South African Medical Journal - Volume 104, Issue 1, 2014
Volumes & issues
Volume 104, Issue 1, 2014
Author W.D. Francois VenterSource: South African Medical Journal 104 (2014)More Less
It is hard not to call the last decade of antiretroviral (ARV) access anything other than a public health, human rights and political success. South African life expectancy has increased by a decade, almost entirely due to effective HIV treatment. The arrest of mother-to-child transmission is one of the most celebrated public health programmes in the country, with transmission rates a fraction of what they were. HIV testing and condom usage rates are among the highest in the world. There are data to suggest that new HIV infection rates are going down and that the 2007 National Strategic Plan for HIV/AIDS goal of reducing new incidence by 50% is within reach. This may be due to a combination of condom access, antiretroviral therapy transmission arrest, or simply the natural trajectory of all infectious diseases, but seemed unattainable just a few years ago.
Author R. KappSource: South African Medical Journal 104 (2014)More Less
Source: South African Medical Journal 104, pp 6 –7 (2014)More Less
There were no sacred cows at October's Hospital Association of South Africa (HASA) conference - all the stark realities of our deeply economically divided society, its regulatory shortcomings and our inequitable healthcare delivery system were aired, and some solutions offered.
Source: South African Medical Journal 104, pp 8 –9 (2014)More Less
The private healthcare sector could, 'within a comparatively short time span', hugely relieve its overburdened public counterpart by nearly doubling its current medical scheme coverage of the population from 17% to 30%. This private subsidy would increase the government's public sector per capita health spend by up to 19%.
A first step towards transparency in pricing of medicines and scheduled substances - publication of guidelines for pharmaco-economic submissions : forum - health and financeSource: South African Medical Journal 104, pp 10 –11 (2014)More Less
The National Department of Health of South Africa recently published guidelines for pharmaco-economic (PE) submissions in accordance with the Medicines and Related Substances Act (Act 101 of 1965), which came into effect on 1 April 2013. These guidelines relate to the compilation of PE submissions for evidence of cost-effectiveness of medicine or scheduled substances. The PE guidelines are a first step towards the creation of a mechanism whereby the value of medicine can be quantified in a transparent manner. The 'voluntary' nature of PE submissions speaks to the current lack of knowledge, understanding and capacity related to pharmaco-economics that exists in the private healthcare market. The current disconnect between the PE guidelines and the Medical Schemes Act should be addressed as a matter of urgency to provide a mechanism whereby guidance in terms of cost-effectiveness from a PE evaluation will be supported by guaranteed reimbursement by medical schemes.
Author D.W. JordaanSource: South African Medical Journal 104, pp 12 –13 (2014)More Less
Surrogacy is not regulated by a single legal instrument only, nor is confirmation of a surrogacy agreement by the High Court an unqualified green light for the surrogacy process to proceed. In the context of the HIV status of the commissioning father, whose gametes are to be used for the conception of the child in pursuance of a surrogacy agreement, the intended in vitro fertilisation of the surrogate mother may only take place on condition that the commissioning father, and his semen, have been tested for HIV; that he has consented to his HIV status being made available to the surrogate mother, and if he is HIV-positive, that sperm washing will be used to minimise the risk of infection and that the surrogate mother has been informed of his HIV status, and given her informed consent.
Source: South African Medical Journal 104, pp 14 –15 (2014)More Less
The Constitution of the Republic of South Africa provides that everyone has the right to an environment that is not harmful to their health and well-being. The illegal dumping of hazardous waste poses a danger to the environment when pollutants migrate into water sources and ultimately cause widespread infection or toxicity, endangering the health of humans who might become exposed to infection and toxins. To give effect to the Constitution, the safe disposal of hazardous waste is governed by legislation in South Africa. Reports of the illegal disposal of waste suggest a general lack of awareness and training in regard to the safe disposal of medical waste.
Traditional male circumcision : balancing cultural rights and the prevention of serious, avoidable harm : forum - opinionAuthor K.G. BehrensSource: South African Medical Journal 104, pp 15 –16 (2014)More Less
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.
