School of Clinical Medicine

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The identification of differentially expressed cell cycle -related genes in breast and colon cancer cell lines in response to chemotherapeutic drugs
(2010-01-27T11:15:07Z) Rupnarain, Charleen
With the high prevalence and high mortality rate of cancer in the global community, it is increasingly essential to accelerate our understanding of the disease, to identify new genetic targets for therapy, and to pursue avenues for improving on the therapies in development and in current use. The aim of this study is to identify cell cycle-related genes whose expression is influenced by the chemotherapeutic drugs curcumin, SAHA, lycopene and thalidomide in breast and colon cancer and normal cell lines. These drugs are currently not in clinical use for cancer in South Africa, and while there have been investigative studies of these chemotherapeutic agents, this study aims to identify the specific genes that are influenced by the drugs. The result of this is that several genes that were not previously documented as targets of these drugs are highlighted. The cell cycle pathway is the area of focus as loss of regulation in the cell cycle is one of the important factors involved in promoting cancer initiation and progression. In the first instance, flow cytometry was used to identify optimal drug concentrations relative to the cell cycle stages. Following this, alterations in gene expression were assessed using a PCR-based differential display after each drug treatment. Subsequently, a more focussed approach was taken in a PCR-array analysis of panels of cell cyclerelated genes. A subset of genes is identified that is implicated in oncogenic transformation in breast cancer. This has the potential to inhibit the genetic pathways involved in breast malignancy by providing targets that perhaps may not be manipulated in current therapies. The gene expression studies here suggest that lycopene and thalidomide function in inhibiting this transformation, and play significant roles in suppressing the oncogenic state of breast cancer. Curcumin and SAHA also exhibit important functions in inhibiting tumourigenesis in colon cancer. While the results propose that the drugs have clear roles in inhibiting breast and colon cancer, they are also implicated in promoting cancer. This research has defined the genes that must be carefully monitored during drug administering as they may promote these and other cancers. The availability of these results to researchers will aid in selecting the criteria for assessing the success rate of these drugs.
The in vitro and in vivo effects of Bulbine frutescens and Bulbine natalensis on cutaneous wound healing
(2010-01-27T13:28:12Z) Pather, Nalini
In recent years, there has been a growing interest in natural and traditional medicines for the treatment of wounds. Attempts to find agents that promote wound-healing and that are affordable, effective and non-toxic have a long history. In South Africa, hundreds of different indigenous plants are used to treat wounds and burns. The merits of relatively few of these have been scientifically evaluated. Bulbine natalensis and Bulbine frutescens of the Asphodelaceae family are indigenous to southern Africa and are widely used as a skin remedy. This study aimed to investigate the in vitro and in vivo effect of Bulbine natalensis and Bulbine frutescens on cutaneous wound healing. In vitro cell culture study: In vitro studies were carried out on dermal fibroblasts and human keratinocytes cultured under standard conditions using Iscove’s Modified Eagles Medium (MEM) and Dulbecco’s MEM respectively. Confluent cultures of both cell lines were treated with varying concentrations of the leaf extracts of B. frutescens and B. natalensis. These cultures were subjected to the MTT, WST-1 and BrdU assays to determine the cytotoxicity and proliferation effect of the extracts. In addition, migration of cells across a score was analysed over a 48 hour period. In vivo animal study: Excisional and incisional wounds were created on the back of 12 domestic pigs. Mirror imaged wounds were created as control wounds. The excisional wounds were biopsied at days 2, 4, 7, 10 and 16 and the incisional wounds were biopsied at day 16. The rate of closure of the wounds was also recorded. Each excisional wound was analyzed for its biochemical composition by estimating the total amount of protein, DNA, collagen and hexosamine that was present in the wound tissue. The wound healing process was documented histologically (using haematoxylin and eosin and a Mallory’s trichrome stain) and immunohistochemically (using anti- α smooth muscle actin, vascular endothelial growth factor WitsETD and transforming growth factor β receptors I and II). The incisional wounds were used to test tensile strength of the healed wounds using a tensiometer.In the in vitro studies, neither extract caused cytotoxicity to either the fibroblast or keratinocyte cells. Cell proliferation was greater than 100% at 0.1-5 and 100-300 μg/ml for Bulbine natalensis and at 0.1μg/ml for Bulbine frutescens. There was no significant difference in the effects of the two leaf extracts on cell proliferation. The biochemical analysis of the wound tissue showed a significant increase in the collagen, protein and total DNA content of both B frutescens and natalensis treated wounds when compared to the untreated wounds. There was no significant difference in the hexosamine content of both B. frutescens- and B. natalensis-treated and untreated wounds. Analysis of the wound tissue displayed an increase rate of closure of the wound tissue treated with B. frutescens and B. natalensis when compared to the untreated wounds. Full re-epithelialisation of both treated wounds occurred earlier than in the untreated wounds. These findings have important implications for the use of these extracts to treat wound healing.
