Improving patient-centred counselling skills among lay healthcare workers in South Africa using the Thusa-Thuso motivational interviewing training and support program.

We developed a motivational interviewing (MI) counselling training and support program for lay counsellors in South Africa-branded "Thusa-Thuso-helping you help", commonly referred to as Thusa-Thuso. We present the results of a pilot study to determine the program's impact on MI technical skills and qualitatively assess the feasibility of a training-of-trainers (TOT) scale-up strategy among counselling staff of non-governmental (NGO) support partners of the human immunodeficiency virus (HIV) treatment program in South Africa. We enrolled adult (≥ 18 years) lay counsellors from ten primary healthcare clinics in Johannesburg (South Africa) selected to participate in the Thusa-Thuso training and support program. Counsellors attended the ten-day baseline and quarterly refresher training over 12 months (October 2018-October 2019). Each counsellor submitted two audio recordings of mock counselling sessions held during the ten-day baseline training and two additional recordings of sessions with consenting patients after each quarterly contact session. We reviewed the recordings using the MI treatment integrity (MITI) coding system to determine MI technical (cultivating change talk and softening sustain talk) and relational (empathy and partnership) competency scores before and after training. After 12 months of support with pilot site counsellors, we were asked to scale up the training to NGO partner team trainers in a once-off five-day Training of trainers (TOT) format (n = 127 trainees from November 2020 to January 2021). We report TOT training experiences from focus group discussions (n = 42) conducted six months after the TOT sessions. Of the 25 enrolled lay counsellors from participating facilities, 10 completed the 12-month Thusa-Thuso program. Attrition over the 12 months was caused by death (n = 3), site exclusion/resignations (n = 10), and absence (n = 2). MI competencies improved as follows: the technical skills score increased from a mean of 2.5 (standard deviation (SD): 0.8) to 3.1 (SD: 0.5), with a mean difference of 0.6 (95% confidence interval (CI): 0.04, 0.9). The MI relational skills score improved from a mean of 3.20 (SD: 0.7) to 3.5 (SD: 0.6), with a mean difference of 0.3 (95% CI: -0.3, 8.5). End-point qualitative data from the counsellors highlighted the value of identifying and addressing specific skill deficiencies and the importance of counsellors being able to self-monitor skill development using the MITI review process. Participants appreciated the ongoing support to clarify practical MI applications. The TOT program tools were valuable for ongoing on-the-job development and monitoring of quality counselling skills. However, the MITI review process was perceived to be too involved for large-scale application and was adapted into a scoring form to document sit-in mentoring sessions. The Thusa-Thuso MI intervention can improve counsellor motivation and skills over time. In addition, the program can be scaled up using an adapted TOT process supplemented with fidelity assessment tools, which are valuable for skills development and ongoing maintenance. However, further studies are needed to determine the effect of the Thusa-Thuso program on patient ART adherence and retention in care. Trial registration: Pan African Clinical Trials Registry No: PACTR202212796722256 (12 December 2022).

"Emotional stress is more detrimental than the virus itself": A qualitative study to understand HIV testing and pre-exposure prophylaxis (PrEP) use among internal migrant men in South Africa.

INTRODUCTION: South Africa has one of the highest rates of internal migration on the continent, largely comprised of men seeking labour in urban centres. South African men who move within the country (internal migrants) are at higher risk than non-migrant men of acquiring HIV yet are less likely to test or use pre-exposure prophylaxis (PrEP). However, little is known about the mechanisms that link internal migration and challenges engaging in HIV services. METHODS: We recruited 30 internal migrant men (born outside Gauteng Province) during August 2022 for in-depth qualitative interviews at two sites in Johannesburg (Gauteng) where migrants may gather, a factories workplace and a homeless shelter. Interviewers used open-ended questions, based in the Theory of Triadic Influence, to explore experiences and challenges with HIV testing and/or PrEP. A mixed deductive inductive content analytic approach was used to review data and explain why participants may or may not use these services. RESULTS: Migrant men come to Johannesburg to find work, but unreliable income, daily stress and time constraints limit their availability to seek health services. While awareness of HIV testing is high, the fear of a positive diagnosis often overshadows the benefits. In addition, many men lack knowledge about the opportunity for PrEP should they test negative, though they express interest in the medication after learning about it. Additionally, these men struggle with adjusting to urban life, lack of social support and fear of potential stigma. Finally, the necessity to prioritize work combined with long wait times at clinics further restricts their access to HIV services. Despite these challenges, Johannesburg also presents opportunities for HIV services for migrant men, such as greater anonymity and availability of HIV information and services in the city as compared to their rural homes of origin. CONCLUSIONS: Bringing HIV services to migrant men at community sites may ease the burden of accessing these services. Including PrEP counselling and services alongside HIV testing may further encourage men to test, particularly if integrated into counselling for livelihood and coping strategies, as well as support for navigating health services in Johannesburg.

