The first confirmed case of COVID-19 in South Africa (SA) was reported on 5 March 2020. [1,2] Since then, SA has become the most affected country in Africa, with 2.9 million cases and >89 000 deaths due to COVID-19 as at 1 November 2021. [3] SA experienced a high number of COVID-19 infections in the first wave, peaking in July. The daily cases then declined before a major surge in December, when the country experienced its second wave of increased cases, probably fuelled by a new variant of the virus. [4] Like many other countries globally, SA implemented an unprecedented national shutdown to combat the spread of the virus. [2,5] The implementation of the National State of Disaster on 15 March gave the government the power to carry out and implement what later became a five-level COVID-19 alert system. Of the five levels of restrictions, the highest, most restrictive is alert level 5 and the lowest alert level 1. Level 5 lockdown measures included drastic restrictions on movement and the closure of all non-essential activities. During level 1, most normal activities were allowed to take place with precautions and adhering to health guidelines. [6] At the onset, on 27 March, SA went into alert level 5 and over the months that followed gradually eased to level 1 in September (at the end of the first wave) and then back to level 3 in December (during the second wave). [1,7] SA is described as having a quadruple burden of disease resulting from non-communicable diseases (such as diabetes and hypertension), communicable diseases (such as HIV/AIDS and TB), an epidemic of maternal, newborn and child illnesses, and violence and injury. [8] The emergence of COVID-19 has placed additional pressure on an already strained healthcare system and has resulted in changes both in demand for and supply of healthcare generally. [9,10] On the demand side, public anxiety and fear of contracting COVID-19 have resulted in patients postponing care. Lockdown restrictions disrupted public transport services that clients use to access health facilities, and the indirect effects of the economic downturn have made healthseeking less manageable. With regard to supply, there has been a shift of resources from other healthcare issues, as hospital wards This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Scale-up of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has reduced the incidence of pulmonary tuberculosis (PTB) in South Africa. Despite the strong association of HIV infection with extrapulmonary tuberculosis (EPTB), the effect of ART on the epidemiology of EPTB remains undocumented. We conducted a retrospective record review of patients initiated on treatment for EPTB in 2009 (ART coverage <5%) and 2013 (ART coverage 41%) at four public hospitals in rural Mopani District, South Africa. Data were obtained from TB registers and patients' clinical records. There was a 13% decrease in overall number of TB cases, which was similar for cases registered as EPTB (n = 399 in 2009 vs. 336 in 2013; P < 0·01) and for PTB (1031 vs. 896; P < 0·01). Among EPTB cases, the proportion of miliary TB and disseminated TB decreased significantly (both P < 0·01), TB meningitis and TB of bones increased significantly (P < 0·01 and P = 0·02, respectively) and TB pleural effusion and lymphadenopathy remained the same. This study shows a reduction of EPTB cases that is similar to that of PTB in the context of the ART scale-up. The changing profile of EPTB warrants attention of healthcare workers.

High rate of loss to follow-up and virological non-suppression in HIV-infected children on antiretroviral therapy highlights the need to improve quality of care in South Africa.

Background: There is a lack of research on technical assistance (TA) interventions in low- and middle-income countries. Variation in local contexts requires tailor-made approaches to TA that are structured and replicable across intervention sites whilst retaining the flexibility to adapt to local contexts. We developed a systematic process of TA using multidisciplinary roving teams to provide support across the various elements comprising local HIV services.Objectives: To examine the effectiveness of targeting specific HIV and TB programme indicators for improvement using roving teams.Method: We conducted a cluster-randomised stepped-wedge evaluation of a TA support package focussing on clinical, managerial and pharmacy services in the Mopani district of the Limpopo province, South Africa (SA). Three roving teams delivered the intervention. Seventeen primary and community healthcare centres that had 400–600 patients on antiretroviral therapy (ART) were selected for inclusion. The TA package was implemented for six consecutive months across facilities until all had received the same level of support. Data were collected from the relevant health management information systems for 11 routine indicators.Results: The mean proportion of PLWH screened for tuberculosis (TB) at ART initiation increased from 85.2% to 87.2% (P = 0.65). Rates of retention in care improved, with the mean proportion of patients retained in care at three months post-ART initiation increasing from 79.9% to 87.4% (P 0.001) and from 70.3% to 77.7% (P 0.01) after six months. Finally, the mean proportion of patients with TB who completed their treatment increased from 80.6% to 82.1% (P = 0.75).Conclusion: Tailored TA interventions in SA using a standardised structure and process led to a significant improvement in retention-in-care rates and to non-significant improvements in the proportion of PLWH screened for TB and of those who completed their treatment.