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- ItemA 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.
- ItemPrevalence and incidence of symmetrical symptomatic peripheral neuropathy in patients with multidrug - resistant TB(2014-01) Conradie, F; Mabiletsa, T; Sefoka, M; et alBackground: 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.
- ItemThe 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.
- ItemClinical access to Bedaquiline Programme for the treatment of drug-resistant tuberculosis(2014-03) Conradie, F; Meintjies, G; Hughes, J; et alWhile 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.
- ItemSelf- 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 alBackground: 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.
- ItemSetting 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.
- ItemShould HIV be a notifiable disease? Old questions with some new arguments(2014-09) Venter, W D F; Black, A; Allais, L; et alHIV notification enters national debate regularly, often introduced by politicians and supported by many individual healthcare workers. We argue that its proponents advance confused or poorly informed rationales for making HIV notifiable. We present reasons why making HIV notifiable would be inappropriate in South Africa, why the public health benefits of a notification programme are not even likely, and why there are risks of public health and human rights harms.
- ItemNeglected sexual dysfunction symptoms amongst chronic patients during routine consultations in rural clinics in the North West province(AOSIS, 2021-04-28) Pretorius, Deidre; Couper, Ian D; Mlambo, Motlatso G.Background: Sexual dysfunction contributes to personal feelings of loss and despair and being a cause of exacerbated interpersonal conflict. Erectile dysfunction is also an early biomarker of cardiovascular disease. As doctors hardly ever ask about this problem, it is unknown how many patients presenting for routine consultations in primary care suffer from symptoms of sexual dysfunction. Aim: To develop an understanding of sexual history taking events, this study aimed to assess the proportion of patients living with symptoms of sexual dysfunction that could have been elicited or addressed during routine chronic illness consultations. Setting: The research was carried out in 10 primary care facilities in Dr Kenneth Kaunda Health District, the North West province, South Africa. This rural area is known for farming and mining activities. Methods: This study contributed to a broader research project with a focus on sexual history taking during a routine consultation. A sample of 151 consultations involving patients with chronic illnesses were selected to observe sexual history taking events. In this study, the patients involved in these consultations completed demographic and sexual dysfunction questionnaires (FSFI and IIEF) to establish the proportions of patients with sexual dysfunction symptoms. Results: A total of 81 women (78%) and 46 men (98%) were sexually active. A total of 91% of the women reported sexual dysfunction symptoms, whilst 98% of men had erectile dysfunction symptoms. The youngest patients to experience sexual dysfunction were a 19-year-old woman and a 26-year-old man. Patients expressed trust in their doctors and 91% of patients did not consider discussion of sexual matters with their doctors as too sensitive. Conclusion: Clinical guidelines, especially for chronic illness care, must include screening for sexual dysfunction as an essential element in the consultation. Clinical care of patients living with chronic disease cannot ignore sexual well-being, given the frequency of problems. A referral to a sexual medicine specialist, psychologist or social worker can address consequences of sexual dysfunction and improve relationships.
- ItemSexual history taking: perspectives on doctor-patient interactions during routine consultations in rural primary care in South Africa(Elsevier Inc., 2021-05-03) Pretorius, Deidre; Couper, Ian; Mlambo, MotlatsoBackground: Sexual history taking for risk behavior contributes to improving health outcomes in primary care. Giving the high numbers of people living with AIDS, every patient in South Africa should be offered an HIV test, which implies that a comprehensive sexual history must be taken. Aim: To describe the optimal consultation process, as well as associated factors and skills required to improve disclosure of sexual health issues during a clinical encounter with a doctor in primary health care settings in North West province, South Africa. Methods: This qualitative study, based on grounded theory, involved the video-recording of 151 consultations of adult patients living primarily with hypertension and diabetes. This article reports on the 5 consultations where some form of sexual history taking was observed. Patient consultations were analyzed thematically, which entailed open coding, followed by focused and verbatim coding using MaxQDA 2018 software. Confirmability was ensured by 2 generalist doctors, a public health specialist and the study supervisors. Main outcome measure: Sexual history was not taken and patients living with sexual dysfunction were missed. If patients understand how disease and medication contribute to their sexual wellbeing, this may change their perceptions of the illness and adherence patterns. Results: Sexual history was taken in 5 (3%) out of 151 consultations. Three themes emerged from these 5 consultations. In the patient-doctor relationship theme, patients experienced paternalism and a lack of warmth and respect. The consultation context theme included the seating arrangements, ineffective use of time, and privacy challenges due to interruptions and translators. Theme 3, consultation content, dealt with poor coverage of the components of the sexual health history. Conclusion: Overall, sexual dysfunction in patients was totally overlooked and risk for HIV was not explored, which had a negative effect on patients' quality of life and long-term health outcomes. The study provided detailed information on the complexity of sexual history taking during a routine consultation and is relevant to primary health care in a rural setting. Pretorius D, Couper I, Mlambo M. Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa. Sex Med 2021;9:100389.
- ItemSexual history taking: doctors’ clinical decision-making in primary care in the North West province, South Africa(AOSIS, 2021-09-29) Pretorius, Deidre; Couper, Ian D; Mlambo, Motlatso G.Background: Clinical reasoning is an important aspect of making a diagnosis for providing patient care. Sexual dysfunction can be as a result of cardiovascular or neurological complications of patients with chronic illness, and if a patient does not raise a sexual challenge, then the doctor should know that there is a possibility that one exists and enquire. Aim: The aim of this research study was to assess doctors’ clinical decision-making process with regards to the risk of sexual dysfunction and management of patients with chronic illness in primary care facilities of the North West province based on two hypothetical patient scenarios. Setting: This research study was carried out in 10 primary care facilities in Dr Kenneth Kaunda health district, North West province, a rural health district. Methods: This vignette study using two hypothetical patient scenarios formed part of a broader grounded theory study to determine whether sexual dysfunction as comorbidity formed part of the doctors’ clinical reasoning and decision-making. After coding the answers, quantitative content analysis was performed. The questions and answers were then compared with standard answers of a reference group. Results: One of the doctors (5%) considered sexual dysfunction, but failed to follow through without considering further exploration, investigations or management. For the scenario of a female patient with diabetes, the reference group considered cervical health questions (p = 0.001) and compliance questions (p = 0.004) as standard enquiries, which the doctors from the North West province failed to consider. For the scenario of a male patient with hypertension and an ex-smoker, the reference group differed significantly by expecting screening for mental health and vision (both p = 0.001), as well as for HIV (p < 0.001). The participating doctors did not meet the expectations of the reference group. Conclusion: Good clinical reasoning and decision-making are not only based on knowledge, intuition and experience but also based on an awareness of human well-being as complex and multidimensional, to include sexual well-being.
- ItemMaternal alcohol use and childrens emotional and cognitive outcomes in rural South AfricaTamsen Rochat; Brian Houle; Alan Stein; J Mitchell; Ruth Bland
- ItemEvidence for use of a healthy relationships assessment tool in the CHARISMA pilot studyElizabeth E. Tolley; Andres Martinez; Seth Zissette; Thesla Palanee-Philips; Florence Mathebula; Siyanda Tenza; Miriam Hartmann; et al et al
- ItemSouthern African HIV Clinicians Society genderaffirming healthcare guideline for South AfricaRutendo Bothma; Willem Venter; Anastacia Tomson; Chris/tine McLachlan; Camilla Wattrus; Kevin Adams; E et al