Migrant men and HIV care engagement in Johannesburg, South Africa.

BACKGROUND: South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. METHODS: We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020-11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. RESULTS: Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported "never visiting a health facility," as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). CONCLUSIONS: Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants' challenges.

A content analysis of two african medical schools' antibiotic stewardship curricula.

Background: Antibiotics are precious substances that have saved millions of lives since their discovery, resulting in significant advances in modern medicine. However, antibiotic resistance and a slowdown in the discovery of new antibiotics with novel mechanisms of action are affecting the sustainability of antibiotics. The objective of this study was to describe the content of South African and Nigerian medical students' curricula with respect to prudent antimicrobial prescribing. Methods: A content analysis framework was used to identify, describe, and count the keywords, key phrases, and sentences relevant to the teaching of prudent antimicrobial prescribing in the complete curricula content of two African countries' medical schools. The courses are taught in the Graduate Entry Medical Programme (GEMP) curriculum (years 3-6) of the South African medical school and years 4-6 of the Nigerian medical school. The frequency of keywords/key phrases relevant to prudent antibiotic prescribing such as antimicrobial stewardship, mechanisms of bacterial resistance, and principles of antibiotic therapy was determined. Results: The two curricula reviewed were found to be different. While the South African medical school uses an integrated curriculum in the GEMP (a stream where candidates with undergraduate degrees are enrolled into the 3rd year of medical school and spend 4 years), the Nigerian medical school operates a traditional (discipline based) curriculum from MBBS 1-6. A greater number of keywords and key phrases were found in the South African curriculum compared to the Nigerian curriculum in relation to prudent antibiotic prescribing and antimicrobial stewardship. The key phrase "antimicrobial stewardship" or "antibiotic stewardship" was absent in the Nigerian curriculum but appeared four times in the South African curriculum. Discussion: The findings of this curriculum review suggest a need for revision of the medical curricula of the two countries, to one that will better prepare learners for antimicrobial stewardship.

Thetha Nami ngithethe nawe (Let's Talk): a stepped-wedge cluster randomised trial of social mobilisation by peer navigators into community-based sexual health and HIV care, including pre-exposure prophylaxis (PrEP), to reduce sexually transmissible HIV amongst young people in rural KwaZulu-Natal, South Africa.

BACKGROUND: Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality and incidence. Effective ART based prevention has not translated into population-level impact in southern Africa due to sub-optimal coverage among youth. We aim to investigate the effectiveness, implementation and cost effectiveness of peer-led social mobilisation into decentralised integrated HIV and sexual reproductive health (SRH) services amongst adolescents and young adults in KwaZulu-Natal (KZN). METHODS: We are conducting a type 1a hybrid effectiveness/implementation study, with a cluster randomized stepped-wedge trial (SWT) to assess effectiveness and a realist process evaluation to assess implementation outcomes. The SWT will be conducted in 40 clusters in rural KZN over 45 months. Clusters will be randomly allocated to receive the intervention in period 1 (early) or period 2 (delayed). 1) Intervention arm: Resident peer navigators in each cluster will approach young men and women aged 15-30 years living in their cluster to conduct health, social and educational needs assessment and tailor psychosocial support and health promotion, peer mentorship, and facilitate referrals into nurse led mobile clinics that visit each cluster regularly to deliver integrated SRH and differentiated HIV prevention (HIV testing, UTT for those positive, and PrEP for those eligible and negative). Standard of Care is UTT and PrEP delivered to 15-30 year olds from control clusters through primary health clinics. There are 3 co-primary outcomes measured amongst cross sectional surveys of 15-30 year olds: 1) effectiveness of the intervention in reducing the prevalence of sexually transmissible HIV; 2) uptake of universal risk informed HIV prevention intervention; 3) cost of transmissible HIV infection averted. We will use a realist process evaluation to interrogate the extent to which the intervention components support demand, uptake, and retention in risk-differentiated biomedical HIV prevention. DISCUSSION: The findings of this trial will be used by policy makers to optimize delivery of universal differentiated HIV prevention, including HIV pre-exposure prophylaxis through peer-led mobilisation into community-based integrated adolescent and youth friendly HIV and sexual and reproductive health care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier-NCT05405582. Registered: 6th June 2022.

