Jill Hanass-Hancock

Background: In South Africa, uptake of HIV oral pre-exposure prophylaxis (PrEP) has been slow among women, who account for 60% of new HIV diagnoses. A gender-enhanced (GE) online group workshop, Masibambane (“Let Us Work Together”) (N = 50), demonstrated greater increases in PrEP stage of change versus providing participants with individual access (IA) to online PrEP educational and motivational materials (N = 50). However, participants began the study at different stages, and it was unclear which women may have benefited most from the intervention. We explored how an underused analytic method could offer greater insight into women’s change trajectories. Methods: Participants completed questionnaires at baseline (“pre-intervention”), post-intervention, and three months after baseline (“follow-up”) and documented readiness through a 5-point stage-of-change (SOC) score based on the transtheoretical model. We used Markov transition matrices to calculate probabilities of different trajectories. Results: Participants who reported 3 (“would like to speak to a counselor”) were most likely to transition to 5 (“ready to take PrEP”) at post-intervention in the GE arm (P _{post, pre} (5|3) = 0.60) but not the IA arm (P _{post, pre} (5|3) = 0.17). Those who scored 2 (“uncertain”) at pre-intervention also exhibited greater probabilities of upward movement in the GE arm. Discussion: Compared to IA, GE women who expressed uncertainty or a desire for counseling at baseline were more likely to shift into a state of readiness, driving the observed difference across study arms. This analysis demonstrates how Markov modeling can provide greater understanding of population change dynamics than mean values alone.

Background: Despite the existence of South African frameworks guiding the inclusion and accessibility of persons with disabilities in the workplace, there is no tool available to guide how healthcare facilities meet the inclusion and accessibility standards set out in the Convention of the Rights of Persons with Disabilities (CRPD) and national frameworks. Objectives: This study sought to achieve consensus among experts regarding the tool that can be utilised to guide the implementation of the CRPD-aligned standards of universal design and reasonable accommodation in the public healthcare sector. Method: A panel of experts (27) in the field of disability across South Africa participated in a two-round modified Delphi technique. The 80% agreement threshold was set to determine the level of agreement among experts. Results: Consensus was reached on all seven domains (with various disability indicators) as outlined by the CRPD to be included in the development of a tool. These domains are, namely, the prohibition of discrimination, protecting and promoting the rights of persons with disabilities, labour and trade union participation, access to technical and vocational training, employment opportunities and career advancement, reasonable accommodation and professional and vocational rehabilitation training programmes for persons with disabilities. Conclusion: The panellists agreed that the developed tool can be utilised to evaluate and guide the implementation of universal design and reasonable accommodation in the public healthcare sector. Contribution: This study provides a consensus-based, CRPD-aligned assessment tool that enables healthcare facilities to systematically evaluate and improve disability inclusion and accessibility in the workplace.

People with disabilities face profound health disparities and systemic barriers to healthcare access, especially in low- and middle-income countries. These barriers range from inaccessible infrastructure and communication formats to negative attitudes and limited training among healthcare workers. This paper focuses on the co-design of the Disability Awareness Toolkit (DAT), a practical, contextually grounded toolkit to promote inclusion and accessibility in health and post-GBV clinical services in South Africa. The development of the DAT followed the co-design framework established by Birds et al., structured around two design cycles. The first cycle focused on creating the Disability Awareness Checklist (DAC) and its accompanying automated reporting system. The second cycle involved the development of the DAC’s implementation support tools, including an intervention menu and a training component. Each cycle incorporated (a) pre-design activities such as literature and document reviews and key interest holder mappings, (b) co-design activities such as workshops with a diverse group of interest holders—including persons with disabilities—alongside DAC facilitator training, and pilot testing in healthcare settings, and (c) post-design adaptation. Feedback was collected using accessible, structured formats to ensure clarity and inclusivity. Any conflicting feedback was resolved through follow-up discussions and consensus-building, reinforcing the participatory and inclusive nature of the process. The iterative co-design process was informed by the lived experiences of healthcare users and providers, revealing the importance of local relevance, flexibility, and power-sensitive collaboration. The final DAT consists of a comprehensive toolkit: the DAC with 53 core elements, automated reporting tools, a practical intervention menu tailored to local contexts, and an integrated training approach. The consultative process led to formally adopting appreciative inquiry as a key facilitation technique, helping participants better identify actionable, locally feasible solutions. The combination of the tool design and appreciative inquiry showed promise to create awareness and initiate change. The DAT’s evolution highlights the power of co-design in addressing healthcare inequalities. It demonstrates how inclusive, locally grounded, and flexible design processes can produce meaningful quality assurance tools that reflect the diverse realities of service users and providers in unequal contexts.