Knowledge, attitudes and reported practices of general practitioners related to adult female patients with urinary incontinence in greater Johannesburg
(2010-01-28T08:09:44Z) Padayachey, Moganambal
BACKGROUND There is an extraordinary common medical condition that affects millions of people, mostly women. It is associated with high levels of disability, discomfort and loss of productivity. People seldom talk about it and suffer in silence and have a fear of being ridiculed or embarrassed. It is not breast cancer, nor osteoporosis, nor heart disease nor is it depression. It is urinary incontinence – the loss of bladder control, which affects the lives of millions of people globally. General Practitioners (GP‟s) do not have a good knowledge about the topic and are therefore not managing Urinary Incontinence (UI) appropriately. AIM To assess the knowledge, attitudes and reported practices of general practitioners related to adult female patients with urinary incontinence in Greater Johannesburg. OBJECTIVES To determine the demographics of the respondents belonging to the various Independent Practitioner Associations (IPA's). Variables include age, sex, year qualified, postgraduate qualifications, and the number of years in clinical practice. To determine the demographics of the respondents practice. Variables include, age distribution, gender distribution, and the number of patients seen with urinary incontinence per month. To determine the knowledge of the respondents regarding urinary incontinence in adult females. Variables include prevalence, aetiology, types of urinary incontinence, associated risk factors and reversible factors. v To determine the attitudes of the respondents regarding urinary incontinence in adult females. Variables include feelings of empathy, frustration, etc. To determine the management of the respondents regarding urinary incontinence in adult females. Variables include access of referral facilities, screening, examination, investigation, and medication. METHODS The study was done amongst the Independent Practitioner Associations in the greater Johannesburg area. A questionnaire was administered to GP‟s attending IPA meetings, data was collected with regards to the demographics of the GPs and their practices as well as the knowledge, attitudes and reported practices of the GPs. RESULTS The response rate cannot be calculated as the number of GPs who attended the IPA meetings is not known. One hundred and thirteen respondents met the inclusion criteria for the study. The data was collected over a 10-month period during 2006. Males accounted for 76 (68.5%) and females for 35 (31.5%) of all respondents. Two (1.8%) respondents had three postgraduate qualifications, 11 (9.7%) respondents had two postgraduate qualifications and 38 (33.6%) respondents had one postgraduate qualification. The prevalence of patients with UI was higher amongst female respondents, 33 (97.1%) as compared to male respondents 67 (88.2%). Feelings of empathy was experienced by 94 (88.7%) respondents and 81 (81%) respondents would never avoided the discussion about UI with patients. Most respondents rated their knowledge on aetiology 82 (78.1%), diagnosis 79 (73.8%), investigation 58 (54.2%) and management 58 (54.7%) as good and very good.