Progress towards unique patient identification and case-based surveillance within the Southern African development community.

Population mobility makes patient-tracking and care linkage in the South African Development Community (SADC) challenging. Case-based surveillance (CBS) through individual-level clinical data linked with a unique patient-identifier (UPI) is recommended. We conducted a mixed-methods landscape analysis of UPI and CBS implementation within selected SADC countries, this included: (1) SADC UPI implementation literature review; (2) assessment of UPI and CBS implementation for high HIV-prevalence SADC countries; (3) UPI implementation case-study in selected South African primary healthcare (PHC) facilities. Research into CBS and UPI implementation for the SADC region is lacking. Existing patient-identification methods often fail and limit patient-tracking. Paper-based records and poor integration between health-information systems further restrict patient-tracking. Most countries were in the early-middle stages of CBS and faced UPI challenges. Our South African case-study found that the UPI often goes uncaptured. Difficulties tracking patients across prevention and care cascades will continue until a functional and reliable UPI is available.

Quasi-experimental evaluation of a financial incentive for first-dose COVID-19 vaccination among adults aged ≥60 years in South Africa.

INTRODUCTION: COVID-19 vaccination coverage in South Africa (RSA) remains low despite increased access to vaccines. On 1 November 2021, RSA introduced the Vooma Voucher programme which provided a small guaranteed financial incentive, a Vooma Voucher redeemable at grocery stores, for COVID-19 vaccination among older adults, a population most vulnerable to serious illness, hospitalisation and death. However, the association of financial incentives with vaccination coverage remains unclear. METHODS: We evaluated the association of the conditional economic incentive programme with first-dose vaccination rates among adults (aged ≥60 years) through a quasi-experimental cohort study. The Vooma Voucher programme was a nationwide vaccination incentive programme implemented for adults aged ≥60 years from 1 November 2021 to 28 February 2022. We ran ITS models to evaluate the Vooma Voucher programme at national and provincial levels. We used data between 1 October 2021 and 27 November 2021 in models estimated at the daily level. Individuals who received their first vaccine dose received a text message to access a ZAR100 ($~7) voucher that was redeemable at grocery stores. RESULTS: The Vooma Voucher programme was associated with a 7.15%-12.01% increase in daily first-dose vaccinations in November 2021 compared with late October 2021. Overall, the incentive accounted for 6476-10 874 additional first vaccine doses from 1 November to 27 November 2021, or 8.31%-13.95% of all doses administered to those aged ≥60 years during that period. This result is robust to the inclusion of controls for the number of active vaccine delivery sites and for the nationwide Vooma vaccination weekend initiative (12 November to 14 November), both of which also increased vaccinations through expanded access to vaccines and demand creation activities. CONCLUSIONS: Financial incentives for COVID-19 vaccination led to a modest increase in first-dose vaccinations among older adults in RSA. Financial incentives and expanded access to vaccines may result in higher vaccination coverage. TRIAL REGISTRATION NUMBER SANCTR: DOH-27-012022-9116.

Applying machine learning and predictive modeling to retention and viral suppression in South African HIV treatment cohorts.

HIV treatment programs face challenges in identifying patients at risk for loss-to-follow-up and uncontrolled viremia. We applied predictive machine learning algorithms to anonymised, patient-level HIV programmatic data from two districts in South Africa, 2016-2018. We developed patient risk scores for two outcomes: (1) visit attendance ≤ 28 days of the next scheduled clinic visit and (2) suppression of the next HIV viral load (VL). Demographic, clinical, behavioral and laboratory data were investigated in multiple models as predictor variables of attending the next scheduled visit and VL results at the next test. Three classification algorithms (logistical regression, random forest and AdaBoost) were evaluated for building predictive models. Data were randomly sampled on a 70/30 split into a training and test set. The training set included a balanced set of positive and negative examples from which the classification algorithm could learn. The predictor variable data from the unseen test set were given to the model, and each predicted outcome was scored against known outcomes. Finally, we estimated performance metrics for each model in terms of sensitivity, specificity, positive and negative predictive value and area under the curve (AUC). In total, 445,636 patients were included in the retention model and 363,977 in the VL model. The predictive metric (AUC) ranged from 0.69 for attendance at the next scheduled visit to 0.76 for VL suppression, suggesting that the model correctly classified whether a scheduled visit would be attended in 2 of 3 patients and whether the VL result at the next test would be suppressed in approximately 3 of 4 patients. Variables that were important predictors of both outcomes included prior late visits, number of prior VL tests, time since their last visit, number of visits on their current regimen, age, and treatment duration. For retention, the number of visits at the current facility and the details of the next appointment date were also predictors, while for VL suppression, other predictors included the range of the previous VL value. Machine learning can identify HIV patients at risk for disengagement and unsuppressed VL. Predictive modeling can improve the targeting of interventions through differentiated models of care before patients disengage from treatment programmes, increasing cost-effectiveness and improving patient outcomes.

