DDT contamination in water resources of some African countries and its impact on water quality and human health.

Dichlorodiphenyltrichloroethane (DDT) usage has been prohibited in developed nations since 1972 but is exempted for use in indoor residual spraying (IRS) in developing countries, including African countries, for malaria control. There have been no previous reviews on DDT residues in water resources in Africa. The study aimed to provide a review of available research investigating the levels of DDT residues in water sources in Africa and to assess the consequent human health risks. A scoping review of published studies in Africa was conducted through a systematic electronic search using PubMed, Web of Science, EBSCO HOST, and Scopus. A total of 24 articles were eligible and reviewed. Concentrations of DDT ranged from non-detectable levels to 81.2 µg/L. In 35% of the studies, DDT concentrations surpassed the World Health Organization (WHO) drinking water guideline of 1 µg/L in the sampled water sources. The highest DDT concentrations were found in South Africa (81.2 µg/L) and Egypt (5.62 µg/L). DDT residues were detected throughout the year in African water systems, but levels were found to be higher during the wet season. Moreover, water from taps, rivers, reservoirs, estuaries, wells, and boreholes containing DDT residues was used as drinking water. Seven studies conducted health risk assessments, with two studies identifying cancer risk values surpassing permissible thresholds in water sampled from sources designated for potable use. Non-carcinogenic health risks in the studies fell below a hazard quotient of 1. Consequently, discernible evidence of risks to human health surfaced, given that the concentration of DDT residues surpassed either the WHO drinking water guidelines or the permissible limits for cancer risk in sampled drinking sources within African water systems. Therefore, alternative methods for malaria vector control should be investigated and applied.

Method and process towards developing a Health Vulnerability Index (HVI) for Extreme Weather Events (EWEs) for local residents in South Africa.

An increase in incidence and amplitude of extreme weather events (EWEs) linked to climate change, has resulted in greater human exposure and vulnerability to weather-related health effects. Increases in the occurrence of EWEs, including storms, flooding, extreme heat and wildfires, will impact health globally, with poor and vulnerable populations disproportionately affected. Vulnerability to EWEs, and the ability to adapt to these weather shocks, are influenced by existing physical, social and political limitations of a given region. As such, developing context-specific health vulnerability indices to inform planning and decision-making for policy makers and citizens alike, should be prioritized. The existence and development of health vulnerability indices in South Africa are limited, therefore, this study provides a foundation from which future indices can build. Mixed methods approaches including evidence and data analysis/synthesis and focus groups are used to understand the interconnections between extreme weather events and human health, including citizens' understanding of emergent vulnerabilities linked to these events. The methods employed in this study include: •A rapid evidence review (RER) including data extraction identifying health impacts and indicators.•Development of a draft health vulnerability index (HVI) framework.•Focus groups and individual interviews testing the draft HVI for citizen input and framework refinement.

The impact of extreme weather events on mental health in Africa: A scoping review of the evidence.

INTRODUCTION: The psychosocial impacts of extreme weather events are contributing to the burden of mental illness, exacerbated by pre-existing vulnerabilities. Despite an emerging global interest in this association, Africa remains poorly represented in the literature. METHODS: A scoping review of peer-reviewed studies was conducted to determine the adverse mental health outcomes associated with extreme weather events in Africa (2008-2021). The review was conducted in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). RESULTS: A total of 12,204 peer-reviewed articles were identified of which 12 were retained for analysis. These studies were all conducted in 8 countries in Sub-Saharan Africa. Adverse mental health outcomes were identified resulting from flood (n = 4), drought (n = 4), extreme heat (n = 1), bushfire (n = 1), and multiple events (n = 2). Findings included pathological outcomes with predictable symptomatology including mood disorders; trauma- and stressor-related disorders; and suicide. Additionally, conditions indicating psychological distress which were below the pathological threshold including emotion regulation difficulties, disturbed sleep, alcohol use, stress, and anxiety. The quantitative evidence for the association between extreme weather events and mental health was limited primarily by a lack of longitudinal data, exposure gradient, and comparison to an unaffected group, as well as a failure to provide an objective exposure measure. The qualitative evidence for this association was complimentary but without sufficient clinical measurement these outcomes cannot be verified as psychological morbidities. In addition, this review provided insight into the mental health of vulnerable communities affected by extreme weather events including those living in poverty, farmers, pastoralists, women, and children. CONCLUSION: This review provided some preliminary evidence for the association between extreme weather events and adverse mental health outcomes for populations in Africa. The review also provides insight to vulnerable populations affected by extreme weather events. Future research with stronger designs and methodologies are recommended.

