu, Ameena Goga

Overview
Several clinical trials are currently underway in search for neutralizing antibody candidates that can effectively prevent HIV infection including prevention of vertical HIV transmission. It is important to understand which neutralizing antibody combinations would be ideal for use in preventing HIV transmission during breastfeeding in the South African context.

Aims
This is study aims to assess the feasibility of using broadly neutralizing antibodies as prophylaxis to protect infants from postnatal HIV infection through breastfeeding, in a South African population dominated by HIV-1 subtype C which has a broad intra-subtype genetic diversity spectrum.

Methods
A facility-based proof-of-concept cross-sectional study is being conducted at Kalafong Provincial Tertiary Hospital. A pilot sample of 12-24 mothers with a current plasma viral load >400 copies/mL will be targeted. Sensitivity to second generation neutralizing antibodies will be assessed in-vitro on viruses isolated from the mother’s breastmilk and compared to viruses isolated from autologous blood plasma. One to three antibodies with good potency and breadth will be identified and used to plan a Phase IIb clinical trial in similar settings.

Collaboration

• South African Breastmilk Reserve
• National Institute for Communicable diseases (NICD)/ National Health Laboratory Services (NHLS)
• University of Pretoria
• Ospedale San Rafaelie
• University of Montpellier

Project status: Data collection

Contact
Dr. Nobubelo Ngandu (Nobubelo.Ngandu@mrc.ac.za), Prof. Ameena Goga (Ameena.Goga@mrc.ac.za

PI: Nobubelo Ngandu, Ameena Goga

Overview
The sub-regional variation in maternal HIV exposure and vertical transmission rates are the current stumbling blocks against progress towards meeting the targets for eliminating mother-to-child transmission of HIV (MTCT) at national level in South Africa. High impact and context-specific district-level interventions in districts with vertical HIV transmission higher than the national average are needed. Ehlanzeni district in Mpumalanga province is one of such high-risk regions. However, routine data is either incomplete or of poor quality making it difficult to accurately identify gaps and opportunities for improving HIV care to mother-infant pairs.

Aims
In order to design an effective intervention(s) to assist Ehlanzeni district lower its MTCT rate, we will measure the distribution and correlates of: Maternal viral load, Maternal HIV incidence, Infant prophylaxis uptake and Infant feeding practices. We will also explore the feasibility and acceptability of use of pre-exposure prophylaxis for mothers and use of neutralizing antibody-based immunotherapy for infants.

Methods
A quantitative cross-sectional study conducted at district level. The inclusion criterion is HIV-positive pregnant women and HIV-positive postnatal women with infants aged 0-24 months. Data collection will involve(i) face-to-face interviews (ii) review of patient clinic records (iii) collection of whole blood samples to measure HIV viral load (iv) collection of DBS samples from HIV-exposed uninfected infants for HIV diagnoses.

Collaboration

• National department of Health
• Ehlanzeni district PMTCT management
• Right to Care (district partner)
• Academy for Quality Healthcare (AQUAH) (district partner)
• National Institute for Communicable diseases (NICD)/ National Health Laboratory Services (NHLS)
• Montpellier University France
• University of Bergen Norway
• Queen Mary University of London UK
• Zvitambo Institute for MCH Research Zimbabwe
• Unviersity of Liverpool UK

Project status:  Data analyses and manuscript writing currently underway.

A sub-study was commenced in September 2020 to evaluate the effect of COVID-19 pandemic and lockdown on uptake of PMTCT services and viral load suppression amongst mothers and infants who participated in this study. Data collection and extraction was complete and data cleaning is currently in progress.

Contact
Dr. Nobubelo Ngandu (Nobubelo.Ngandu@mrc.ac.za),  ; Prof. Ameena Goga (Ameena.Goga@mrc.ac.za)

PI: Prof. Ameena Goga, Dr Terusha Chetty and Prof. Helen Schneider

Overview

The National Department of Health (NDoH) is implementing an integrated sexual, reproductive, maternal and newborn health (SRMNH) initiative to improve sexual, reproductive, maternal and neonatal health outcomes in South Africa.  This initiative called “Mphatlalatsane” (meaning “the last star before the dawn”) seeks to reduce unplanned pregnancies, maternal and neonatal mortality, and stillbirths, by testing a potentially replicable quality improvement (QI) model for national scale-up through government adoption and funding. The Mphatlalatsane Initiative embraces QI interventions to make small facility-based changes that the system can absorb and sustain if they work.  The SAMRC, in partnership with the SAMRC Health Services to Systems Research Unit, School of Public Health, University of the Western Cape, is responsible for evaluating the impact and implementation processes of the Mphatlalatsane Initiative in the QI-intensive sites. The evaluation will only focus on the maternal and newborn components.

On 30 January 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern (PHEIC).  As of 22 July 2020, more than 15 million confirmed cases across 118 countries and over 617 000 deaths have been reported; South Africa reported over 382 000 confirmed COVID-19 cases with 5 173 death.

