Search

Background: Cervical cancer affects mostly young women from poor countries and disadvantaged populations. Limited information is available that specifically outline the presenting features and treatment outcomes of young patients treated for cervical cancer. Objectives: The aim of this study was to evaluate treatment decisions and outcomes in young women (under the age of 39 years) with cervical cancer who were treated at a single institution in South Africa. Design and methods: Retrospective analysis was used to review medical records of patients younger than 39 years of age with cervical cancer who were referred for radiation from January 2015 to December 2017. Data were collected on patient demographics, HIV status, stage, treatment and survival outcome. Results: During the study period, 92 patients under the age of 39 years of age were referred for radiotherapy. The median age was 33 years of age (24-38 years). Overall, 35.9% (n = 33) were HIV-positive. Disease characteristics indicated that 65.2% (n = 60) were Stage IIIB and above. Seventy patients (76.1%) received primary chemoradiation, radiation or adjuvant chemoradiation. HIVnegative patients were significantly more likely to be prescribed curative therapy (86.2% compared to 60.6%; p = 0.05). Two-year overall survival was 71.8% (65.1-78.5%) for the primary chemoradiation cohort and 80% (78.2-81.8%) for patients who received adjuvant chemoradiation. The outcome was significantly impacted by the delivery of concurrent chemotherapy in the primary chemoradiation group but not by HIV status of the patients. Conclusion: Young women presenting with cervical carcinoma at our institution had a high prevalence of HIV and were mostly at an advanced stage. Though the HIV status of a patient impacted treatment intent, more than 80% of the cohort received a > 40 Gy external beam radiotherapy (RT) and the two-year overall survival was greater 70% in the curative group. [ABSTRACT FROM AUTHOR]

Background: South Africa, with one of the highest HIV prevalences in the world, introduced the universal test and treat (UTT) programme in September 2016. Barriers to sustained viral suppression may include drug resistance in the pre-treated population, non-adherence, acquired resistance; pharmacokinetics and pharmacodynamics, and concurrent use of alternative treatments. Objective: The purpose of this review is to highlight potential challenges to achieving sustained viral load suppression in South Africa (SA), a major expectation of the UTT initiative. Methodology: Through the PRISMA approach, published articles from South Africa on transmitted drug resistance; adherence to ARV; host genetic factors in drug pharmacokinetics and pharmacodynamics, and interactions between ARV and herbal medicine were searched and reviewed. Results: The level of drug resistance in the pre-treated population in South Africa has increased over the years, although it is heterogeneous across and within Provinces. At least one study has documented a pre-treated population with moderate (> 5%) or high (> 15%) levels of drug resistance in eight of the nine Provinces. The concurrent use of ARV and medicinal herbal preparation is fairly common in SA, and may be impacting negatively on adherence to ARV. Only few studies have investigated the association between the genetically diverse South African population and pharmacokinetics and pharmacodynamics of ARVs. Conclusion: The increasing levels of drug resistant viruses in the pre-treated population poses a threat to viral load suppression and the sustainability of first line regimens. Drug resistance surveillance systems to track the emergence of resistant viruses, study the burden of prior exposure to ARV and the parallel use of alternative medicines, with the goal of minimizing resistance development and virologic failure are proposed for all the Provinces of South Africa. Optimal management of the different drivers of drug resistance in the pre-treated population, non-adherence, and acquired drug resistance will be beneficial in ensuring sustained viral suppression in at least 90% of those on treatment, a key component of the 90-90-90 strategy. [ABSTRACT FROM AUTHOR]

