Background: While caregiver and health system factors are known to influence paediatric ART outcomes, their roles within routine rural South African settings remain insufficiently characterised. Aim: The aim of this study is to assess the association between caregiver-mediated ART adherence, perceived healthcare access and service quality with viral suppression among children receiving ART in a rural South African province. Methods: A cross-sectional study was conducted among 86 children aged <15 years receiving ART in routine paediatric HIV care. Viral load suppression was defined as <1000 copies/mL. Predictor variables included caregiver-reported adherence (30-day recall; adherent vs. non-adherent), perceived healthcare access and perceived service quality. Associations were assessed using Chi-square or Fisher’s exact tests, where appropriate. Effect sizes were estimated using risk differences. Results: Overall, 77.9% of the child participants were virally suppressed. Caregiver-reported adherence was significantly associated with VLS (p = 0.034). The probability of viral suppression was 100% among adherent children compared to 73.2% among non-adherent children (risk difference: 26.8 percentage points). Caregiver-reported adherence demonstrated high specificity (100%) and positive predictive value (100%) but low sensitivity (22.4%) and negative predictive value (26.8%), indicating that while reported adherence reliably identified children who were suppressed, non-adherence did not consistently predict virological failure. Perceived healthcare access (p = 0.372) and service quality (p = 0.267) were not significantly associated with viral suppression. Conclusions: Caregiver-mediated adherence was strongly associated with viral suppression, whereas perceived health system factors were not independently associated with treatment outcomes in this cohort. These findings should be interpreted cautiously given the cross-sectional design and reliance on short-term adherence measures. Strengthening household-level adherence support is critical for improving paediatric HIV outcomes in rural settings.

Background: Donor human milk (DHM) is a critical alternative for vulnerable infants when maternal milk is unavailable, but its clinical utilisation in South Africa is constrained by limited understanding of how maternal knowledge, perceived safety, cultural meanings and social contexts shape local acceptance. Aim: To explore postnatal mothers’ knowledge, perceptions and sociocultural influences shaping acceptance of DHM in Richards Bay, KwaZulu-Natal. Methods: A qualitative design informed by interpretive phenomenology was used. Twenty-two postnatal mothers were purposively recruited from a private hospital. Semi-structured interviews were conducted in English or isiZulu, and data were transcribed, translated where necessary, and analysed using reflexive thematic analysis supported by reflexivity, peer debriefing, member checking and an audit trail. Results: Four themes were developed. DHM was largely unfamiliar, with participants reporting limited prior information and little exposure through routine maternal healthcare. Safety concerns centred on infection, donor health, screening, storage and milk processing, although confidence in healthcare institutions facilitated acceptance for some mothers. Acceptance was also shaped by maternal identity, emotional attachment to breastfeeding, spiritual and cultural beliefs, and family and community influence. Limited awareness did not equate to fixed rejection: after DHM was explained, participants distinguished between receiving and donating: willingness to receive DHM for their own infants was conditional on safety assurance and provider recommendation, whereas willingness to donate was expressed more readily and was often motivated by altruism and reciprocity. These findings indicate an interaction between informational uncertainty, institutional trust, cultural meaning and social legitimacy in shaping DHM decisions. Conclusion: Supporting informed decision-making about DHM, and potentially its uptake, requires more than increasing awareness. Routine antenatal and postnatal education, provider training, transparent communication about safety, and culturally responsive family and community engagement may help convert conditional openness into informed acceptance and donation.

Introduction: HIV status disclosure to children remains complex and constrained by child-, caregiver-, and health-system-level factors. Aim: To assess factors associated with caregiver-reported HIV status disclosure among children and adolescents receiving antiretroviral therapy (ART) and explore associations between disclosure status and selected treatment-related indicators in rural Eastern Cape province. Methods: A cross-sectional study of 87 caregiver–child dyads was conducted across five public ART clinics. Data were collected using caregiver questionnaires and abstraction from ART records. Bivariate associations were assessed using Pearson’s chi-square or Fisher’s exact tests, and multivariable binary logistic regression was performed to identify caregiver-related factors independently associated with HIV status non-disclosure. Results: Overall, 44.8% (n = 39) of children and adolescents had been informed of their HIV status. Status disclosure was associated with older age and legal guardian caregiving (p < 0.001, respectively). Participants who had been disclosed to had higher rates of viral suppression (74.4% vs. 29.2%), optimal ART adherence (87.2% vs. 45.8%), and independent medication administration (82.1% vs. 33.3%) (all p < 0.001). In multivariable analysis, caregiver readiness to discuss HIV was associated with lower odds of non-disclosure (AOR = 0.037; 95% CI: 0.004–0.381), whereas the perceived need for additional disclosure training and counselling (AOR = 15.97; 95% CI: 3.05–83.53) and biological-parent caregiving (AOR = 11.92; 95% CI: 2.16–65.67) were associated with higher odds of non-disclosure. Conclusion: HIV disclosure was associated with developmental, caregiving, and treatment-related factors. Strengthening structured caregiver preparation and disclosure support within routine paediatric HIV services may improve implementation, although longitudinal studies are needed to clarify temporal relationships and causal pathways.