In March 2020, the South African government declared a state of disaster and implemented several measures to prevent the spread of the disease, restricting face-to-face interactions and allowing only essential activities.  The effect that COVID-19 has had/will have on the uptake, continuity and quality of maternal and neonatal healthcare services is still uncertain; much depends on whether South Africa’s efforts to prevent further spread of the virus are effective. Generating research evidence on the impact of COVID-19 on SRMNH services is of utmost importance as it will inform policies and practises on how to mitigate some of that impact. The evaluation of Mphatlalatsane offers an ideal opportunity to add specific COVID-19 research questions.

Aims
The overall evaluation aim is to determine whether a system-level, complex, patient-centred QI intervention reduces institutional maternal mortality ratio, stillbirth rate and neonatal mortality rate by 50% in five years.

The study objectives are as follows:

• To assess the effect of the COVID-19 pandemic on the service utilization and quality of routine non-COVID-19-related SRMNH services in the public sector;
• To assess the effect of the COVID-19 pandemic on the Mphatlalatsane Initiative intervention delivery;
• To assess the contextual and implementation process factors that shape the effectiveness of the Mphatlalatsane Initiative, which will include a specific focus on how COVID-19 affects the delivery of SRMNH services, and health workers’ and managers’, who respectively deliver and manage these services, experiences and perceptions of COVID-19.

Collaboration
The NDoH, in collaboration with the South African Medical Research Council, Clinton Health Access Initiative (CHAI), the SAMRC-University of Pretoria Maternal and Infant Health Strategies Unit (SAMRC-UP), the University of Limpopo Trust-Limpopo Initiative for New-born Care, and the University of Western Cape.

Project status
The study is funded by ELMA Philanthropies. We received ethical approval from the University of the Western Cape to commence with assessing contextual and implementation processes and has produced a report on the first round of interviews we conducted with the collaboration partners. A revised proposal (necessitated by COVID-19 restrictions) has received ethical approval from the South African Medical Research Council and the data collection is currently ongoing.

Contact person
Dr Terusha Chetty (terusha.chetty@mrc.ac.za)

PI: Prof Prakash Jeena

PI MRC: Prof. Ameena Goga, Dr Terusha Chetty

PI UP: Prof Jeane Cloete, Dr Maria Karsas

PI University of Witswatersrand: Prof David Moore

PI UKZN: Prof Moherndran Archary, Dr Ashendri Pillay

Overview
In South Africa, antimicrobial usage and the prevalence of paediatric community-acquired infections (CAI) and healthcare-associated infections (HAI) are mostly unknown. More robust evidence is required, given the current context of the COVID-19 pandemic.  A cross-sectional point prevalence survey will be conducted in 2021 over two consecutive months at three tertiary/quaternary health care hospitals in South Africa, namely, Chris Hani Baragwanath Academic Hospital (CHBAH), Inkosi Albert Luthuli Central Hospital (IALCH) and Steve Biko Academic Hospital (SBAH).

Objective

To evaluate the antimicrobial usage and prevalence of neonatal and paediatric CAI and HAI at three regional/tertiary centres in South Africa.

Collaboration
The study is a collaborative effort between the South African Medical Research Council, Steve Biko Academic Hospital, University of Pretoria, and Chris Hani Baragwanath Hospital, University of Witwatersrand.

Project status

The proposal has received ethical approval and will be starting data collection in July 2021

Contact person
Dr. Terusha Chetty (Terusha.Chetty@mrc.ac.za)

PIs: Dr Vundli Ramokolo and Dr Wanga Zembe-Mkabile

Aim

To measure the impact of the COVID-19 pandemic on child morbidity including nutritional status, household food security, and dietary diversity, and access to health services

Methods

Cross-sectional follow-up of participants enrolled in a pregnancy cohort study. Consenting mothers/caregivers will be interviewed on the child’s dietary intake and morbid outcomes, grant access and utilization and other factors. Child anthropometry will be measured and data from the previous cohort study will be used as a baseline.

Project status

Data collection preparations underway.

Contact person: Dr Vundli Ramokolo (vundli.ramokolo@mrc.ac.za)

Aim

To assess the nutritional status and dietary patterns of recipients and non-recipients of the CSG in Langa Township, Western Cape

Methods

Community-based prospective pregnancy cohort study conducted in Langa township between. Mother-child pairs were recruited during pregnancy and followed until 2 years postpartum. Data on access to the CSG, child feeding practices and anthropometry were collected. 

Status

Data collected between March 2016 and March 2020. Data analysis and manuscript writing underway.