Expanding women’s awareness of and access to HIV pre-exposure prophylaxis (PrEP) is key to enhancing its uptake, yet young women face difficulties in deciding whether to initiate any form of PrEP. Understanding factors that shape decision-making to initiate PrEP can support uptake and continuation. The Masibambane (“Let us work together”) pilot in eThekwini (Durban), South Africa, compared a gender-enhanced (GE) online group workshop (N = 50) to an “individual access” (IA) control condition (N = 50) for women (ages 18–25 years). Both conditions aimed to increase knowledge and motivation to initiate oral PrEP. This study used 3-month follow-up qualitative interviews from 40 women (20 per condition). The Transtheoretical Model of Health Behavior Change guided interviews and a framework analysis was used to understand stages of and influences on PrEP decision-making. Underscoring that PrEP uptake is not a straightforward or singular decision, most respondents, regardless of condition, conveyed shades of contemplation for initiating PrEP; only a few stated they currently were using or were uninterested in PrEP. Many viewed PrEP as an effective woman-controlled method and believed their partners placed them at risk of HIV. Other considerations included relationship status, pill modality, daily adherence, and side effects. For those who prepared to use PrEP, logistical barriers were frequent. Peers were perceived as sources of encouragement for adopting PrEP. Given these findings, HIV prevention efforts need to include interventions to support PrEP decision-making, recognizing that the process is continuous, multifaceted, and changes over time. This study elucidated relevant factors for supporting young women’s PrEP decision-making in South Africa.

As the global population's ageing accelerates, especially in low-middle-income countries (LMICs), an increase in age-related and sexual health challenges can be expected. However, a focus on reproductive ages, ageism, taboos, stigma and limited resources, has contributed to a neglect of older adults’ sexuality as broadly defined by the World Health Organization (WHO). We used qualitative methods to explore the attitudes and perceptions of sexuality and sexual behaviour among older adults aged 50 years and above. Focus group discussions with 37 South African men and women (aged 50–78) were thematically analysed using an ethnographic and phenomenological naturalistic paradigm. Four major themes emerged: 1) Importance of sexuality and sexual activity, 2) gendered perspectives on sexual activity, 3) health state as a barrier to sexual activity, and 4) cultural influences on sexuality and behaviour. Study highlights the significant role cultural norms and beliefs can play in old-age sexuality, with distinct gender differences in sexual practices. Health conditions, including chronic illnesses, disabilities, frailty and HIV status can act as barriers to sexual activities in old age. Understanding these barriers and facilitators is crucial to addressing the sexual health concerns of older adults. A holistic approach and further research for a nuanced understanding of older adults’ need for and enjoyment of sexual activity to inform policy and programmes is needed. The scarcity of data and evidence on this subject in LMICs hinders the development of policies and targeted interventions for successful healthy ageing.

