The title is from the programme of the 5th South African AIDS conference held in Durban in June. The conference brought together clinical scientists, basic scientists, educators and learners, law and human rights experts, practitioners (doctors, nurses, community carers), community workers, NGOs, members of civil society and lay members of so-called key populations (e.g. sex workers), pharmaceutical industry representatives, people from the world of work, politicians and policy makers.
Cancer patients with deeper pockets live longer in South Africa, survivors, social workers and staffers from among 35 nongovernmental support organisations told a unique 'Voice of Cancer' Forum in Cape Town last month.
The screening and treatment access gulf between the public and private sector was dramatically illustrated in story after story told by survivors who had journeyed the vastly differing routes - with outcomes speaking for themselves.
Two powerful doctor bodies, the Independent Practitioner Associations' Foundation (IPAF), and the SA Private Practitioners Foundation (SAPPF), are pitching in to help government clean up the primary health care delivery mess. Both agree with national health minister, Dr Aaron Motsoaledi, that a complete 're-engineering' of the dysfunctional public health care sector is needed for any variation of National Health Insurance (NHI) to succeed. However, Motsoaledi and his cabinet colleagues also believe that the private sector cannot be left to 'wayward' profit-driven market forces and is as much in need of re-engineering.
South African health and wellbeing indicators are poor for a middle-income country, and are usually attributed to inequity. Despite notable successes, South Africa's Gini co-efficient is one of the highest globally, compounded by weaknesses in implementation and planning, lack of creativity in designing incentive frameworks, and shortfalls in management and information systems.
This is the history of an act of philanthropy: the creation of a Fellowship allowing scholars from Australia, New Zealand and South Africa to study postgraduate medicine at Oxford University. More specifically, it examines how a charitable fund has operated with respect to the South African clinicians and medical scientists who have been its beneficiaries for the past 60 years.
In 1938, Lord Nuffield (born William Morris) signed a deed of trust, creating the Dominion Scholarships Fund. To understand and assess this decision, it makes sense to locate the donation within the broader context of Nuffield's philanthropy, and especially his support for academic medicine at Oxford University.
A 12-year-old girl was admitted to hospital with a week's history of severe abdominal pain, distension and generalised weakness, and was managed for incomplete intestinal obstruction. Plain abdominal films were compatible with ileus, and ultrasound showed no ascites, no lymphadenopathy, and normal abdominal and pelvic organs.
Dr Leslie E Whitfield was born in Krugersdorp and matriculated from Krugersdorp High School. While waiting for admission to study at the Medical School of the University of the Witwatersrand, he spent a year following various pursuits, necessitated by the fact that places in the Medical School were reserved for servicemen returning from World War II.
As national and international attention shifts towards improving health system performance, efficiencies must be maximised wherever possible. There will be increasing focus on escalating public and private sector health care costs in South Africa with the proposed introduction of national health insurance (NHI) and other health system strengthening initiatives. Furthermore, the intended benefits of NHI will not materialise unless there are significant improvements in health system performance.
To the Editor: In South Africa, more than two-thirds of patients newly infected with tuberculosis (TB) are co-infected with HIV. Since 1989, international organisations have urged countries to align their national TB and HIV / AIDS control efforts so as to reduce the burden of these diseases. In 2010, the National Department of Health (DoH) called for the integration of TB and HIV / AIDS services to effectively manage these dual epidemics. Without a national policy or guideline on how to integrate these services, many districts have developed innovative activities to co-ordinate improved patient care.
To the Editor: A healthy 37-year-old woman with no eye disorders or prior eye surgery climbed from 1 980 m to 5 681 m on Kilimanjaro. She took acetazolamide, a carbonic anhydrase inhibitor, as prophylaxis against acute mountain sickness. She had no mountain sickness, but developed progressive painless blurred vision during her summit attempt on day 5. Her husband noted that her eyes looked opaque.
Background. Use of blood and blood products in the medical wards at Groote Schuur Hospital, Cape Town, has increased substantially and significantly increased expenditure. It was suspected that the increased burden of HIV / AIDS could be a contributing factor.
Methods. Doctors voluntarily completed a structured questionnaire when blood or blood products were utilised over a 3-month period in 2009. Statistical analysis was performed using Microsoft Excel, SPSS and STATISTICA.
Results. Of 67 patients analysed, 46 (68.6%) were female, mean age 36.7 (standard deviation (SD) 8.7) years; 21 (31.3%) were male, mean age 39.3 (SD 13.5) years; and 41 (61.2%) were HIV positive, of whom 17 (41.5%) were on antiretroviral therapy (ART). HIV-infected patients were on average 10 years younger than HIV-uninfected patients (p=0.012). Anaemia was the cytopenia necessitating transfusion in 68.7% of cases, but its causes differed between HIV-infected and uninfected patients. The median CD4 count was 203 cells/μl (range 24 - 540) for HIV-infected patients on ART and 74 cells/μl (range 2 - 276) for those not on ART (p=0.012). The mean numbers of packed red cell and fresh-frozen plasma units transfused in the HIV-infected not on ART, HIV-infected on ART and HIV-uninfected groups were 3.3, 2.0 and 1.5 (p=0.013) and 13.5, 2.7 and 1.0 (p<0.001), respectively. ART in HIV-positive patients markedly decreased transfusion requirements (p<0.001). There was one minor transfusion reaction.