PIs

Dr Wanga Zembe-Mkabile and Dr Vundli Ramokolo

Contact: Dr Wanga Zembe-Mkabile (wanga.zembe@mrc.ac.za), Dr Vundli Ramokolo (vundli.ramokolo@mrc.ac.za)

PI: Prof. Ameena Goga

Co-PI: Vuyolwethu Magasana, Trisha Ramraj, Witness Chirinda, Duduzile Nsibande, Terusha Chetty, Vundli Ramokolo

Overview
The project aims to explore how HIV incidence amongst pregnant and lactating women can be reduced. Specifically, we aimed to test the feasibility and effectiveness of Pre-exposure prophylaxis (PrEP) and reasons for withdrawal amongst HIV negative pregnant women enrolled in a PrEP study in KZN. Additionally, we sought to develop a risk score to identify young pregnant or lactating women at highest risk of HIV acquisition. Our deliverables include reports, peer reviewed publications, policy briefs, data that could guide policy makers on whether to invest in additional work to test the role of PrEP in HIV negative pregnant women.

Objectives and Status

1. To explore the acceptability and feasibility of PrEP, and reasons for study withdrawal amongst HIV negative pregnant or lactating women enrolled in CAP016: Immediate or Deferred Pre-exposure Prophylaxis for HIV Prevention: Safe Options for Pregnant and Lactating Women: An Open-Label Randomised Control Study, a study currently funded by the SAMRC and led by Prof Dhayendre Moodley, University of KwaZulu-Natal. Collaboration: Prof Dhayendre Moodley, University of KwaZulu-Natal. Lead: Vuyolwethu Magasana
2. To conduct a desk review on the legislative and regulatory framework around PrEP in pregnant and lactating women
3. To develop a simple risk measurement tool to identify which young pregnant or lactating women are at risk of HIV infection. This paper has been completed and submitted for publication. Lead author: Trisha Ramraj
4. To write a proposal to test an intervention aimed at reducing HIV incidence in young pregnant and lactating women. Lead: Terusha Chetty and Vundli Ramokolo: Funder: UNICEF

Contact person
Prof. Ameena Goga (ameena.goga@mrc.ac.za), Vuyolwethu.Magasana@mrc.ac.za, Duduzile.Nsibande@mrc.ac.za, Trisha.Ramraj@mrc.ac.za, Terusha.Chetty@mrc.ac.za; Vundli.Ramokolo@mrc.ac.za

PI: Prof. Ameena Goga

Overview
In 2015 South Africa adopted PMTCT Option B+ which recommends lifelong antiretroviral therapy for all pregnant and lactating women regardless of CD4 cell count.

Aim
To document the processes and models used for PMTCT Option B+ implementation, to measure the effects of PMTCT Option B+ on health services for mothers and children and to evaluate early effectiveness of PMTCT Option B+ in the initial 1-2 years post-implementation.

Collaboration
National Department of Health, Centers for Disease Control and Prevention, UNICEF, National Institute for Communicable Diseases

Project status
The project has been completed.  The detailed survey report  is available here.  Research papers for peer reviewed publication are currently being written.

Contact person
Prof. Ameena Goga (ameena.goga@mrc.ac.za)

PI: Prof. Ameena Goga and Dr. Witness Chirinda

Overview
There are few studies assessing the long-term outcomes, at approximately 3-4 years of age of HIV exposed and HIV unexposed children. These data are critical for monitoring the impact of the national PMTCT programme and the fourth millennium development goal.

Aim
To assess the survival of mothers and their HIV exposed uninfected (HEU) or HIV unexposed infants, previously enrolled in the 2012-14 South African PMTCT Evaluation (SAPMTCTE), at 2-3 years postpartum

Collaboration
UNICEF, National Department of Health

Project status
Data collection completed, analysis and write up in progress.

Contact person
Dr. Witness Chirinda (witness.chirinda@mrc.ac.za)

Protocol chair: SAMRC: Prof. Ameena Goga

Protocol co-chairs: University of the Witwatersrand - Dr David Moore; University of Pretoria - Prof Jeané Cloete and Prof Ute Feucht; Sefako Makgatho Health Sciences University: Prof Dini Mawela; University of Cape Town- Prof Liesl Zühlke; University of Stellenbosch - Prof Helena Rabi; University of KwaZulu-Natal - Dr Moherdran Archery; University of the Free State - Dr Nomakhuwa Tabane; Limpopo - Dr Ntsako Gabaza Tiva

Overview

Given the risk of respiratory infections, and high exposure to HIV, TB and malnutrition in South Africa, the course that COVID-19 disease will take in hospitalised South African children is not known. This study aims to describe the epidemiology, clinical characteristics and outcome of hospitalised children with COVID-19 at academic and non-academic hospitals in South Africa. Data from hospitalised children with COVID-19 will be extracted from medical notes and laboratory records and entered into a surveillance database that is an expansion of the national DATCOV surveillance platform – this is a data platform developed by the National Institute for Communicable Diseases (NICD) in response to COVID-19. This expanded database will form the national paediatric COVID-19 Registry.

Primary Objective

To describe the epidemiology and clinical characteristics and outcome of paediatric SARS-CoV-2 infection amongst children hospitalised at academic and non-academic hospitals.