The adverse health effects associated with drought in Africa.

Droughts are associated with several health effects and Africa is uniquely vulnerable. Despite this, there has been no previous review of the literature on the health effects of drought in Africa. This study systematically reviewed the epidemiological research on the association between drought and adverse health effects in Africa (2012-2019). A total of fifteen articles were included in the review after screening 1922 published (peer-reviewed) and unpublished articles. These studies were all conducted in 9 Sub-Saharan African countries. The drought-related health effects identified were on adverse nutritional health (n = 8) including malnutrition resulting in reduced body size and wasting, stunting and underweight, mortality from food insecurity, anaemia from food insecurity and nutrition-related disability from food insecurity; drought and diseases due to microbial contamination of water (n = 6) including cholera, diarrhoeal diseases, scabies, vector-borne diseases and malaria-related mortality; and drought and health behaviours (n = 1) including HIV prevention and care behaviours. The study found limited evidence of a high prevalence of malnutrition, an increased prevalence of anaemia, cholera, scabies, dengue and an increased incidence in child disabilities during periods of drought. Additionally, there was limited evidence on improved child nutritional health with improved water and sanitation access, and an increased prevalence of child wasting, stunting and underweight in drought-prone areas. No evidence of drought on other health outcomes was found. However, all the studies had more than one limitation including weak study design, a lack of comparison to a drought period, uncertainty on the onset and end of drought, lack of control for confounding, presence of contextual factors, weak outcome and/or exposure measure, small sample size and lack of generalizability. This review found weak evidence for all health outcomes measured but highlights key areas for further research and contextual factors which need to be considered for interventions.

Tuberculosis treatment intervention trials in Africa: A cross-sectional bibliographic study and spatial analysis.

BACKGROUND: Mycobacterium Tuberculosis (TB) poses a substantial burden in sub-Saharan Africa and is the leading cause of death amongst infectious diseases. Randomised controlled trials (RCTs) are regarded as the gold standard for evaluating the effectiveness of interventions. We aimed to describe published TB treatment trials conducted in Africa. METHODS: This is a cross-sectional study of published TB trials conducted in at least one African country. In November 2019, we searched three databases using the validated Africa search filter and Cochrane's sensitive trial string. Published RCTs conducted in at least one African country were included for analysis. Records were screened for eligibility. Co-reviewers assisted with duplicate data extraction. Extracted data included: the country where studies were conducted, publication dates, ethics statement, trial registration number, participant's age range. We used Cochrane's Risk of Bias criteria to assess methodological quality. RESULTS: We identified 10,495 records; 175 trials were eligible for inclusion. RCTs were published between 1952 and 2019. The median sample size was 206 participants (interquartile range: 73-657). Most trials were conducted in South Africa (n = 83) and were drug therapy trials (n = 130). First authors were from 30 countries globally. South Africa had the most first authors (n = 55); followed by the United States of America (USA) (n = 28) and Great Britain (n = 14) with fewer other African countries contributing to the first author tally. Children under 13 years of age eligible to participate in the trials made up 17/175 trials (9.71%). International governments (n = 29) were the most prevalent funders. Ninety-four trials provided CONSORT flow diagrams. Methodological quality such as allocation concealment and blinding were poorly reported or unclear in most trials. CONCLUSIONS: By mapping African TB trials, we were able to identify potential research gaps. Many of the global north's researchers were found to be the lead authors in these African trials. Few trials tested behavioural interventions compared to drugs, and far fewer tested interventions on children compared to adults to improve TB outcomes. Lastly, funders and researchers should ensure better methodological quality reporting of trials.

'Building on shaky ground'-challenges to and solutions for primary care guideline implementation in four provinces in South Africa: a qualitative study.