Acute coronary syndromes in black South African patients with human immunodeficiency virus infection
(2011-10-19) Becker, Anthony Charles
Background: South Africa is considered to be a country in epidemiologic transition with increasing rates of cardiovascular disease. In addition, it faces an HIV pandemic, with an estimated 5.5 million people infected and five hundred thousand HIV-related deaths annually. Current evidence suggests that patients infected with HIV are at a heightened risk for acute coronary syndromes (ACS) related to traditional cardiovascular risk factors, as well as factors related to the virus and its treatment (highly active anti-retroviral therapy (HAART)). HIV infection itself may independently predispose to coronary artery disease (CAD) by promoting endothelial dysfunction, a heightened pro-inflammatory state, dyslipidaemia and thrombosis, the aetiology of which is thought to be multifactoral in nature. Protease inhibitor (PI) therapy, as part of HAART, has the potential to induce an adverse metabolic phenotype, including: dyslipidaemia, insulin resistance, endothelial dysfunction and a prothrombotic state. The attributable risk of these factors in HIV-associated CAD and ACS is currently unknown, but it seems that the risk of ACS is increased by prolonged exposure to PI’s. No data currently exists on CAD in HIV patients not receiving HAART, which is problematic considering that this makes up the majority of patients in sub-Saharan Africa and that the combination of epidemiologic transition and HIV infection has the potential for greater cardiovascular morbidity, particularly with respect to atherothrombotic events. viii Aims: The aims of this thesis are twofold. Firstly, to confirm reports of epidemiologic transition in South Africa from a broad epidemiological perspective. Secondly, by focusing on treatment-naïve HIV positive black South Africans with ACS, it aims to determine differences compared to HIV negative patients with respect to demographics and risk factors, angiographic and treatment related factors as well as markers of thrombosis and inflammation with a view to providing more focused primary and secondary prevention. Methods: All the studies contained in this thesis were conducted in the Department of Cardiology, Chris Hani Baragwanath Hospital and adhere to the declaration of Helsinki. The first of the epidemiological studies, The Heart of Soweto (HOS) study (Chapter 3), was a prospectively designed registry that recorded epidemiologic data relating to the presentation, investigations and treatment of 1593 patients from Soweto with newly diagnosed cardiovascular disease during the year 2006. The second study (Chapter 4) was a cross sectional study of patients with ACS admitted to the Baragwanath coronary care unit over the year 2004 compared to the years 1975-1980. The HIV sub-study (chapters 5-8) was a prospective single centre study conducted from March 2004 to February 2008. During this time, 30 consecutive black HIV patients presenting with ACS (ACS+: HIV+ group) were enrolled. For each HIV patient with ACS, the first presenting non-HIV black patient with ACS was selected as a case control comparator (ACS+ : HIV- group). In addition, a second control group of 30 asymptomatic HIV patients, who were matched for age, sex and ethnicity (ACS- : HIV+ group), were recruited from the HIV clinic. The methodology used to compare the groups involved: clinical and demographic data collection, routine blood test evaluation, angiographic ix analysis and specific laboratory testing of various research blood parameters (including thrombotic screening and markers of inflammation and endothelial activation). Results: Chapter 3 presents the results of the large HOS study, which showed good evidence to support the theory of epidemiologic transition in Soweto. Adding to this data are the results of Chapter 4, which clearly demonstrate a substantial increase in the number of patients diagnosed with ACS at Baragwanath in recent years. Consistent with a population in epidemiologic transition, there was more than a ten-fold increase in the rate of coronary events over two decades, paralleled by increased rates of modifiable risk factors. Chapter 5 presents the clinical and angiographic data from the HIV sub-study. HIV patients with ACS were younger and had fewer traditional risk factors for CAD except for higher rates of smoking and lower HDL cholesterol levels. HIV patients had less atherosclerotic burden angiographically, but a higher thrombus burden in the infarct related arteries, suggesting a possible prothrombotic state. In addition, HIV patients had higher rates of in-stent restenosis of bare metal coronary stents at follow up. Chapters 6 and 7 present data on the thrombotic parameters between the groups, with Chapter 6 focusing mainly on coagulation pathways and Chapter 7 focusing on antiphospholipid antibodies (aPL). Chapter 8 presents data on levels of pro-inflammatory cytokines and endothelial activation markers. Greater evidence of thrombophilia was found in HIV patients with ACS as evidenced by lower Protein C (PC) levels, higher levels of Factor VIII and a higher inflammatory burden with greater degrees of endothelial cell activation - all of which increase thrombotic risk. Antiphospholipid antibodies were more prevalent in HIV patients but did not seem to be