Secondary Objectives

1. To describe immunological responses in a subset of children with COVID-19 (confirmed on PCR or by clinical suspicion and including cases of multi-system inflammatory syndrome in children (MIS-C) admitted to academic or non-academic hospitals.
2. To gather data on co-morbidities amongst SARS-CoV-2 positive hospitalised children and cases of multi-system inflammatory syndrome in children (MIS-C)  
3. To document COVID-19-related complications amongst SARS-CoV-2 positive hospitalised children and children with MIS-C at academic hospitals in the South African context, including cardiac, autoinflammatory/autoimmune, rheumatological, dermatological etc.
4. To determine the proportion of SARS-CoV-2 positive hospitalised children who present with respiratory symptoms.
5. To determine the proportion of SARS-CoV-2 positive hospitalised children who need admission to an intensive care unit.
6. To determine the proportion of SARS-CoV-2 positive hospitalised children who are HIV positive

Collaboration: The study is a collaborative effort between the South African Medical Research Council,  University of the Witwatersrand, Chris Hani Baragwanath Hospital, Nelson Mandela Children’s Hospital, Charlotte Maxeke Hospital, Rahima Moosa Hospital, University of  Pretoria, Steve Biko Academic Hospital, Sefako Makgatho Health Sciences University George Mukhari Academic Hospital, University of Cape Town, Red Cross Children’s Hospital, University  of Stellenbosch, Tygerberg Hospital, University of KwaZulu-Natal, Inkosi  Albert Luthuli Hospital,  King Edward Hospital, University of Free State, Universitas, Pelanomi, Bongani Regional Hospital, Dihlabeng Regional Hospital, Boitumelo Regional Hospital, University of Limpopo, Mankweng Hospital and Polokwane hospital, National Institutes of Communicable Diseases, Perinatal HIV Research Unit, Wits Reproductive Health and HIV Institute

Project status

Data collection in progress

Contact person: Prof. Ameena Goga (ameena.goga@mrc.ac.za)

Protocol chair: SAMRC: Prof. Ameena Goga

Protocol co-chairs: University of the Witwatersrand: Prof David Moore, Dr Firdose Nakwa, Dr Shannon Cawood, Prof Debbie White, Dr Gary Reubenson; University of Pretoria: Prof Jeané Cloete, Prof Ute Feucht; Sefako Makgatho Health Sciences University: Prof Dini Mawela; University of Cape Town: Prof Kate Webb, Prof Chris Scott, Prof Heather Zar, Prof Liesl Zühlke; University of KwaZulu Natal: Dr Kogie Chinniah, Dr Moherndren Archary; University of the Free State: Dr Michael Pienaar and Dr Nomakhuwa Tabane

Overview

In children, severe acute respiratory syndrome corona virus type 2 (SARS-CoV2) related disease includes both acute COVID-19 disease and post-acute Multisystem Inflammatory Syndrome in Children (MISC). There is very little information about acute COVID-19 disease and MISC in children presenting to hospital in low and middle-income countries. The aim of this study is to understand the clinical characteristics of SARS-CoV2 related disease in neonates, children and adolescents aged 0-19 years presenting to hospital in LMICs. The study will be set in a network of 20 children’s and maternity hospitals in four countries in Africa and Asia (Ethiopia, India, Pakistan, South Africa). SAMRC is the coordinating centre in South Africa with network hospitals existing within regional clusters. Network hospitals will be supported to improve their diagnostics, therapies, data collection systems, and clinical guidelines for best practice management and therapy. Testing processes will follow the local hospital standard operating procedures for each site. There are three components to the study: (i) prospective surveillance; (ii) prospective case control study; and (iii) retrospective data extraction.

Our objectives are to use hospital network surveillance systems to:

• Describe clinical presentations, comorbidities, diagnostic and laboratory features, currently available therapies, and long-term outcomes
• Understand the association between severity of SARS-CoV2 related disease and comorbidities in LMIC children

Collaboration

The study is a collaborative effort between the South African Medical Research Council,  University of the Witwatersrand, Chris Hani Baragwanath Hospital, Nelson Mandela Children’s Hospital, Charlotte Maxeke Hospital, Rahima Moosa Hospital, University of  Pretoria, Steve Biko Academic Hospital, Sefako Makgatho Health Sciences University, George Mukhari Academic Hospital, University of Cape Town, Red Cross Children’s Hospital, University of KwaZulu-Natal, Inkosi  Albert Luthuli Hospital,  King Edward Hospital, Mahatma Gandhi Memorial Hospital, Greys Hospital, University of Free State, Universitas, Pelanomi Hospital

Project status

Data collection in progress

Contact person: Prof. Ameena Goga (ameena.goga@mrc.ac.za)

PI: Prof. Ameena Goga, Prof Tanya Doherty and Dr Christiane Horwood

Overview
In 2017 HIV and infant feeding guidance was updated in South Africa, in response to the 2016 WHO update..

Aim
We sought to determine whether a participatory mentorship approach to guidelines dissemination increases knowledge, attitude and skills of health workers.

Collaboration
UKZN, WHO, University of Bergen

Project status

This study has been completed and papers have been published.