OBJECTIVES: Clinical guidelines support evidence-informed quality patient care. Our study explored perspectives of South African subnational health managers regarding barriers to and enablers for implementation for all available primary care guidelines. DESIGN: We used qualitative research methods, including semistructured, individual interviews and an interpretative perspective. Thematic content analysis was used to develop data categories and themes. SETTING: We conducted research in four of nine South African provinces with diverse geographic, economic and health system arrangements (Eastern Cape, Western Cape, KwaZulu-Natal, Limpopo). South Africa is a middle-income country with high levels of inequality. The settings represented public sector rural and peri-urban health facilities. PARTICIPANTS: Twenty-two participants with provincial and district health management roles, that comprised implementation and/or training on primary care guidelines, were included. RESULTS: Participants recommended urgent consideration of health system challenges, particularly financial constraints, impacting on access to the guidelines themselves and to medical equipment and supplies necessary to adhere to guidelines. They suggested that overcoming service delivery gaps requires strengthening of leadership, clarification of roles and enhanced accountability. Participants suggested that inadequate numbers of skilled clinical staff hampered guideline use and, ultimately, patient care. Quality assurance of training programmes for clinicians-particularly nurses-interdisciplinary training, and strengthening post-training mentorship were recommended. Furthermore, fit-for-purpose guideline implementation necessitates considering the unique settings of facilities, including local culture and geography. This requires guideline development to include guideline end users. CONCLUSIONS: Guidelines are one of the policy tools to achieve evidence-informed, cost-effective and universal healthcare. But, if not effectively implemented, they have no impact. Subnational health managers in poorly resourced settings suggested that shortcomings in the health system, along with poor consultation with end users, affect implementation. Short-term improvements are possible through increasing access to and training on guidelines. However, health system strengthening and recognition of socio-cultural-geographic diversity are prerequisites for context-appropriate evidence-informed practice.

Legislative landscape for traditional health practitioners in Southern African development community countries: a scoping review.

BACKGROUND AND OBJECTIVES: Globally, contemporary legislation surrounding traditional health practitioners (THPs) is limited. This is also true for the member states of the Southern African Development Community (SADC). The main aim of this study is to map and review THP-related legislation among SADC countries. In order to limit the scope of the review, the emphasis is on defining THPs in terms of legal documents. METHODS: This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews methods. Two independent reviewers reviewed applicable legal definitions of THPs by searching the Southern African Legal Information Institute (SAFLII) database in April 2018 for legislation and bills. To identify additional legislation applicable in countries not listed on SAFLII and/or further relevant SADC legislation, the search engines, Google and PubMed, were used in August 2018 and results were reviewed by two independent reviewers. Full texts of available policy and legal documents were screened to identify policies and legislation relating to the regulation of THPs. Legislation was deemed relevant if it was a draft of or promulgated legislation relating to THPs. RESULTS: Four of 14 Southern African countries have legislation relating to THPs. Three countries, namely South Africa, Namibia and Zimbabwe, have acknowledged the roles and importance of THPs in healthcare delivery by creating a council to register and formalise practices, although they have not operationalised nor registered and defined THPs. In contrast, Tanzania has established a definition couched in terms that acknowledge the context-specific and situational knowledge of THPs, while also outlining methods and the importance of local recognition. Tanzanian legislation; thus, provides a definition of THP that specifically operationalises THPs, whereas legislation in South Africa, Namibia and Zimbabwe allocates the power to a council to decide or recognise who a THP is; this council can prescribe procedures to be followed for the registration of a THP. CONCLUSIONS: This review highlights the differences and similarities between the various policies and legislation pertaining to THPs in SADC countries. Legislation regarding THPs is available in four of the 14 SADC countries. While South Africa, Tanzania, Namibia and Zimbabwe have legislation that provides guidance as to THP recognition, registration and practices, THPs continue to be loosely defined in most of these countries. Not having an exact definition for THPs may hamper the promotion and inclusion of THPs in national health systems, but it may also be something that is unavoidable given the tensions between lived practices and rigid legalistic frameworks.

Using the behavior change wheel to identify barriers to and potential solutions for primary care clinical guideline use in four provinces in South Africa.