Background: Little is known of stroke outcomes in low- and middle-income countries with limited formal stroke rehabilitation services and of homebased-stroke services delivered within the primary health care (PHC) context by community health workers (CHWs). Objectives: To describe and analyze the outcomes of patients with stroke from a rural PHC setting in the Western Cape, South Africa. Methods: In a longitudinal survey, 93 stroke patients, referred to home and community-based care services (HCBC) between June 2015 and December 2017, were assessed at baseline, one month and three months. Changes in function (Barthel Index (BI)), caregiver strain (Caregiver Strain Index (CSI)), impact of environmental factors and satisfaction with stroke care were measured. Results: HCBC was delayed, fragmented and brief (median session duration 20 minutes (IQR 15.0–30.0)). Although function improved significantly, dependence remained high: median BI score changed from 40.0 (IQR 15.0–70.0) to 62.5 (IQR 30.0–81.25) (p =.019). A third (33.0% (30/91)) of caregivers initially experienced strain and the median CSI score remained 3.0 (IQR 0.0–7.0) (p =.672). Overall, patient and caregiver satisfaction with HCBC was low with only 46.9% (31/66) of caregivers and 17.4% (12/69) of patients satisfied with all aspects of care. Only 47.6% of assistive product needs were met. Environmental factors negatively impacted on patient function and caregiving. Conclusions: Clinical practice pathways and referral guidelines should be developed for the HCBC platform. Specific training of CHWs, focusing on how to educate, support and train family caregivers, provide assistive devices and refer to health services is needed. [ABSTRACT FROM AUTHOR]

Background: Understanding the psychopathology accompanying alcohol use disorder (AUD) is important as it impacts negatively on quality of life (QoL) with subsequent implications for treatment and recovery. We evaluated the association of psychiatric comorbidity with QoL among treatment-seeking South African AUD patients. Methods: Cross-sectional assessment of 101 (Male, n = 65; 64.5%) patients with AUD was done using the World Health Organisation Quality of Life (WHOQoL)-Bref, the World Health Organisation Disability Assessment Scale (WHODAS) and Mini-International Neuropsychiatric Interview (MINI) to collect QoL, disability and psychopathology data, respectively. Results: Psychiatric comorbidity was noted in 63 (62.3%) of the patients with most (55.6%) having more than one disorder. Mood (39; 61.9%) and anxiety (33; 52.4%) were the most common co-occurring disorders. Disability scores were not significantly different between comorbidity and gender groups However, QoL scores were significantly lower for participants with comorbidity in three of the four WHOQOL domains and declined with increasing number of psychiatric disorders. Focussing on the two main psychopathologies, participants with anxiety alone consistently had the lowest QoL scores compared to those with neither or both disorders (p < 0.05). Conclusion: The results confirm the well-known high rate of psychiatric comorbidity in patients with AUD and the negative impact it has on QoL. The results should alert clinicians managing AUD patients to screen for comorbid psychopathology and include findings into their treatment plan as this may impact on the patient's QoL. [ABSTRACT FROM AUTHOR]