Publications:

1. Goga A, Doherty T, Manda S, et al. Translating new evidence into clinical practice: a quasi-experimental controlled before–after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa. BMJ Open 2020;10:e034770. doi:10.1136/bmjopen-2019-034770
2. Horwood C, Haskins L,Goga A,Doherty T, John V, Engebretsen IMS, Feucht U, Rollins N, Kroon M,Sanders D, Tylleskar T. An educational intervention to update health workers about HIV and infant feeding. Maternal & Child Nutrition. https://doi.org/10.1111/mcn.12922
3. Doherty T, Horwood C, Magasana V, Goga A, Feucht U, Sanders D, Tylleskar T, Kauchali S, Rollins N, Kroon M, Engebretsen IMS.  Breastfeeding advice for reality: women’s perspectives on infant feeding support received in primary health care settings in South Africa. Accepted by Maternal and Child Nutrition: https://doi.org/10.1111/mcn.12877

Contact person
Prof. Ameena Goga (ameena.goga@mrc.ac.za),  Prof Tanya Doherty (Tanya.Doherty@mrc.ac.za)

PI: Prof. Ameena Goga

SAMRC co-investigator: Duduzile Nsibande

Overview
This study aimed to answer the following questions: Can routine PMTCT data be used for antenatal HIV surveillance in the South African context?  What value will such an approach add? Could such an approach replace the SAANCHSS?

Aim
The overall objective of the study was to assess the utility of PMTCT program (DHIS) data for HSS among pregnant women.

Collaboration
The study was a collaborative effort between the Medical Research Council, National Department of Health, CDC and NICD/NHLS, Epicentre and UNAIDS.

Project status
The project has been completed. The detailed survey report can be found here and policy brief here. Research papers for peer reviewed publication are currently under review.

Contact person
Prof. Ameena Goga (ameena.goga@mrc.ac.za)

PI: MRC: Prof. Ameena Goga co-PIs UWC: Prof Debra Jackson CDC: Dr Thu-Ha Dinh

Co-investigators: South African Medical Research Council:  Prof Carl Lombard, Dr Selamawit Woldesenbet, Ms Vundli Ramokolo  National Department of Health:  Dr Yogan Pillay, NICD/NHLS Prof Gayle Sherman, Prof Adrian Puren.

Overview
Within seven years of implementing the national PMTCT program, South Africa had successfully scaled up its PMTCT services. Interventions to prevent mother-to-child transmission of HIV were offered in more than 95% of antenatal clinics and maternity institutions country-wide. In 2008, 2010 and 2013 the South African National Department of Health (NDOH) updated its PMTCT policy to include more efficacious interventions to reduce mother-to-child transmission of HIV. These efforts are to meet the National Strategic Plan (NSP 2012-2016) targets of reducing the MTCT rate of HIV to less than 2% by six weeks and < 5% by 18-months.

The South African PMTCT Evaluation was implemented in 2010, 2011 and 2012 to track population-level impact of the national PMTCT programme. These data were (critically important to monitor progress towards meeting the targets set in the South African National Strategic Plan (of reducing vertical transmission to less than 5% at 18 months by 2016), and the 4th and 6th millennium development goals (i.e. ‘reduce under-five mortality rate by two thirds, between 1990 and 2015, and halt the spread of HIV/AIDS’).

Aim
To periodically conduct facility-based surveys to monitor the effectiveness of the South African National PMTCT programme until 18 months postpartum.

Collaboration
The survey was a collaborative effort between the Medical Research Council, University of the Western Cape, National Department of Health, Centers for Disease Control and Prevention, Atlanta, NICD/NHLS, Wits Infant HIV Diagnostics, UNICEF and Provincial Departments of Health. All findings were reported to all stakeholders to improve implementation of the national PMTCT programme.

The SAPMTCTE was funded predominantly by the Centers for Disease Control and Prevention, Atlanta, with contributions from the National Department of Health, NICD/NHLS, Global Fund and UNICEF.

Project status

The 2010 situational assessment, conducted to document systems for early infant diagnosis at primary health care level, has been completed and can be obtained here. The 2010 survey has been completed. Results were presented at numerous conferences including SAAIDS 2011, IAS 2011, APHA 2011 and Perinatal priorities 2011. The detailed 2010 survey report can be found here.

The 2011 SAPMTCTE-6 weeks has been completed. Results were released by the Minister of Health and at the International AIDS Conference 2012. The Executive Summary with preliminary 2011 results can be found here. 

The 2012 survey has been completed and the report can be found here. The six weeks results were presented to the Minister of Health on the 28th August 2014. All HIV exposed infants were subsequently followed up at 3, 6, 9, 12, 15 and 18 months. The 18-month follow-up was completed by 12th September 2014 and  results were released at the AIDS 2016 Conference.