Health Technology Assessment in Support of National Health Insurance in South Africa.

South Africa has embarked on major health policy reform to deliver universal health coverage through the establishment of National Health Insurance (NHI). The aim is to improve access, remove financial barriers to care, and enhance care quality. Health technology assessment (HTA) is explicitly identified in the proposed NHI legislation and will have a prominent role in informing decisions about adoption and access to health interventions and technologies. The specific arrangements and approach to HTA in support of this legislation are yet to be determined. Although there is currently no formal national HTA institution in South Africa, there are several processes in both the public and private healthcare sectors that use elements of HTA to varying extents to inform access and resource allocation decisions. Institutions performing HTAs or related activities in South Africa include the National and Provincial Departments of Health, National Treasury, National Health Laboratory Service, Council for Medical Schemes, medical scheme administrators, managed care organizations, academic or research institutions, clinical societies and associations, pharmaceutical and devices companies, private consultancies, and private sector hospital groups. Existing fragmented HTA processes should coordinate and conform to a standardized, fit-for-purpose process and structure that can usefully inform priority setting under NHI and for other decision makers. This transformation will require comprehensive and inclusive planning with dedicated funding and regulation, and provision of strong oversight mechanisms and leadership.

Reduction in initiations of HIV treatment in South Africa during the COVID pandemic.

BACKGROUND: In response to the global pandemic of COVID-19, countries around the world began imposing stay-at-home orders, restrictions on transport, and closures of businesses in early 2020. South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, fear of transmission, and government responses may have led to a reduction in antiretroviral treatment (ART) initiations for HIV-infected individuals in countries like South Africa. METHODS: We analyzed national, public sector, facility-level data from South Africa's District Health Information System (DHIS) from January 2019 to March 2021 to quantify changes in ART initiation rates stratified by province, setting, facility size and type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. We excluded facilities with missing data, mobile clinics, and correctional facilities. We estimated the total number of ART initiations per study month for each stratum and compared monthly totals, by year. RESULTS: At the 2471 facilities in the final data set (59% of all ART sites in the DHIS), 28% fewer initiations occurred in 2020 than in 2019. Numbers of ART initiations declined sharply in all provinces in April-June 2020, compared to the same months in 2019, and remained low for the rest of 2020, with some recovery between COVID-19 waves in October 2020 and possible improvement beginning in March 2021. Percentage reductions were largest in district hospitals, larger facilities, and urban areas. After the initial decline in April-June 2020, most provinces experienced a clear inverse relationship between COVID-19 cases and ART initiations but little relationship between ART initiations and lockdown level. CONCLUSIONS: The COVID-19 pandemic and responses to it resulted in substantial declines in the number of HIV-infected individuals starting treatment in South Africa, with no recovery of numbers during 2020. These delays may lead to worse treatment outcomes for those with HIV and potentially higher HIV transmission. Exceptional effort will be needed to sustain gains in combatting HIV.

Assessment of facility-based tuberculosis data quality in an integrated HIV/TB database in three South African districts.