BACKGROUND: Clinical practice guidelines risk having little impact on healthcare if not effectively implemented. Theory informed, targeted implementation may maximise their impact. Our study explored barriers to and facilitators of guideline implementation and use by South African primary care nurses and allied healthcare workers in four provinces in South Africa. We also proposed interventions to address the issues identified. METHODS: We used qualitative research methods, comprising focus group discussions using semi-structured topic guides. Seven focus group discussions were conducted (48 providers) in four South African provinces (Eastern Cape, Western Cape, Kwazulu-Natal, Limpopo). Participants included mostly nurses, dieticians, dentists, and allied health practitioners, from primary care facilities in rural and peri-urban settings. The analysis proceeded in three phases. Firstly, two analysts conducted inductive thematic content analysis to develop themes of data. This was followed by fitting emergent themes to the Theoretical Domains Framework and finally to the associated Behaviour Change Wheel to identify relevant interventions. RESULTS: Participants are knowledgeable about guidelines, generally trust their credibility and are receptive and motivated to use them. Guidelines are seen by nurses to provide confidence and reassurance, as well as professional authority and independence where doctors are scarce. Barriers to guideline use include: inadequate systems for printed book distribution, insufficient and substandard photocopies, linguistic inappropriateness (e.g. complicated language, lack of summaries, unavailable in local languages), unsupportive auditing procedures, limited involvement of end-users in guideline development, and patchy training that may not filter back to all providers. Future aspirations identified include: improving the design features of guidelines, accessible places to find guidelines, making digitally-formatted versions available, more supplementary materials (e.g. posters) to support patient engagement, accessible clinical support following training, and in-facility training for all professional cadres to ensure fair access, similar levels of capability and interdisciplinary consistency. CONCLUSIONS: South African primary care nurses and allied health practitioners have high levels of motivation to use guidelines, but face many systemic barriers. We used the Behaviour Change Wheel to suggest relevant, implementable interventions addressing identified barriers. This theory-informed approach may improve clinical guideline implementation and impact healthcare for South Africa.

National stakeholders' perceptions of the processes that inform the development of national clinical practice guidelines for primary healthcare in South Africa.

BACKGROUND: There is increased international focus on improving the rigour of clinical practice guideline (CPG) development practices. However, few empirical studies on CPG development have been conducted in low- and middle-income countries. This paper explores national stakeholders' perceptions of processes informing CPG development for primary healthcare in South Africa, focusing on both their aspirations and views of what is actually occurring. METHODS: A qualitative study design was employed including individual interviews with 37 South African primary care CPG development role-players. Participants represented various disciplines, sectors and provinces. The data were analysed through thematic analysis and an interpretivist conceptual framework. RESULTS: Strongly reflecting current international standards, participants identified six 'aspirational' processes that they thought should inform South African CPG development, as follows: (1) evidence; (2) stakeholder consultation; (3) transparency; (4) management of interests; (5) communication/co-ordination between CPG development groups; and (6) fit-for-context. While perceptions of a transition towards more robust processes was common, CPG development was seen to face ongoing challenges with regards to all six aspirational processes. Many challenges were attributed to inadequate financial and human resources, which were perceived to hinder capacity to undertake the necessary methodological work, respond to stakeholders' feedback, and document and share decision-making processes. Challenges were also linked to a complex web of politics, power and interests. The CPG development arena was described as saturated with personal and financial interests, groups competing for authority over specific territories and unequal power dynamics which favour those with the time, resources and authority to make contributions. These were all perceived to affect efforts for transparency, collaboration and inclusivity in CPG development. CONCLUSION: While there is strong commitment amongst national stakeholders to advance CPG development processes, a mix of values, politics, power and capacity constraints pose significant challenges. Contrasting perspectives regarding managing interests and how best to adapt to within-country contexts requires further exploration. Dedicated resources for CPG development, standardised systems for managing conflicting interests, and the development of a political environment that fosters collaboration and more equitable inclusion within and between CPG development groups are needed. These initiatives may enhance CPG quality and acceptability, with associated positive impact on patient care.

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders.