Contact person
Prof. Ameena Goga
ameena.goga@mrc.ac.za

The following papers have been published as a result of our association with this work

Journal Articles

2014/15 Financial Year

1. Goga AE, Dinh TH, Jackson DJ, Lombard C, Delaney KP, Puren A, Sherman G, Woldesenbet S, Ramokolo V, Crowley S, Doherty T, Chopra M, Shaffer N, Pillay Y. First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa. Journal of Epidemiology and Community Health. 2015 Mar;69(3):240-8. Epub 2014 Nov 4. DOI: 10.1136/jech-2014-204535 [Original]
2. Woldesenbet SA, Jackson D, Goga AE, Crowley S, Doherty T, Mogashoa MM, Dinh TH, Sherman GG. Missed opportunities for early infant HIV diagnosis: results of a National Study in South Africa. Journal of Acquired Immune Deficiency Syndromes. 2015 Mar 1;68(3):e26-32. Epub 2014 Dec 2. DOI: 10.1097/QAI.0000000000000460 [Original]

2015/16 Financial Year

1. Dinh TH, Delaney KP, Goga A, Jackson D, Lombard C, Woldesenbet S, Mogashoa M, Pillay Y, Shaffer N. Impact of maternal HIV seroconversion during pregnancy on early Mother to Child Transmission of HIV (MTCT) measured at 4-8 weeks postpartum in South Africa 2011-2012: a National Population-Based Evaluation. PLoS One. 2015 May 5;10(5):e0125525. DOI: 10.1371/journal.pone.0125525 [Original]
2. Woldesenbet S, Jackson D, Lombard C, Dinh TH, Puren A, Sherman G, Ramokolo V, Doherty T, Mogashoa M, Bhardwaj S, Chopra M, Shaffer N, Pillay Y, Goga A. Missed opportunities along the prevention of mother-to-child transmission services cascade in South Africa: uptake, determinants, and attributable risk (the SAPMTCTE). PLoS One. 2015 Jul 6;10(7):e0132425. DOI: 10.1371/journal.pone.0132425 [Original]

2016/17 Financial Year

1. Goga AE, Dinh TH, Jackson DJ, Lombard CJ, Puren A, Sherman G, Ramokolo V, Woldesenbet S, Doherty T, Noveve N, Magasana V, Singh Y, Ramraj T, Bhardwaj S, Pillay Y; South Africa PMTCT Evaluation (SAPMCTE) Team. Population-level effectiveness of PMTCT Option A on early mother-to-child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT. Journal of Global Health. 2016 Dec;6(2):020405. Epub 2016 Sep 16. DOI: 10.7189/jogh.6.020405 [Original]
2. Woldesenbet SA, Jackson DJ, Lombard CJ, Dinh TH, Ramokolo V, Doherty T, Sherman GG, Pillay Y, Goga AE. Structural level differences in the mother-to-child hiv transmission rate in South Africa: a multilevel assessment of individual-, health facility-, and provincial-level predictors of infant HIV transmission. Journal of Acquired Immune Deficiency Syndromes. 2017 Apr 15;74(5):523-530. Epub 2017 Jan 18. DOI: 10.1097/QAI.0000000000001289 [Original]

2017/18 Financial Year

1. Hamilton E, Bossiky B, Ditekemena J, Esiru G, Fwamba F, Goga AE, Kieffer MP, Tsague LD, Van De Ven R, Wafula R, Guay L. Using the PMTCT cascade to accelerate achievement of the global plan goals. Journal of Acquired Immune Deficiency Syndromes. 2017 May 1;75 Suppl 1:S27-S35. Epub 2017 Apr 12. DOI: 10.1097/QAI.0000000000001325 [Review]
2. Sherman GG, Mazanderani AH, Barron P, Bhardwaj S, Niit R, Okobi M, Puren A, Jackson DJ, Goga AE. Toward elimination of mother-to-child transmission of HIV in South Africa: how best to monitor early infant infections within the prevention of mother-to-child transmission program. Journal of Global Health. 2017 Apr 12;7(1):010701. DOI: 10.7189/jogh.07.010701 [Original]
3. Ramokolo V, Goga AE, Lombard C, Doherty T, Jackson DJ, Engebretsen IMS. In-utero ART exposure and birth and early growth outcomes among HIV-exposed uninfected infants attending immunization services: results from National PMTCT Surveillance, South Africa. Open Forum Infectious Diseases. 2017 Oct;4(4):ofx187-ofx. Epub 2017 Aug 30. DOI: 10.1093/ofid/ofx187 [Original]
4. Ngandu NK, Van Malderen C, Goga A, Speybroeck N. Wealth-related inequality in early uptake of HIV testing among pregnant women: an analysis of data from a national cross-sectional survey, South Africa. BMJ Open. 2017 Jul;7(7):e013362. DOI: 10.1136/bmjopen-2016-013362 [Original]
5. Goga A, Chirinda W, Ngandu NK, Ngoma K, Bhardwaj S, Feucht U, Davies N, Ntloana M, Mhlongo O, Silere-Maqetseba T, Moyo F, Sherman G. Closing the gaps to eliminate mother-to-child transmission of HIV (MTCT) in South Africa: Understanding MTCT case rates, factors that hinder the monitoring and attainment of targets, and potential game changers. South African Medical Journal. 2018 Mar 03;108(3 Suppl1):s17-s24. DOI: 10.7196/SAMJ.2017.v108i3b.12817 [Editorial]
6. Ramraj T., Jackson, D., Dinh, TH., Olorunju, S., Lombard, C., Sherman, G., Puren, A., Noveve, N., Singh, Y., Magasana, V., Bhardwaj, S., Cheyip, M., Mogashoa, M., Pillay, Y., Goga, AE. Adolescent access to care and risk of early mother-to-child HIV transmission.Journal of Adolescent Health.https://doi.org/10.1016/j.jadohealth.2017.10.007
7. Larsen L, Cheyip M, Aynalem G, Dinh TH, Jackson D, Ngandu N, Chirinda W, Mogashoa M, Kindra G, Lombard C, Goga A. Uptake and predictors of early postnatal follow-up care amongst mother-baby pairs in South Africa: Results from three population-based surveys, 2010-2013. 2017 Journal of Global Health. Dec;7(2):021001. doi: 10.7189/jogh.07.021001.
8. Sherman GG, Haeri Mazanderani AF, Barron P, Bhardwaj S, Niit R, Okobi M, Puren D, Jackson DJ, Goga AE. Towards eMTCT of HIV in SA: How best to monitor the PMTCT Program. 2017 JoGH. Published April 2017 online. http://www.jogh.org/documents/issue201701/jogh-07-010701.XML
9. Woldesenbet S, Jackson D, Lombard C, Dinh T, Ramokolo V, Doherty T. Goga A. Structural Level Differences in the Mother-to-Child HIV Transmission Rate in South Africa: A Multilevel Assessment of Individual-, Health facility-, and Provincial- Level Predictors of Infant HIV Transmission. J Acquir Immune Defic Syndr. 2017. Published online January 2017. Available from: https://www.pubfacts.com/fulltext/28107227/