causal in the pathogenesis of thrombosis. x Conclusion: Soweto, a large, predominantly black urban area in South Africa, is in a state of epidemiologic transition, with an increasing prevalence of modifiable cardiovascular risk factors and ischaemic heart disease. Treatment-naïve HIV positive black patients presenting with ACS have different clinical and angiographic features compared to the HIV negative population. The patients are younger, more commonly male, with high rates of smoking, lower HDL levels and less atherosclerotic burden. However, there is a higher thrombotic burden, suggesting a prothrombotic state, which was evident by lower PC levels, higher factor VIII levels with a higher inflammatory burden and a greater degree of endothelial cell activation – all factors associated with a pro-atherogenic and prothrombotic state. The exact pathogenic role of HIV, independent of associated modifiable and non-modifiable risk factors, is difficult to determine, but may be important as a contributory factor in an already “vulnerable” patient. Importantly, we identified modifiable risk factors in the HIV group. Smoking may play a crucial role in the pathogenesis of ACS in these otherwise seemingly low risk patients and remains an important target for cardiovascular risk reduction. The role of HDL in the pathogenesis and prevention of HIV-associated CAD needs to be further defined, as does the role of drug eluting coronary stents in the prevention of in-stent restenosis. Cardiovascular risk assessment and appropriate primary prevention should be an important component in the management of HIV patients, regardless of treatment status. With the anticipated increase in CVD in South Africa, further research projects appropriate to the South African context will be vital in order to explore cost effective ways to provide primary and secondary prevention in order to effectively deal with the burden of epidemiological transition as well as the cardiovascular burden likely to be imposed by the HIV pandemic.
A brief history of South Africa's response to Aids
(2014) Simelela, N.P.; Venter, W.D.F.
The story of the AIDS response in South Africa over the past 4 years is one of great progress after almost a decade of complex and tragic denialism that united the world and civil society in a way not seen since the opposition to apartheid. Today the country can boast >2 million people on antiretroviral therapy, far and away the largest number in the world. Prevention efforts appear to be yielding results. The estimated number of annual new HIV infections declined by 79 000 between 2011 and 2012. New HIV infections among adults aged 15 - 49 years are projected to decline by 48% by 2016, from 414 000 (2010) to ~215 000 (2016). The national incidence rate has reached its lowest level since the disease was first declared an epidemic in 1992, translating into reductions in both infant and under-5 mortality and an increase in life expectancy from 56 to 60 years over the period 2009 - 2011 alone. This is largely thanks to a civil society movement that was prepared to pose a rights-based challenge to a governing party in denial, and to brave health officials, politicians and clinicians working in a hostile system to bring about change.
Factors associated with mortality in HIV-infected people in rural and urban South Africa
(2014) Otwombe, KN; Petzold, M; Modisenyane, T
Background: Factors associated with mortality in HIV-infected people in sub-Saharan Africa are widely reported. However rural urban disparities and their association with all-cause mortality remain unclear. Furthermore, commonly used classical Cox regression ignores unmeasured variables and frailty. Objective: To incorporate frailty in assessing factors associated with mortality in HIV-infected people in rural and urban South Africa. Design: Using data from a prospective cohort following 6,690 HIV-infected participants from Soweto (urban) and Mpumalanga (rural) enrolled from 2003 to 2010; covariates of mortality were assessed by the integrated nested Laplace approximation method. Results: We enrolled 2,221 (33%) rural and 4,469 (67%) urban participants of whom 1,555 (70%) and 3,480 (78%) were females respectively. Median age (IQR) was 36.4 (31.0 44.1) in rural and 32.7 (28.2 38.1) in the urban participants. The mortality rate per 100 person-years was 11 (9.7 12.5) and 4 (3.6 4.5) in the rural and urban participants, respectively. Compared to those not on HAART, rural participants had a reduced risk of mortality if on HAART for 6 12 (HR: 0.20, 95% CI: 0.10 0.39) and 12 months (HR: 0.10, 95% CI: 0.05 0.18). Relative to those not on HAART, urban participants had a lower risk if on HAART 12 months (HR: 0.35, 95% CI: 0.27 0.46). The frailty variance was significant and 1 in rural participants indicating more heterogeneity. Similarly it was significant but B1 in the urban participants indicating less heterogeneity. Conclusion: The frailty model findings suggest an elevated risk of mortality in rural participants relative to the urban participants potentially due to unmeasured variables that could be biological, socio economic, or healthcare related. Use of robust methods that optimise data and account for unmeasured variables could be helpful in assessing the effect of unknown risk factors thus improving patient management and care in South Africa and elsewhere.