Tenofovir is less toxic than other nucleoside reverse-transcriptase inhibitors used in antiretroviral therapy (ART) and may improve retention of human immunodeficiency virus (HIV)–infected patients on ART. We assessed the impact of national guideline changes in South Africa (2010) and Zambia (2007) recommending tenofovir for first-line ART. We applied regression discontinuity in a prospective cohort study of 52,294 HIV-infected adults initiating first-line ART within 12 months (±12 months) of each guideline change. We compared outcomes in patients presenting just before and after the guideline changes using local linear regression and estimated intention-to-treat effects on initiation of tenofovir, retention in care, and other treatment outcomes at 24 months. We assessed complier causal effects among patients starting tenofovir. The new guidelines increased the percentages of patients initiating tenofovir in South Africa (risk difference (RD) = 81 percentage points, 95% confidence interval (CI): 73, 89) and Zambia (RD = 42 percentage points, 95% CI: 38, 45). With the guideline change, the percentage of single-drug substitutions decreased substantially in South Africa (RD = −15 percentage points, 95% CI: −18, −12). Starting tenofovir also reduced attrition in Zambia (intent-to-treat RD = −1.8% (95% CI: −3.5, −0.1); complier relative risk = 0.74) but not in South Africa (RD = −0.9% (95% CI: −5.9, 4.1); complier relative risk = 0.94). These results highlight the importance of reducing side effects for increasing retention in care, as well as the differences in population impact of policies with heterogeneous treatment effects implemented in different contexts. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) continues to be a major global health problem. While progress has been made to improve TB cure rates, South Africa's 76 % smear-positive pulmonary TB (PTB) case cure rate remains below the WHO target of 85 %. We report on the trends of TB smear non-conversion and their predictors at the end of an intensive phase of treatment, and how this impacted on treatment outcomes of smear-positive PTB cases in Eden District, Western Cape Province, South Africa.Methods: Routinely collected, retrospective data of smear-positive PTB cases from the electronic TB register in Eden District between 2007 and 2013 was extracted. Non-conversion was defined as persistent sputum smear-positive PTB cases at the end of the two or three month intensive phase of treatment. Chi-square test for linear trend and simple linear regression analysis were used to analyse the change in percentages and slope of TB smear non-conversion rates over time. Risk factors for TB non-conversion, and their impact on treatment outcomes, were evaluated using logistic regression models.Results: Of 12,742 total smear-positive PTB cases included in our study, 12.8 % (n = 1627) did not sputum smear convert; 13.3 % (1411 of 10,574) of new cases and 9.9 % (216 of 2168) of re-treatment cases. Although not statistically significant in either new or re-treatment cases, between 2007 and 2013, smear non-conversion decreased from 16.4 to 12.7 % (slope = -0.60; 95 % CI: -1.49 to 0.29; p = 0.142) in new cases, and from 11.3 to 10.8 % in re-treatment cases (slope = -0.29; 95 % CI: -1.06 to 0.48; p = 0.376). Male gender, HIV co-infection and a >2+ acid fast bacilli (AFB) smear grading at the start of TB treatment were independent risk factors for non-conversion (p < 0.001). Age was a risk factor for non-conversion in new cases, but not for re-treatment cases. Non-conversion was also associated with unsuccessful treatment outcomes (p < 0.01), including treatment default and treatment failure.Conclusions: Smear-positive PTB cases, especially men and those with identified risk factors for non-conversion, should be closely monitored throughout their treatment period. The South African TB control program should invest in patient adherence counselling and education to mitigate TB non-conversion risk factors, and to improve conversion and TB cure rates. [ABSTRACT FROM AUTHOR]

Background: The implementation of collaborative TB-HIV services is challenging. We, therefore, assessed TB treatment outcomes in relation to HIV infection and antiretroviral therapy (ART) among TB patients attending a primary care service with co-located ART and TB clinics in Cape Town, South Africa.Methods: In this retrospective cohort study, all new TB patients aged ≥ 15 years who registered and initiated TB treatment between 1 October 2009 and 30 June 2011 were identified from an electronic database. The effects of HIV-infection and ART on TB treatment outcomes were analysed using a multinomial logistic regression model, in which treatment success was the reference outcome.Results: The 797 new TB patients included in the analysis were categorized as follows: HIV- negative, in 325 patients (40.8 %); HIV-positive on ART, in 339 patients (42.5 %) and HIV-positive not on ART, in 133 patients (16.7 %). Overall, bivariate analyses showed no significant difference in death and default rates between HIV-positive TB patients on ART and HIV-negative patients. Statistically significant higher mortality rates were found among HIV-positive patients not on ART compared to HIV-negative patients (unadjusted odds ratio (OR) 3.25; 95 % confidence interval (CI) 1.53-6.91). When multivariate analyses were conducted, the only significant difference between the patient categories on TB treatment outcomes was that HIV-positive TB patients not on ART had significantly higher mortality rates than HIV-negative patients (adjusted OR 4.12; 95 % CI 1.76-9.66). Among HIV-positive TB patients (n = 472), 28.2 % deemed eligible did not initiate ART in spite of the co-location of TB and ART services. When multivariate analyses were restricted to HIV-positive patients in the cohort, we found that being HIV-positive not on ART was associated with higher mortality (adjusted OR 7.12; 95 % CI 2.95-18.47) and higher default rates (adjusted OR 2.27; 95 % CI 1.15-4.47).Conclusions: There was no significant difference in death and default rates between HIV-positive TB patients on ART and HIV negative TB patients. Despite the co-location of services 28.2 % of 472 HIV-positive TB patients deemed eligible did not initiate ART. These patients had a significantly higher death and default rates. [ABSTRACT FROM AUTHOR]