Author Norman D. GoldstuckSource: South African Medical Journal 104 (2014)More Less
In this month's SAMJ, Millard et al. report the results of an innovative study comparing surgical circumcision to that using a Unicirc device plus tissue adhesive. This is a follow-up to their earlier study using a similar non-disposable device (Gomco). This study is timely because South Africa (SA) is not on target to meet its planned objective of circumcising 80% of men between the ages of 15 and 49 or 4.3 million by 2015 and points the way toward a faster, easier method that may aid in voluntary medical male circumcision (VMMC) scale-up in areas of Africa with a high prevalence of HIV infection.
Charting a path along the continuum of PMTCT of HIV-1, to elimination, and finally to eradication : editorialSource: South African Medical Journal 104, pp 18 –20 (2014)More Less
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. At the far end of the continuum, the spectacular findings in the case of the Mississippi 'cured' baby indicate that eradication is possible.
Challenging times for environmental health in South Africa : the role of the Environmental Health Research Network : editorialSource: South African Medical Journal 104, pp 20 –21 (2014)More Less
Environmental health aims to create environments supportive of good health and to minimise disease. This is achieved by controlling environmental factors that impact adversely on human health. Throughout Africa, modern environmental health hazards, including mercury, lead, air toxins, water contaminants, pesticides, and domestic and hazardous waste, need to be addressed alongside longstanding environmental health concerns such as poor housing, inadequate water and sanitation, and exposure to indoor air pollution from the use of solid and liquid fuels for cooking.
Extrapulmonary tuberculosis among adults : experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa : researchSource: South African Medical Journal 104, pp 22 –24 (2014)More Less
Background. Extrapulmonary tuberculosis (EPTB) occurs in 15 - 20% of immunocompetent and 20 - 70% of HIV-infected patients with tuberculosis. There are few recent incidence data for EPTB.
Methods. Adults (N=2 963) with culture-proven EPTB seen over 2 years at Chris Hani Baragwanath Academic Hospital, the main referral hospital serving Soweto, Johannesburg, South Africa, were retrospectively studied for pattern and incidence.
Results. The commonest sites of EPTB were the pleura (39.1%), lymph nodes (31.0%), blood (21.8%), meninges (7.3%), and peritoneum (2.9%). Disseminated tuberculosis occurred in 25.0%. The median age was 33 years (range 18 - 87 years). Males comprised 53.2% overall, with a female majority in the peritonitis group. For Soweto, the incidence of adult EPTB was 88.6/100 000 population, rising to 139.4/100 000 and 125.7/100 000 in the 25 - 34-year and 35 - 44-year age groups, respectively. There was no secondary peak in the elderly (17.9/100 000).
Conclusions. This retrospective cohort showed a high incidence of EPTB, most marked in the 25 - 44-year age group. Culture of extrapulmonary sites is of importance to confirm diagnosis of tuberculosis and to ensure antituberculosis drug susceptibility testing.
Prevalence and incidence of symmetrical symptomatic peripheral neuropathy in patients with multidrug-resistant TB : researchSource: South African Medical Journal 104, pp 24 –26 (2014)More Less
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.
Diagnostic yield of fine needle aspiration biopsy in HIV-infected adults with suspected mycobacterial lymphadenitis : researchSource: South African Medical Journal 104, pp 27 –28 (2014)More Less
Background. Fine needle aspiration biopsy (FNAB) has been shown to be the diagnostic procedure of choice for superficial lymphadenitis in tuberculosis endemic regions.
Methods. We conducted a retrospective laboratory-based study to determine the bacteriological yield of clinically suspected mycobacterial tuberculous lymphadenitis following FNAB in adults, and specifically HIV-positive patients, to determine the need for the introduction of automated nucleic acid amplification tests (NAATs) such as the Xpert MTB/RIF assay as the initial diagnostic modality.
Results. A diagnostic yield of 80% was achieved, significantly higher in HIV-positive v. HIV-negative patients (84% v. 52%, respectively; p<0.001).
Conclusion. The results justify using automated NAATs such as the Xpert MTB/RIF assay as the initial diagnostic modality to expedite management in HIV-infected patients.
Source: South African Medical Journal 104, pp 29 –32 (2014)More Less
Background. Current recommendations for spinal tuberculosis (TB) not requiring open surgery include core needle biopsy to confirm TB and determine drug sensitivity. International figures show the positive culture yield from core needle biopsies is 50 - 83%.
Objectives. To (i) assess the yield of percutaneous needle biopsies; (ii) identify factors that may lead to a negative result; and (iii) determine whether, TB being suspected, needle biopsy is justified.