Parents' perceptions of HIV counselling and testing in schools : Ethical, legal and social implications
(2014-01) Gwandure, R; Ross, E; Dhai, A; et al
In view of the high prevalence of HIV and AIDS in South Africa, particularly among adolescents, the Departments of Health and Education have proposed a school-based HIV counselling and testing (HCT) campaign to reduce HIV infections and sexual risk behaviour. Through the use of semi-structured interviews, our qualitative study explored perceptions of parents regarding the ethico-legal and social implications of the proposed campaign. Despite some concerns, parents were generally in favour of the HCT campaign. However, they were not aware of their parental limitations in terms of the Children’s Act. Their views suggest that the HCT campaign has the potential to make a positive contribution to the fight against HIV and AIDS, but needs to be well planned. To ensure the campaign’s success, there is a need to enhance awareness of the programme. All stakeholders, including parents, need to engage in the programme as equal partners.
Charting the path along the continuum of PMCT or HIV-1 to elimination and finally to eradication
(2014-01) Ramkissoon, A; Coovadia, H
In this editorial we traverse the continuum of transmission of HIV-1 from mothers to children to highlight the biomedical history of this problem. Treatment has progressed from prevention with antiretrovirals (ARVs) through to a broader set of interventions, including various breastfeeding options and other health system improvements, that have increased the possibility of eliminating mother-to-child-transmission (MTCT) of HIV.
Extrapulmonary tuberculosis among adults : Experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
(2014-01) Karstaedt, A.S.
Prevalence and incidence of symmetrical symptomatic peripheral neuropathy in patients with multidrug - resistant TB
(2014-01) Conradie, F; Mabiletsa, T; Sefoka, M; et al
Background: Symptomatic symmetrical peripheral neuropathy (SSPN) is common in patients with HIV infection. It is also a common adverse event associated with both tuberculosis (TB) treatment and antiretroviral therapy (ART), particularly stavudine. While tenofovir is the one of recommended first-line nucleotide reverse transcriptase inhibitors (NRTIs), there is a risk of nephrotoxicity when using tenofovir together with the aminoglycosides needed to treat multidrug-resistant (MDR) TB. Thus, stavudine is often chosen as a treatment option for the HIV-infected MDR TB patient. Objective: To assess whether use of stavudine both before and during treatment for MDR TB increased the prevalence and incidence of SSPN. Method: MDR TB patients at Sizwe Tropical Disease Hospital were examined for signs of prevalent SSPN. Age, gender, HIV status, alcohol use, TB and HIV treatment regimens both prior to admission and current, and concomitant medications were recorded. Results: In this cohort of 246 patients, we found that 24.4% of patients with MDR TB had SSPN at time of admission for treatment of MDR TB. They were more likely to be HIV-infected (odds ratio (OR) 3.21; 95% CI 1.25 - 8.21) and tended to have longer (>7 months) exposure to stavudine (OR 1.81; 95% CI 0.90 - 3.63). Incident SSPN occurred in 17% of patients and was associated with older age (hazard ratio (HR) 3.00; 95% CI 1.30 - 6.89) and exposure to terizidone (HR 2.98; 95% CI 0.94 to 4.61) or, to a lesser extent, with stavudine (crude HR 1.62; 95% CI 0.65 - 4.01) in the first 6 months of MDR TB treatment. This common adverse event emphasises the need for the development of less toxic drugs for the treatment of MDR TB.
Traditional male circumcision : Balancing cultural rights and the prevention of serious, avoidable harm.
(2014-01) Behrens, K G
The right to participate in cultural practices should be protected. However, it is a limited right, and does not entail a right to activities that cause serious and avoidable harms. I argue that the harms currently resulting from traditional circumcision are very serious, and that we have an obligation to ensure that the practice is effectively regulated so as to minimise them
The cost of harmful alcohol use in South Africa
(2014-02) Matzopoulos, R G; Truen, S; Bowman, B; et al.