Objective In April 2010, South Africa replaced stavudine with tenofovir in first-line antiretroviral therapy ( ART) despite tenofovir's higher cost. We examined treatment outcomes over 24 months amongst patients initiated on tenofovir-based vs. stavudine-based first-line regimens. Methods Prospective cohort analysis of 3940 patients newly initiating either stavudine-based ( April 2009 to March 2010) or tenofovir-based ( April 2010 to March 2011) ART in Johannesburg, South Africa. Cox proportional hazards models and Fine and Gray's competing risk regression accounting for death were used to model mortality and loss to follow-up, respectively. Linear and log-binomial regression were used to evaluate associations with immunologic response and unsuppressed virus (≥400 copies/ml), respectively. Results About 1878 patients prescribed tenofovir and 2062 patients prescribed stavudine were included. One hundred and sixty-six (8.8%) tenofovir and 244 (11.8%) stavudine patients died. Three hundred and fifty (18.6%) tenofovir and 379 (18.4%) stavudine patients were lost to follow-up over 24 months on ART. Adjusted regression models showed tenofovir and stavudine were comparable regarding death, loss to follow-up, immunologic response and virologic status. Conclusions We found no difference in mortality, loss to follow-up, immunological and virologic outcomes over the first 24-months on ART associated with tenofovir compared with stavudine. [ABSTRACT FROM AUTHOR]

Background: South Africa is one of the countries in the world with a high burden of tuberculosis (TB). High rates of unfavourable treatment outcomes have remained a feature of TB control in the country. The objective of the current study was to examine the treatment outcomes of TB among health care workers (HCWs) at a rural general hospital in the Mpumalanga province of the country, as well as the clinical care that was provided to the HCWs. The purpose of the study was to identify possible areas for improvement in the TB care services provided to HCWs in the hospital, especially with regard to their clinical management. Method: The research described in this article consists of a retrospective descriptive study. Relevant data on HCWs diagnosed with TB in the hospital during 2007, the TB care services offered to the HCWs, and the treatment outcomes of the HCWs were captured from the occupational health and TB control programme registers at the hospital onto a data capture sheet for the study and were subsequently analysed manually. Results: Nine HCWs, eight females and one male, were diagnosed and treated for TB in the hospital during 2007, an incidence rate of 941/100 000. Their ages ranged from 39 to 54 years, with a mean age of 48 years. By occupation, the nine HCWs consisted of six nurses (67%), one porter (11%), one general assistant (11%), and one clerk (11%). Of those treated for TB, seven (78%) had smearpositive pulmonary TB (PTB) and two (22%) had extra-pulmonary TB (EPTB). TB culture and drug susceptibility testing (DST) was undertaken for only one HCW. The HIV status was known for only two (22%) of the nine HCWs under review. Neither of the two HCWs with EPTB had the diagnosis confirmed by bacteriological or histopathological method. The seven HCWs with smear- positive PTB achieved a cure, and the two HCWs with EPTB successfully completed treatment, resulting in a treatment success rate of 100% for the nine HCWs. Conclusion: The HCWs at Themba Hospital in the Mpumalanga province of South Africa who were diagnosed and treated for TB during 2007 all achieved favourable treatment outcomes. However, in view of the high rate of HIV/TB co-infection and the increasing problem of drug-resistant TB in the country, the clinical care provided to HCWs with TB by the hospital should be improved with regard to routine HIV counselling and testing and the routine early provision of DST. A protocol for the comprehensive management of HCWs with TB is currently undergoing development. [ABSTRACT FROM AUTHOR]