2018/19 Financial Year

1. Goga A. Birth HIV testing and paediatric treatment programmes. Lancet HIV. 2018 Dec;5(12):e675-e6. Epub 2018 Nov 8. DOI: 10.1016/s2352-3018(18)30291-1 [Letter]
2. Goga A, Singh Y, Jackson D, Mukungunugwa S, Wafula R, Eliya M, Ng'ambi WF, Nabitaka L, Chirinda W, Bhardwaj S, Essajee S, Hayashi C, Pillay Y. How are countries in sub-Saharan African monitoring the impact of programmes to prevent vertical transmission of HIV? British Medical Journal. 2019 Mar 26;364:l660. Epub 2019 Mar 26. DOI: 10.1136/bmj.l660 [Original]
3. Ramraj T, Goga AE, Larsen A, Ramokolo V, Bhardwaj S, Chirinda W, Jackson D, Nsibande D, Ayalew K, Pillay Y, Lombard CJ, Ngandu NK; South Africa PMTCT Evaluation (SAPMCTE) Team. Completeness of patient-held records: observations of the Road-to-Health Booklet from two national facility-based surveys at 6 weeks postpartum, South Africa. Journal of Global Health. 2018 Dec;8(2):020901. Epub 2018 Sep 15. DOI: 10.7189/jogh.08.020901 [Original]

2019/20 Financial Year:

1. Jackson DJ, Swanevelder S, Doherty D, Lombard C, Bhardwaj S, Goga A. Changes in rates of early exclusive breastfeeding in South Africa from 2010 to 2013: before and during implementation of a change in national breastfeeding policy. BMJ Open 2019;9:e028095. http://dx.doi.org/10.1136/bmjopen-2018-028095
2. Hunt GM, Ledwaba J, Salimo A, Kalimashe M, Dinh TH, Jackson D, Sherman G, Puren A, Ngandu NK, Lombard C, Morris L, Goga A. Prevalence of HIV-1 drug resistance amongst newly diagnosed HIV-infected infants age 4–8 weeks, enrolled in three nationally representative PMTCT effectiveness surveys, South Africa: 2010, 2011–12 and 2012–13. BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
3. Jackson DJ, Dinh TH, Lombard CJ, Sherman GG and Goga AE. An approach for evaluating early and long term mother-to-child transmission of HIV (MTCT) in low and middle income countries: a South African experience. BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
4. Kuhn L and Goga AE. Moving towards elimination: findings from the South Africa prevention of mother to child transmission evaluation (SAPMTCTE). BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
5. Larsen A, Magasana V , Dinh TH , Ngandu N , Lombard C , Cheyip M , Ayalew K , Chirinda W , Kindra G , Jackson D and Goga A. Longitudinal adherence to maternal antiretroviral therapy and infant Nevirapine prophylaxis from 6 weeks to 18 months postpartum amongst a cohort of mothers and infants in South Africa. BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
6. Mathivha E, Olorunju S, Jackson D, Dinh TH, du Plessis N and Goga A. Uptake of care and treatment amongst a national cohort of HIV positive infants diagnosed at primary care level, South Africa. BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
7. Ngandu NK, Jackson D, Lombard C, Nsibande DF, Dinh TH, Magasana V, Mogashoa M and Goga AE. Factors associated with non-attendance at scheduled infant follow-up visits in an observational cohort of HIV-exposed infants in South Africa, 2012–2014. BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
8. Ngandu NK, Maduna V, Sherman G, Noveve N, Chirinda W, Ramokolo V, Lombard C and Goga AE. Infrastructural and human-resource factors associated with return of infant HIV test results to caregivers: secondary analysis of a nationally representative situational assessment, South Africa, 2010. BMC Infectious Diseases, 16 September 2019. https://bmcinfectdis.biomedcentral.com/articles/supplements/volume-19-supplement-1.
9. Singh Y, Jackson D, Bhardwaj S, Titus N, Goga A. National surveillance using mobile systems for health monitoring: complexity, functionality and feasibility

