The Southern African Journal of HIV Medicine is focused on HIV/AIDS treatment, prevention and related topics relevant to clinical and public health practice. The purpose of the journal is to disseminate original research results and support high-level learning related to HIV Medicine. It publishes original research articles, editorials, case reports/case series, reviews of state-of-the-art clinical practice and correspondence.

Child mortality in South Africa: Fewer deaths, but better data are needed

Background: Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage. Methods: For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February–March 2018 in South Africa’s KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes. Results: Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media. Conclusions: Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women’s knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women’s breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.

Introduction: Despite the importance of healthcare acceptability, the public health community has yet to agree on its explicit definition and conceptual framework. We explored different definitions and conceptual frameworks of healthcare acceptability, and identified commonalities in order to develop an integrated definition and conceptual framework of healthcare acceptability. Materials and Methods: We applied qualitative thematic content analysis on research articles that attempted to define healthcare acceptability. We searched online databases and purposefully selected relevant articles that we imported into ATLAS.ti 8.4 for deductive and inductive analysis which continued until there were no new information emerging from selected documents (data saturation). Results: Our analysis of the literature affirmed that healthcare acceptability remains poorly defined; limiting its application in public health. We proposed a practical definition attempting to fill identified gaps. We defined acceptability as a “multi-construct concept describing the nonlinear cumulative combination in parts or in whole of the fit between the expected and experienced healthcare from the patient, provider or healthcare systems and policy perspectives in a given context.” Practice Implications: We presented and described a workable definition and framework of healthcare acceptability that can be applied to different actors including patients, healthcare providers, researchers, managers or policy makers. Keywords: Defining and conceptualising acceptability; healthcare; content analysis.

Introduction: In South Africa over the past 20 years, immunisation has saved countless lives as well as prevented illnesses and disabilities. Despite this, vaccine-preventable illnesses remain a danger. The demand for and uptake of immunisation services are shaped by a variety of factors that can either act as barriers or facilitators to immunisation uptake. The aim of this project was to identify the supply and demand barriers and develop local strategies to improve childhood immunisation in four zero-dose districts in South Africa. Materials and Methods: This study used a mixed-method approach. In each of these four districts, 15 in-depth key informant interviews with health workers and local health managers and four focus group discussions (10 participants per focus group discussion) with community members and caregivers were held over a three-month period. Transcribed interviews were thematically analysed using qualitative analysis software (Nvivo^®) into 10 factors as identified as important in influencing immunisation demand and uptake in previous studies. A further four were identified during the data analysis process. Results: Despite the varying role of factors affecting demand and uptake of immunisation services, three consistent findings stand out as major barriers across all districts. The first is interaction with healthcare staff. This clearly highlights the crucial role that the interactions between patients and staff play in shaping perceptions and behaviours related to immunisation services. The second is the overall experience of care at healthcare facilities. This emphasises the role that patient experience of services plays in perceptions and behaviours related to immunisation services. The third is family dynamics. This highlights the important role family dynamics play in shaping individuals’ decisions regarding immunisation uptake as well as the impact it has on the ability of people to access health services. Discussion: The role played by the different factors in the demand and uptake of immunisation services varied across the four districts examined in this study. Each of the districts presents a unique landscape where different factors have varying degrees of importance in affecting the utilisation of immunisation services. In some districts, certain factors are major barriers, clearly hindering the demand and uptake of immunisation services, while in others, these same factors might be a relatively minor barrier. This discrepancy highlights the unique nature of healthcare challenges across the districts and the need for tailored strategy recommendations to address them effectively.

Background. In South Africa (SA), adolescent pregnancy, particularly in very young girls, is an issue of keen public and political concern given its social and health implications. Objective. To provide a quantitative baseline that SA can use for targeting its efforts to address adolescent pregnancy and for measuring progress over time. Methods. Using public sector service data for deliveries and terminations of pregnancies, we estimated adolescent pregnancy rates among adolescent girls aged 10 - 14 and 15 - 19 years for the financial years 2021/22 - 2024/25. Results. In 2025, the adolescent pregnancy rate (including births and terminations) for 15 - 19-year-olds was 48.9 per 1 000. For 10 - 14-year-olds, it was 1.2 per 1 000. Both the total number of births and the adolescent pregnancy rates dropped annually over the 4-year period of review, and reversed the previous trend of increases from 2017/18 through to 2020/21. Although there were decreases in births and adolescent pregnancy rates in all provinces, there were greater decreases in the more rural provinces compared with the more urban provinces (e.g. Western Cape and Gauteng). Termination of pregnancy rates were also higher in more urban provinces. Conclusion. While SA already has a strong policy framework for addressing adolescent pregnancy, there is a need for a national strategy and improved co-ordination of efforts. Indeed, the updated 2025 World Health Organization guidelines on preventing adolescent pregnancy and mitigating its adverse impacts highlight the need for a broad, multisectoral approach.