BACKGROUND: Clinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa's health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level. METHODS: We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data. RESULTS: We conducted 37 in-depth interviews from June 2014-July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process. CONCLUSIONS: Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Series: Clinical Epidemiology in South Africa. Paper 2: Quality and reporting standards of South African primary care clinical practice guidelines.

OBJECTIVES: Clinical practice guidelines (CPGs) development has evolved over the past decade, with greater emphasis now being placed on transparency, rigor of development, and reporting standards. Our evaluation assesses the quality of the guideline development processes and reporting of selected South African primary care (PC) CPGs. STUDY DESIGN AND SETTING: CPGs were iteratively identified by two authors, seeking CPGs reflecting common conditions with which patients present in South African PC settings. CPGs could address diagnosis, treatment, or clinical management. Each CPG was independently appraised by two reviewers using the AGREE II (Appraisal of Guideline REsearch and Evaluation) quality checklist, and the weighted scoring algorithm to calculate scores for the six domains. RESULTS: We included 16 CPGs from the National Department of Health and clinical professional associations. Overall, the domains of rigor of development, editorial independence, and applicability had the lowest median scores (0, 4%, and 13%, respectively). Clarity of presentation reported the highest median score (69%), with seven CPGs scoring above 70%. CONCLUSIONS: The methodological quality of the selected South African PC CPGs was generally poor to moderate. Concerted efforts should be made to ensure that transparent, rigorous, and up-to-date evidence assessments are conducted and well reported by CPG developers.

The role of alcohol use in antiretroviral adherence among individuals living with HIV in South Africa: Event-level findings from a daily diary study.

OBJECTIVE: Using daily diary methods, we aimed to test the hypothesis that at the event-level consuming alcohol increases the likelihood that antiretrovirals (ARV) will be missed on a particular day. METHODS: This prospective cohort study of 74 (52 female, 22 male) people living with HIV (PLHIV) in South Africa collected event-level data on ARV adherence and alcohol consumption using structured daily phone interviews over a period of 42days generating 2718 data points. We used generalized estimating equations (GEE) analyses to assess univariate and multivariate associations between alcohol and adherence, controlling for sociodemographics and testing for effect modification. RESULTS: Controlling for sociodemographics, each alcohol measure was a statistically significant predictor of non-adherence on a particular day; any drinking compared to no drinking (daytime: AOR=3.18, 95% CI=2.25-4.49; evening: AOR=3.43, 95% CI=2.12-5.53), consuming more alcohol than one normally consumes (daytime: AOR=1.06, 95% CI=1.02-1.11; evening: AOR=1.10, 95% CI=1.05-1.15), and drinking at low to moderate risk level (daytime: 4.29, 95% CI=2.81-6.56; evening: AOR=4.24, 95% CI=2.38-7.54) and high to very high risk levels (daytime: AOR=2.31, 95% CI=1.56-3.42; evening: AOR=3.08, 95% CI=1.91-4.98) were all significantly related to missing ARVs in the daytime and evening. CONCLUSIONS: These data provide support for an event-level relationship between alcohol and non-adherence. Interventions that mitigate alcohol use among people on ARVs or provide strategies to maintain optimal adherence among those who drink are needed.

Engaging adolescents in tuberculosis and clinical trial research through drama.

BACKGROUND: The South African Tuberculosis Vaccine Initiative is based in Worcester where tuberculosis (TB) is endemic, and incidence rates are amongst the highest nationally. In high TB burden settings after an early childhood peak, incidence rates start to rise again in adolescents, therefore they are an important target group for tuberculosis vaccine research. In 2012, learners from a local school developed a one-off theatrical production out of an educational comic book Carina's Choice, developed by the South African Tuberculosis Vaccine Initiative in 2010. A Wellcome Trust International Engagement grant allowed for this one-off production to be further developed, with input from university students and staff, and rolled out to schools in the Worcester area as an engagement and education intervention. METHODS: Focus group feedback was used to identify key messages and to develop the play's script. Qualitative methods were used to collect and analyse relevant data. Interviews were conducted with learner-actors, pre- and post-focus group feedback was obtained from a sample of school-going adolescents, and pre- and post-questionnaires were administered to adolescent audience members. RESULTS: From the pre-drama focus group discussions, topics such as TB symptoms, stigma and transmission were identified as areas that needed attention. After the performances, adolescents showed improved knowledge on the identified topics and they discussed TB prevention measures. They highlighted transmission of TB during pregnancy as a further topic to be addressed in future iterations of the drama. Although stigma is a difficult phenomenon to interpret, post-drama participants understood that TB transmission could occur in all individuals. Learner-actors agreed with focus group participants that the play could impact the wider community if it were rolled out. Feedback from the South African Tuberculosis Vaccine Initiative staff verified that recruitment for an upcoming trial was facilitated by the preparedness that the play provided in recruitment areas. The study showed that before and after evaluations provide data on the usefulness of the play as an education tool. CONCLUSIONS: Theatre, presented and motivated by adolescent peers, can raise awareness of TB, and assist clinical trial preparedness and further engagement between trial staff and their trial community.