Background. The economic, social and health costs associated with alcohol-related harms are important measures with which to inform alcohol management policies and laws. This analysis builds on previous cost estimates for South Africa. Methods. We reviewed existing international best-practice costing frameworks to provide the costing definitions and dimensions. We sourced data from South African costing literature or, if unavailable, estimated costs using socio-economic and health data from secondary sources. Care was taken to avoid possible causes of cost overestimation, in particular double counting and, as far as possible, second-round effects of alcohol abuse. Results. The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of the 2009 gross domestic product (GDP). The tangible financial cost of harmful alcohol use alone was estimated at R37.9 billion, or 1.6% of the 2009 GDP. Discussion. The costs of alcohol-related harms provide a substantial counterbalance to the economic benefits highlighted by the alcohol industry to counter stricter regulation. Curtailing these costs by regulatory and policy interventions contributes directly and indirectly to social well-being and the economy. Conclusions. Existing frameworks that guide the regulation and distribution of alcohol frequently focus on maximising the contribution of the alcohol sector to the economy, but should also take into account the associated economic, social and health costs. Current interventions do not systematically address the most important causes of harm from alcohol, and need to be informed by reliable evidence of the ongoing costs of alcohol-related harms.
The research ethics evolution : From Nuremberg to Helsinki
(2014-03) Dhai, A
Health research sets out to acquire not only theoretical knowledge but also benefits for many people and often society as a whole, and is therefore justified. The quandary, though, is how such an important, shared purpose can be pursued with full protection of individuals and communities, in particular those with vulnerabilities. Abuses in the field surfaced in the early 1800s, and by the 1890s, anti-vivisectionists were calling for laws to protect children because of the increasing numbers of institutionalised children being subjected to unethical research. When read together, the Nuremberg Code and the Universal Declaration of Human Rights can be interpreted as establishing a basis for underpinning the principles of free and informed consent and avoiding harms and exploitation in scientific experiments involving human participants. The Declaration of Helsinki has been recognised as one of the most authoritative statements on ethical standards for human research in the world.
New imaging approaches for improving diagnosis of childhood tuberculosis
(2014-03) Bélard, S; Andronikou, S; Pillay, T; et al
Successfully controlling malaria in South Africa
(2014-03) Blumberg, I; Frean, J; Moonasar, D
Following major successes in malaria control over the past 75 years, South Africa is now embarking on a malaria elimination campaign with the goal of zero local transmission by the year 2018. The key control elements have been intensive vector control, primarily through indoor residual spraying, case management based on parasitological diagnosis using evidence-based drug policies with artemisinin-based combination therapy since 2001, active health promotion in partnership with communities living in the malaria transmission areas, and cross-border collaborations. Political commitment and long-term funding for the malaria control programme have been a critical component of the programme’s success. Breaking the cycle of transmission through strengthening of active surveillance using sensitive molecular tests and field treatment of asymptomatic persons, monitoring for antimalarial drug resistance and insecticide resistance, strengthening cross-border initiatives, and ongoing programme advocacy in the face of a significant decrease in disease burden are key priorities for achieving the elimination goal.
Clinical access to Bedaquiline Programme for the treatment of drug-resistant tuberculosis
(2014-03) Conradie, F; Meintjies, G; Hughes, J; et al
While clinical disease caused by drug-sensitive Mycobacterium tuberculosis (MTB) can usually be treated successfully, clinical disease caused by drug-insensitive MTB is associated with a poorer prognosis. In December 2012, a new drug, bedaquiline, was approved by the US Food and Drug Administration. This article documents the process whereby the National Department of Health, Right to Care and Médecins Sans Frontières obtained access to this medication for South Africans who might benefit from subsequent implementation of the Clinical Access to Bedaquiline Programme.