2020/21 Financial Year

1. Goga AE. Impact of breastfeeding, maternal antiretroviral treatment and health service factors on 18-month vertical transmission of HIV and HIV-free survival: Results from a nationally representative HIV-exposed infant cohort, South Africa. In press. Journal of Epidemiology & Community Health
2. Nsibande D, Goga A, Laubscher R, Lombard C, Cheyip M, Jackson D, Larsen A, Mogashoa M, Dinh T-H, Ngandu N.The long journey towards optimal uptakeUptake of antenatal care in high HIV -prevalence settings: an exampleResults from three population-based surveys in South Africa. South African Medical Journal 2020;110(7):671-677. DOI:10.7196/SAMJ.2020.v110i7.14325

Book Chapters

2017/18 Financial Year

1. Goga A, Sherman G, Chirinda W, Ng`oma K, Bhardwaj S, Doherty T, Pilly Y, Barron P. Eliminating mother-to-child transmission of HIV in South Africa, 2002–2016: progress, challenges and the last mile plan. Chapter 13. In: Padarath A, Barron P (eds).  South African Health Review 2017. Durban: Health Systems Trust; 2017 Aug 23. P137-146, 20^th edition. Epub 2017 May.

PI: University of Pretoria (UP) Dr Nicolette du Plessis MRC co-PI Prof Ameena Goga

Co-investigators: UP: Prof Theunis Avenant  NHLS/UP: Dr Ahmad HaeriMazanderani

Overview
This study focused on the public health impact and feasibility of universal versus targeted very early infant diagnosis. The Mississippi baby, Visconti cohort and Berlin patient have raised optimism regarding the benefits of very early diagnosis and treatment initiation in functional HIV cure. Since the reported initial apparent functional cure in the Mississippi baby several debates about the optimal timing of early infant diagnosis have occurred in South Africa and Internationally.

The key questions were:

• In the context of PMTCT Option B what testing approach should be used to identify HIV infected infants as early as possible so that treatment can be initiated?
• What would be the impact and added benefit of universal versus targeted very early infant diagnosis?
• If a targeted approach is used, which combination of criteria would have the highest sensitivity and positive predictive value for infant HIV infection?
• What is the optimal treatment to use once a neonate has been identified as being HIV infected?
• Can universal or targeted birth infant diagnosis be incorporated into routine health care settings?

In this study we tested all participating HIV exposed infants for HIV infection within 72 hours of birth and initiate all HIV infected neonates on treatment.

Aim
To investigate the public health impact and feasibility of universal versus targeted very early infant diagnosis (VEID). Specifically we are investigating the impact of VEID on (i) early treatment initiation amongst HIV exposed infants and on (ii) infant outcomes at birth, 6 weeks, 10 weeks, 14 weeks, 6 months and 9 months and on the health system.

Collaboration
The study is a collaborative effort between the Medical Research Council, Department of Paediatrics and Child Health, Kalafong hospital, University of Pretoria, and Rahima Moosa Mother and Child Hospital (RMMH) University of Witwatersrand, National Health Laboratory system and National Department of Health.

Project status
Data collection started in August 2014 at Kalafong hospital and ended in December 2016. Two PhD students have graduated.

Publications

1. Mazanderani AH, Murray TY, Sherman GG, Snyman T, George J, Avenant T, Goga AE, Pepper MS, du Plessis N. Non-nucleoside reverse transcriptase inhibitor levels among HIV-exposed uninfected infants at the time of HIV PCR testing – findings from a tertiary healthcare facility in Pretoria, South Africa. JIAS. 22(6):e25284. doi: 10.1002/jia2.25284.

2. Du Plessis NM, Muller CJB, Avenant T, Pepper MS, Goga AE. An Early Infant HIV Risk Score for Targeted HIV Testing at Birth. Pediatrics. 2019 Jun;143(6). pii: e20183834. doi: 10.1542/peds.2018-3834. Epub 2019 May 17.

Contact person
Prof. Ameena Goga (ameena.goga@mrc.ac.za)