Alcohol Expectancies and Inhibition Conflict as Moderators of the Alcohol-Unprotected Sex Relationship: Event-Level Findings from a Daily Diary Study Among Individuals Living with HIV in Cape Town, South Africa.

Literature from sub-Saharan Africa and elsewhere supports a global association between alcohol and HIV risk. However, more rigorous studies using multiple event-level methods find mixed support for this association, suggesting the importance of examining potential moderators of this relationship. The present study explores the assumptions of alcohol expectancy theory and alcohol myopia theory as possible moderators that help elucidate the circumstances under which alcohol may affect individuals' ability to use a condom. Participants were 82 individuals (58 women, 24 men) living with HIV who completed daily phone interviews for 42 days which assessed daily sexual behavior and alcohol consumption. Logistic generalized estimating equation models were used to examine the potential moderating effects of inhibition conflict and sex-related alcohol outcome expectancies. The data provided some support for both theories and in some cases the moderation effects were stronger when both partners consumed alcohol.

Challenges in Exploratory Methods for Tuberculosis Research in South Africa.

Haunted by a legacy of apartheid governance that left millions in material poverty, South Africa has among the highest tuberculosis (TB) morbidity and mortality rates in the world. Our Social Markers of TB research project shared a vision of working with ethnographic research methods to understand TB-infected persons, their families, care providers, and social networks. We argue that felt and enacted TB stigma and the related HIV-TB stigma impaired our ability to collect the necessary data for a full portrait of TB-infected persons and their lived conditions. To circumvent this limitation, each researcher improvised and augmented conventional anthropological methods with more creative, directed, and at times destabilizing methods. We present three case studies as useful illustrations of the complexities and challenges we encountered in our attempts to conduct ethically sound TB research. We discuss the implications of our call for "improvisation" for the politics of research and ethical oversight.

Growing everyday: the Pan African Clinical Trials Registry.

The Pan African Clinical Trial Registry (http://www.pactr.org), established as the AIDS, Tuberculosis and Malaria Registry (ATM) has developed into the registry of choice for African trials. The register was formally launched as a World Health Organization primary register in September 2009. Data analysis shows that registry applications have increased steadily since then, as has representation throughout the region. New developments to the registry include the implementation of a real-time Global Information Systems map on the portal and development of Standard Operating Procedures while focused efforts on dissemination continue. http://www.pactr.org is now well-placed to provide a valuable resource for researchers, clinicians, policy-makers and consumers on the continent.

One of a kind--the Pan African Clinical Trials Registry, a regional registry for Africa.

The 2004 Ministerial Summit on Health Research called on the World Health Organization to to establish a registry network with the intention of providing a single access point to identify trials. In 2007 the International Committee of Medical Journal Editors amended their support of this initiative stating that only trials registered prospectively on a member registry of the WHO's Network of Primary Registers would be published. The Pan African Clinical Trials Registry (www.pactr.org), was established in early 2007 as the AIDS, TB and Malaria (ATM) Clinical Trials Registry with the aim of piloting the concept of a registry that would cater to the specific needs of African trialists. In 2009 the ATM Registry expanded its remit to include all diseases for all regions of Africa; The Pan African Clinical Trials Registry became the first and is presently the only African member of the World Health Organization's Network of Primary Registers.