Self- induction of abortion among women accessing second- trimester abortion services in the public sector, Western Cape Province, South Africa : An exploratory study
(2014-04) Constant, D; Grossman, D; Lince, N; et al
Background: Despite South Africa's liberal abortion law permitting abortion on request in the first trimester and under restricted conditions for second-trimester pregnancies, the practice of unsafe self-induced abortion persists. However, the prevalence of this practice, the methods used and the reasons behind it are relatively under-researched. As part of a larger study seeking to improve abortion services in the Western Cape Province, we explored reports of prior attempts to self-induce abortion among women undergoing legal second-trimester abortion. Objectives: To describe the prevalence and methods of and factors related to unsuccessful attempts at self-induction of abortion by women presenting without complications and seeking second-trimester abortion at public health facilities in the Western Cape. Methods: In a cross-sectional study from April to August 2010, 194 consenting women undergoing second-trimester abortion were interviewed by trained fieldworkers using structured questionnaires at four public sector facilities near Cape Town. Results: Thirty-four women (17.5%; 95% confidence interval 12.7 - 23.4) reported an unsuccessful attempt to self-induce abortion during the current pregnancy before going to a facility for second-trimester abortion. No factors were significantly associated with self-induction, but a relatively high proportion of this small sample were unemployed and spoke an indigenous African language at home. A readily available herbal product called Stametta was most commonly used; other methods included taking tablets bought from unlicensed providers and using other herbal remedies. No use of physical methods was reported. Conclusions: The prevalence of unsafe self-induction of abortion is relatively high in the Western Cape. Efforts to inform women in the community about the availability of free services in the public sector and to educate them about the dangers of self-induction and unsafe providers should be strengthened to help address this public health issue.
Perceptions of mental illness among Muslim general practitioners in South Africa
(2014-05) Mohamed- Kaloo, Z; Laher, S
Background: Mental health literacy on the part of medical practitioners is an important component of mental healthcare. General practitioners (GPs) are typically the first doctors consulted by a person who is ill. Exploration of their perceptions regarding mental illness, aetiological issues and treatment is important. Objective: To investigate perceptions of mental illness in a sample of ten South African Muslim GPs (five male, five female) in the Lenasia area (Johannesburg, South Africa). Methods: Using a qualitative approach, semi-structured interviews were conducted with each GP. The questionnaire encompassed 37 questions relating to the context in which the GPs practised, perceptions of mental illness, understanding of religion and culture, and treatment of mental illness (including aspects of spiritual illness). Thematic content analysis was used to analyse the data. Results: Six dominant themes were identified, namely GPs' understanding of mental illness and its causation; stigma, secrecy and somatisation; the beneficial effects of religion in mental illnesses; perceptions of spiritual illnesses; collaboration with traditional healers; and collaboration with psychiatrists and psychologists. Conclusion: Greater awareness regarding the stigmatisation of mental illness is needed. Furthermore, it is important that healthcare professionals have an understanding of religious and cultural taxonomies of illness as well as the use of traditional healing as a mode of treatment. Participants identified a need for increased collaboration between healthcare professionals, including traditional healers.
The challenges of managing breast cancer in the developing world- a perspective from sub- Saharan Africa
(2014-05) Edge, J; Buccimazza, I; Cubasch, H; et al.
Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer, and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.
Setting ART initiation targets in response to changing guidelines : The importance of addressing both steady-state and backlog
(2014-06) Martin, C; Naidoo, N P; Venter, W D F; et al.
Background: Target setting is useful in planning, assessing and improving antiretroviral treatment (ART) programmes. In the past 4 years, the ART initiation environment has been transformed due to the change in eligibility criteria (starting ART at a CD4+ count <350 cells/μl v. <200 cells/μl) and the roll-out of nurse-initiated management of ART. Objective: To describe and illustrate the use of a target-setting model for estimating district-based targets in the era of an expanding ART programme and changing CD4+ count thresholds for ART initiation. Method: Using previously described models and data for annual new HIV infections, we estimated both steady-state need for ART initiation and backlog in a North West Province district, accounting for the shift in eligibility. Comparison of actual v. targeted ART initiations was undertaken. The change in CD4+ count threshold adds a once-off group of newly eligible patients to the pool requiring ART – the backlog. The steady-state remains unchanged as it is determined by the annual rate of new HIV infections in previous years. Results: The steady-state need for the district was 639 initiations/month, and the backlog was ~15 388 patients. After the shift in eligibility in September 2011, the steady-state target was exceeded over several months with some backlog addressed. Of the total backlog for this district, 72% remains to be cleared. Conclusion: South Africa has two pools of patients who need ART: the steady-state of HIV-infected patients entering the programme each year, determined by historical infection rates; and the backlog created by the shift in eligibility. The healthcare system needs to build longterm capacity to meet the steady-state need for ART and additional capacity to address the backlog.

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