Although treatment default by psychiatric patients or mental health care users is a global challenge, this behavior is reported to be higher in South Africa. The Manguzi District Hospital in rural Kwa-Zulu Natal Province, South Africa, experiences high rates of treatment default by psychiatric patients. The objective of this study was to determine the reasons for treatment defaulting at Manguzi Hospital, KwaZulu-Natal Province, South Africa. An explorative qualitative design, using in-depth interviews, was conducted with mental health care users who had defaulted out-patient psychiatric treatment. Twenty-one mental health care users were interviewed before data saturation was reached. Nvivo version 11 was used to analyze the qualitative data. Major themes that emerged confirmed that social factors are key contributions to treatment defaulting, and these include denial of the mental disorders; belief that they are cured; lack of, or disintegration of social support; preference for traditional medicine; and flaws in the health care system. Social determinants of treatment outcomes for mental disorders require tailor-made support systems for patients in these rural communities, which include increase in health literacy and attention to the cultural understanding of mental disorders. [ABSTRACT FROM AUTHOR]

Background: The frequent occurrence of medicine stockouts represents a significant obstacle to tuberculosis control in South Africa. Stockouts can lead to treatment alterations or interruptions, which can impact treatment outcomes. This study investigates the determinants and effects of TB drug stockouts and whether poorer districts are disproportionately affected.Methods: TB stockout data, health system indicators and TB treatment outcomes at the district level were extracted from the District Health Barometer for the years 2011, 2012 and 2013. Poverty terciles were constructed using the Census 2011 data to investigate whether stockouts and poor treatment outcomes were more prevalent in more impoverished districts. Fixed-effects regressions were used to estimate the effects of TB stockouts on TB treatment outcomes.Results: TB stockouts occurred in all provinces but varied across provinces and years. Regression analysis showed a significant association between district per capita income and stockouts: a 10% rise in income was associated with an 8.50% decline in stockout proportions. In terms of consequences, after controlling for unobserved time invariant heterogeneity between districts, a 10% rise in TB drug stockouts was found to lower the cure rate by 2.10% (p < 0.01) and the success rate by 1.42% (p < 0.01). These effects were found to be larger in poorer districts.Conclusions: The unequal spread of TB drug stockouts adds to the socioeconomic inequality in TB outcomes. Not only are stockouts more prevalent in poorer parts of South Africa, they also have a more severe impact on TB treatment outcomes in poorer districts. This suggests that efforts to cut back TB drug stockouts would not only improve TB treatment outcomes on average, they are also likely to improve equity because a disproportionate share of this burden is currently borne by the poorer districts. [ABSTRACT FROM AUTHOR]

Background: Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services., Methods: 300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation., Results: Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status., Conclusion: There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT., (Copyright © 2019 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Tuberculosis (TB) with human immunodeficiency virus (HIV) coinfection is the highest clinical epidemiology and public health issue. Despite many programs established to tackle the epidemic, TB target controls have not been reached. One of the many factors attributed to the failure in TB treatment is HIV coinfection. The aim of this study is to assess the survival rate of HIV infection among TB patients and the risk factors of death among the TB patients with HIV coinfection during the retro of directly observed treatment, short-course (DOTS) program., Methods: This study is a retrospective cohort conducted to compare the survivorship between TB/HIV patients for 8 months DOTS. Death among TB patients was considered as failures and those defaulted or survived were censored. The Cox proportional-hazards regression and log-linear model were used to establish the hazard ratio (HR) of death for each variable at baseline and estimate the risk factors effect among TB patients., Results: The findings revealed that 50% of death from TB/HIV patients were from HIV coinfection (advanced HR = 2.01, 95% confidence interval = 1.13-3.17). The risk of death was significantly higher in HIV-positive TB patients (P = 0.000) during the extension care phase. TB/HIV-positive patients on antiretroviral therapy have decreased survival rate (log-rank test = 14.88, df = 2, P = 0.0001). The probability of TB patients surviving is significantly decreased in HIV positive with some factors such as age, weight, smoking, and alcohol found significant., Conclusion: The probability of survival in HIV-positive TB patients was significantly lower during the TB treatment. Weight loss, age, alcohol, smoking, and pregnancy were showed to affect the survival probability of TB/HIV patients' coinfection significantly., Competing Interests: None