Conclusion. HIV / AIDS is a significant factor contributing to the increased use of blood and blood products in the medical wards at Groote Schuur Hospital. Being on ART appeared to reduce the requirement for blood and blood products.
Objectives. To determine the prevalence of vaginal pathogens during pregnancy and their impact on postpartum infectious morbidity among antiretroviral-naïve HIV-infected, and HIV-uninfected, women.
Methods. Vaginal swabs were obtained during early labour by speculum examination prior to digital vaginal examination, and sent for microscopy and culture. Women were assessed for infectious complications within 24 - 72 hours of delivery, and up to 2 weeks postpartum.
Results. Laboratory results were available for 801 women who delivered vaginally (418 HIV infected and 383 uninfected). The baseline characteristics of the two groups were comparable, and the median CD4 count for HIV-infected women (N=391) was 416/μl. Fifty-five per cent (54.8%) of women had positive cultures (439/801), more among those who were HIV infected than uninfected (60% v. 49.1%, p=0.002). Women with positive cultures had slightly higher rates of infectious morbidity than those without (20.5% v. 15.2%, p=0.052). Trichomonas vaginalis and group B streptococci were significantly associated with sepsis (p=0.023 and <0.001, respectively), whereas the presence of Candida species seemed to be protective (relative risk 0.69, p=0.014).
Conclusion. The study shows that a high proportion of pregnant women have pathogenic organisms in the lower genital tract that are associated with development of postpartum infectious morbidity.
The prevalence of hepatitis B virus (HBV) infection in 1 765 HIV-positive patients in rural Eastern Cape was 7.1%. This is lower than the previously reported rural prevalence and is similar to urban prevalence. Male sex and baseline alanine aminotransferase (ALT) were significant predictors of HBV status. Most HBV-positive patients had normal baseline ALT, making ALT an insensitive screening test for HBV status.
Objectives. To determine asthma and allergy phenotypes inunselected urban black teenagers and to associate bronchial hyperresponsiveness (BHR) with asthma, other atopic diseases and allergen sensitisation.
Methods. This was a cross-sectional study of 211 urban high school black children of Xhosa ethnicity. Modified ISAAC questionnaires regarding asthma, eczema and rhinitis were administered. BHR was assessed by methacholine challenge using hand-held nebulisers. Skinprick tests (SPTs) were performed for 8 aeroallergens and 4 food allergens.
Results. Asthma was reported in 9%, and 16% demonstrated BHR. Rhinitis was reported in 48% and eczema in 19%. Asthma was strongly associated with BHR. Asthma was associated with eczema whereas BHR was associated with rhinitis. SPTs were positive in 34% of subjects, aeroallergens in 32%, and food allergens in 5%. The most common sensitivities were to house dust mites (HDM) and German cockroach. BHR was associated with sensitivity to any aeroallergen, cat, HDM, cockroach and bermuda grass. The number of positive SPTs was associated with asthma and BHR. With each level of SPT positivity, there was 40% increased prevalence of asthma and 70% increased prevalence of BHR. The rate of allergen sensitisation in subjects with BHR (72%) was much higher than those without BHR (28%); house dust mite sensitivity was 69% in subjects with BHR and 18% in those without.
Conclusions. These are the highest rates of allergen sensitisation in subjects with BHR documented in an African setting and the widest difference in sensitisation rates between subjects with and without BHR.
Background. Non-alcoholic steatohepatitis (NASH) can lead to cirrhosis and hepatocellular carcinoma. The NASH fibrosis score (NFS) has proven to be a reliable, non-invasive marker for prediction of advanced fibrosis. Aspartate aminotransferase-to-platelet ratio index (APRI) is a simpler calculation than NFS, but has never been studied in patients with non-alcoholic fatty liver disease (NAFLD). Aim. To validate APRI as a non-invasive marker of liver fibrosis in subjects with NAFLD to be used in clinical practice.
Design / Methods. The cohort consisted of 111 patients with histological diagnoses of NAFLD. The biopsy samples were staged and graded according to the NASH clinical research network (CRN) criteria. These were grouped into fatty liver disease (FLD), NASH, no/mild fibrosis, and advanced fibrosis. The sensitivity and specificity of APRI were compared with NFS and aspartate aminotransferase-to-alanine aminotransferase (AST/ALT) ratio.
Results. The APRI was significantly higher in the advanced fibrosis group. The area under receiver operating characteristic (ROC) curve for APRI was 0.85 with an optimal cut-off of 0.98, giving a sensitivity of 75% and a specificity of 86%. The NFS was significantly lower in the advanced fibrosis group. The ROC for NFS gave an area under curve (AUC) of 0.77 and a cut-off value of -1.3 with a sensitivity of 76% and specificity of 69%. The positive predictive value for APRI was 54% as opposed to 34% for NFS. The negative predictive value was 93% for APRI and 94% for NFS.
Conclusion. APRI compared favourably to NFS and was superior to AST/ALT for the prediction of advanced fibrosis. We therefore propose the use of APRI in a new algorithm for the detection of advanced fibrosis.