Young women with and without disabilities in South Africa experience challenges accessing sexual reproductive health and rights (SRHR) services, and this may increase during a crisis. We conducted a longitudinal cohort study with 72 young women with and without disabilities (18–25 years) in eThekwini, South Africa (2020–2022) via a series of in-depth interviews including quantitative and qualitative data on participants’ experiences during the COVID-19 pandemic and access to SRHR. Participants reported that barriers to accessing SRHR services included lockdown regulations, prioritization of COVID-19 at health care facilities, fear of COVID-19 infection, transport challenges, and youth-unfriendly clinics. Participants with disabilities experienced additional barriers to SRHR services, including ongoing (inaccessible services) and pandemic-specific (e.g., masks making lipreading impossible) barriers. Participants reported both non-partner and partner violence, with women with disabilities reporting this more frequently, physical and sexual partner violence, as well as physical and emotional abuse from caregivers. Participants with disabilities were not reporting incidents of violence to caregivers or officials because they had ‘normalized’ the experience of violence, were not believed when trying to disclose, feared that reporting would increase their problems, or could not access services due to disability-related barriers. Inclusive and accessible SRHR information, education, and services are needed. This includes disability-specific staff training, disability audits, and caregiver support and training.

Introduction: Disability and HIV are intricately linked, as people with disabilities are at higher risk of contracting HIV, and living with HIV can lead to impairments and disability. Despite this well‐established relationship, there remains limited internationally comparable evidence on HIV knowledge and access to testing for people with disabilities.Methods: We used cross‐sectional data from 37 Multiple Indicator Cluster Surveys. Surveys were from six UNICEF regions, including East Asia and Pacific (n = 6), East and Central Asia (n = 7), Latin America and the Caribbean (n = 6), Middle East and North Africa (n = 4), South Asia (n = 2) and sub‐Saharan Africa (n = 12). A total of 513,252 people were eligible for inclusion, including 24,695 (4.8%) people with disabilities. We examined risk ratios and 95% confidence intervals for key indicators on HIV knowledge and access to testing for people with disabilities by sex and country. We also conducted a meta‐analysis to get a pooled estimate for each sex and indicator.Results: Men and women with disabilities were less likely to have comprehensive knowledge about HIV prevention (aRR: 0.74 [0.67, 0.81] and 0.75 [0.69, 0.83], respectively) and to know of a place to be tested for HIV (aRR: 0.95 [0.92, 0.99] and 0.94 [0.92, 0.97], respectively) compared to men and women without disabilities. Women with disabilities were also less likely to know how to prevent mother‐to‐child transmission (aRR: 0.87 [0.81, 0.93]) and ever have been tested for HIV (aRR: 0.90 [0.85, 0.94]).Conclusions: Men and women with disabilities have lower overall HIV knowledge and in particular women with disabilities also indicate lower testing rates. Governments must include people with disabilities in HIV programmes by improving disability‐inclusion and accessibility to HIV‐related information, education and healthcare services.

Peer-to-peer chain recruitment has been used for descriptive studies, but few intervention studies have employed it. We used this method to enroll sexually active women ages 18 to 25 into an online Pre-Exposure Prophylaxis (PrEP) information and motivation intervention pilot in eThekwini (Durban), South Africa. Seeds (N = 16) were recruited by study staff and randomized to Masibambane, Ladies Chat, a Gender-Enhanced group-based WhatsApp Workshop (GE), or Individual-Access (IA), a control condition that provided participants with online information/motivation materials only. Each seed could recruit up to three women to participate in the same study condition, with an incentive for each enrolled woman; participants in subsequent waves could choose to recruit or not. We evaluated if peer-to-peer recruitment was self-sustaining and resulted in enrolling women who, in subsequent waves, had less contact with the health care system and less knowledge about PrEP than the initial seeds. Over three recruitment waves beyond the seeds, 84 women were recruited. Almost 90% of women became recruiters, with each recruiting on average 1.90 women and 1.26 eligible enrolled women. The approach was successful at reaching women with less education but not women with less health system contact and PrEP knowledge across waves. IA participants had a slightly higher, though non-significantly different, percentage of individuals who became Peer Health Advocates (PHAs) than GE participants and, on average, they recruited slightly more women who enrolled. Our findings demonstrated that peer-to-peer recruitment is a feasible and self-sustaining way to recruit SA young women into a PrEP intervention study.