Methods. We conducted a multicentre retrospective review of 44 patients treated for suspected spinal TB between January 2009 and April 2012, who did not require open surgery. Data captured included demographics, relevant history, outcome of investigations and histopathological findings in patients.
Results. The overall positive TB culture rate was 59%. Age, duration of symptoms, HIV and neurological status, erythrocyte sedimentation rate and core size had no statistical influence. Of the 7 patients receiving TB treatment at the time of biopsy, 3 were culture-positive. Multidrug resistance was evident in 12% of positive cultures. The positive culture yield was 40% at Tygerberg Hospital and 75% at Groote Schuur Hospital, with no difference in histological yield. This was attributed to the practice of decontaminating specimens prior to culture at Tygerberg Hospital. The highest culture yield (32%) came from samples showing non-necrotising chronic inflammatory changes.
Conclusion. Percutaneous biopsy remains an important tool to diagnose and manage spinal TB. The yield of transpedicular biopsies in this study was comparable with international figures. Specimen decontamination prior to culture had a direct negative influence on biopsy culture yield, as did prior TB treatment.
Source: South African Medical Journal 104, pp 32 –36 (2014)More Less
Background. The workforce of 'physician-scientists' is ageing and decreasing in numbers. The responsibility to combat this trend rests on future generations of healthcare professionals and it is therefore valuable to evaluate medical students' attitudes towards research.
Objective. To establish the attitudes of University of Cape Town (UCT) medical students towards research and to investigate the factors influencing these attitudes.
Methods. An anonymous, cross-sectional, self-administered questionnaire was administered to medical students from years 1 to 6 studying medicine at UCT in 2011. Questions were primarily closed-ended and consisted of Likert scales.
Results. Out of a population of 1 195 medical students, 733 were sampled (63%); 65% were female, 53% were preclinical students (years 1 - 3) and 47% were in their clinical years (year 4 - 6). Overall, 61% of students had a positive attitude towards research and 74% felt that participation in research was important to their medical school education; 22% had been involved in voluntarily extracurricular research, 4% had presented at a scientific meeting and 3% had published in peer-reviewed journals. A number of perceived barriers to student research were identified including a lack of adequate training, time and research opportunities.
Conclusion. Students believed that research was important and had a positive attitude towards it. However, few had been involved in voluntary research and produced work worthy of presentation and/or publication. Addressing identified barriers and improving students' attitudes may begin to reverse the trend in declining numbers of physician-scientists.
Source: South African Medical Journal 104, pp 37 –39 (2014)More Less
Background. There is little in the literature on HIV and diabetes mellitus (DM) in sub-Saharan Africa.
Objective. To assess the characteristics of HIV and DM in patients receiving antiretroviral therapy (ART) in Botswana.
Methods. A retrospective case-control study was conducted at 4 sites. Each HIV-infected patient with DM (n=48) was matched with 2 HIV-infected controls (n=108) by age (±2 years) and sex. Primary analysis was conditional logistic regression to estimate univariate odds and 95% confidence intervals (CIs) for each characteristic.
Results. There was no significant association between co-morbid diseases, tuberculosis, hypertension or cancer and risk of diabetes. DM patients were more likely to have higher pre-ART weight (odds ratio (OR) 1.09; 95% CI 1.04 - 1.14). HIV-infected adults >70 kg were significantly more likely to have DM (OR 12.30; 95% CI 1.40 - 107.98). Participants receiving efavirenz (OR 4.58; 95% CI 1.44 - 14.57) or protease inhibitor therapy (OR 20.7; 95% CI 1.79 - 240.02) were more likely to have DM. Neither mean pre-ART CD4 cell count (OR 1.0; 95% CI 0.99 - 1.01) nor pre-ART viral load >100 000 copies/ml (OR 0.71; 95% CI 0.21 - 2.43) were associated with a significant risk of diabetes.
Conclusions. These findings suggest a complex interrelation among traditional host factors and treatment-related metabolic changes in the pathogenesis of DM inpatients receiving ART. Notably, pre-ART weight, particularly if >70 kg, is associated with the diagnosis of diabetes in HIV-infected patients in Botswana.
Parents' perceptions of HIV counselling and testing in schools : ethical, legal and social implications : researchSource: South African Medical Journal 104, pp 40 –42 (2014)More Less
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.