Cultural constructions of masculinity in rural South Africa perpetuate gender-based violence (GBV), yet women’s perspectives remain underexplored, particularly in the high-prevalence OR Tambo District. This study examined women’s perceptions and lived experiences of masculinity constructs contributing to GBV in Gxulu. It is a rural community situated in the Libode Eastern Cape Province, South Africa, under the Nyandeni municipality 5160 A phenomenological qualitative design using purposive sampling for saturation was used. Semi-structured interviews conducted in isiXhosa and English were analyzed using reflexive thematic analysis. A total of 29 women participated in the study, with an average age of 33.4 years. The study found that women held negative and positive perceptions of masculine characteristics. Participants perceived that masculinity may be characterized by unfaithfulness, with expectations of men to lead and make decisions possibly contributing to financial abuse of women. Masculinity may also be characterized by substance and alcohol misuse, with expectations of men being financially stable providers possibly contributing to physical abuse. Additionally, women perceived that alcohol led to sexual abuse and created men who were unable to express their emotions, leading to emotional abuse. These women’s insights reveal aspects of masculinity fueling GBV cycles, underscoring the need for norm-corrective, community-based interventions to foster gender-equitable norms in the rural Eastern Cape.

Background Child mortality remains a major public health challenge in low- and middle-income countries, with Sub-Saharan Africa carrying a disproportionate share of the global burden. In South Africa, rural and under-resourced areas such as Mount Fletcher in the Eastern Cape continue to record high rates of preventable under-five deaths. The effectiveness of national and provincial health promotion strategies depends heavily on local awareness, acceptance, and participation, yet little is known about how caregivers in rural communities such as Mount Fletcher understand and experience these interventions. Objective To explore the awareness and perceptions of health promotion strategies among caregivers to reduce child mortality in Mount Fletcher, and to identify the barriers and facilitators influencing their uptake. Methods A qualitative descriptive study was conducted among 20 mothers and primary caregivers of children under five years attending Taylor Bequest Clinic in Mount Fletcher, Elundini Local Municipality. Participants were selected through purposive sampling and took part in semi-structured, audio-recorded interviews conducted in isiXhosa or English. Data were transcribed verbatim and analysed thematically using ATLAS.ti (version 8), guided by the Health Belief Model. Results Participants demonstrated good awareness of core child-survival interventions, including immunisation, exclusive breastfeeding, nutrition, hygiene, and clinic attendance, and generally held positive attitudes toward health promotion services and healthcare workers. However, participants identified substantial barriers to the uptake of these strategies, including poverty, transport costs and distance to health facilities, long clinic waiting times and staff shortages, and the continued influence of traditional and cultural beliefs on health-seeking behaviour. Conclusion Caregivers in Mount Fletcher are broadly aware of, and hold favourable attitudes toward, child health promotion strategies, but structural, economic, and cultural barriers continue to limit their consistent use. Strengthening community health worker outreach, addressing health system constraints, and engaging traditional and community leaders alongside biomedical health education may help translate existing awareness into more consistent uptake of child mortality reduction interventions in similar rural South African settings.

Background: The Undetectable = Untransmittable (U=U) message that people with HIV who maintain an undetectable viral load on antiretroviral therapy cannot sexually transmit the virus is scientifically established, yet awareness among South African adolescents remains poorly understood. This study assessed teenagers’ knowledge, perceptions, and acceptance of U=U in Mossel Bay Municipality, Western Cape. Methods: A qualitative, descriptive-exploratory study using semi-structured interviews with 15 purposively sampled teenagers (aged 13–19) across six schools. Interviews were transcribed and thematically analysed in ATLAS.ti, with a second reviewer coding a subset of transcripts. Results: Basic HIV knowledge was consistently accurate, but U=U awareness was low; 60% (9/15) had never heard the term, and understanding among the rest was partial. Only 46.7% (7/15) had tested HIV, citing fear, procedural anxiety, and parental gatekeeping as barriers; testing-related stigma persisted even among those who tested negatively. Once introduced to U=U, participants responded with cautious hope, distinguishing between acceptance in friendships versus more conditional acceptance in romantic relationships. Stigma, endorsed by all participants, was the dominant barrier, compounded by traditional, religious, and family silence. Conclusions: Teenagers possess the capacity to understand U=U; once explained, no downsides were identified. The core challenge is reach and trust, not receptiveness. Curriculum integration, provider training, and peer-led messaging are recommended.