BACKGROUND: Assessment of data quality is essential to successful monitoring & evaluation of tuberculosis (TB) services. South Africa uses the Three Interlinked Electronic Register (TIER.Net) to monitor TB diagnoses and treatment outcomes. We assessed the quality of routine programmatic data as captured in TIER.Net. METHODS: We reviewed 277 records from routine data collected for adults who had started TB treatment for drug-sensitive (DS-) TB between 10/2018-12/2019 from 15 facilities across three South African districts using three sources and three approaches to link these (i.e., two approaches compared TIER.NET with the TB Treatment Record while the third approach compared all three sources of TB data: the TB treatment record or patient medical file; the TB Identification Register; and the TB module in TIER.Net). We report agreement and completeness of demographic information and key TB-related variables across all three data sources. RESULTS: In our first approach we selected 150 patient records from TIER.Net and found all but one corresponding TB Treatment Record (99%). In our second approach we were also able to find a corresponding TIER.Net record from a starting point of the paper-based, TB Treatment Record for 73/75 (97%) records. We found fewer records 55/75 (73%) in TIER.Net when we used as a starting point records from the TB Identification Register. Demographic information (name, surname, date of birth, and gender) was accurately reported across all three data sources (matching 90% or more). The reporting of key TB-related variables was similar across both the TB Treatment Record and the TB module in TIER.Net (p>0.05). We observed differences in completeness and moderate agreement (Kappa 0.41-0.60) for site of disease, TB treatment outcome and smear microscopy or X-ray as a diagnostic test (p<0.05). We observed more missing items for the TB Treatment record compared to TIER.Net; TB treatment outcome date and site of disease specifically. In comparison, TB treatment start dates as well as HIV-status recording had higher concordance. HIV status and lab results appeared to be more complete in the TB module in TIER.Net than in the TB Treatment Records, and there was "good/substantial" agreement (Kappa 0.61-0.80) for HIV status. DISCUSSION AND CONCLUSION: Our key finding was that the TB Module in TIER.Net was more complete in some key variables including TB treatment outcome. Most TB patient records we reviewed were found on TIER.Net but there was a noticeable gap of TB Identification patient records from the paper register as compared to TIER.Net, including those who tested TB-negative or HIV-negative. There is evidence of complete and "good/substantial" data quality for key TB-related variables, such as "First GeneXpert test result" and "HIV status." Improvements in data completeness of TIER.Net compared to the TB Treatment Record are the most urgent area for improvement, especially recording of TB treatment outcomes.

Reduction in initiations of drug-sensitive tuberculosis treatment in South Africa during the COVID-19 pandemic: Analysis of retrospective, facility-level data.

In response to the global pandemic of COVID-19, South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, the deprioritization of TB activities, fear of transmission, and societal restrictions led to a reduction in tuberculosis (TB) treatment initiations. We analysed monthly public sector, facility-level data from South Africa's District Health Information System (DHIS) from January 2019 to April 2021 to quantify changes in TB treatment initiation numbers stratified by province, setting, and facility type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. At the 1189 facilities that reported observations for all 28 months of our study period, TB treatment initiations in 2020 were 20.4% lower than in 2019 and 21.9% lower in the first four months of 2021 than in 2019. At the 3669 facilities that reported observations in ≤28 months, numbers of TB treatment initiations declined sharply in all provinces in May-August 2020, compared to the same months in 2019. After recovering somewhat in the last four months of 2020, numbers plummeted again in early 2021. Percentage reductions were somewhat larger in urban and peri-urban areas than in rural areas. Most provinces experienced a clear inverse relationship between COVID-19 cases and TB treatment initiations but little relationship between TB treatment initiations and lockdown level. The COVID-19 pandemic and responses to it resulted in substantial declines in the number of individuals starting treatment for TB in South Africa and risked progress toward achieving TB management goals. Exceptional effort will be needed to sustain gains in combating TB.

Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa.

Background: Most estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here. Methods: In this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level. Results: Of the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31-45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level. Discussion: Integration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.

Impact of an antibiotic stewardship programme in a surgical setting.

BACKGROUND: Antibiotics are miracles of science and critical for many surgical procedures. However, the emergence of multidrug resistant pathogens resulting from inappropriate antibiotic use is a threat to modern medicine. This study aimed to determine the appropriateness of antibiotic use, cost, consumption and impact of an antibiotic stewardship intervention round in a surgical ward setting. METHODS: Baseline antibiotic utilisation was determined with a retrospective cross-sectional study in two surgical wards in a tertiary academic hospital in South Africa where medical records of 264 patients who received antibiotics were reviewed. In the second stage of the study, records of 212 patients who received antibiotics were reviewed during a weekly antibiotic stewardship intervention round. The volume of antibiotics consumed was determined using defined daily doses (DDDs)/1000 patients' days, and the appropriateness of the antibiotic prescription for treatment was also determined using a quality-of-use algorithm. RESULTS: There was a reduction in the volume of antibiotic consumption from a total 739.30 DDDs/1000 to 564.93 DDDs/1000 patient days, with reduction in inappropriate antibiotic use from 35% to 26% from baseline to antibiotic stewardship programme stages, respectively. There was an overall increase in culture targeted therapy in both wards in the antibiotic stewardship programme stage. CONCLUSION: The implementation of an antibiotic stewardship programme led to a reduction in antibiotic consumption and improvement in appropriate use of antibiotics.

Educational antimicrobial stewardship programs in medical schools: a scoping review.

OBJECTIVE: The objective of this scoping review was to identify the available evidence on antimicrobial stewardship programs for teaching medical students about rational antimicrobial use, including the content taught and the method of instruction used. INTRODUCTION: Antibiotics are a precious resource whose discovery have saved millions of lives. They are used extensively in surgical procedures, cancer chemotherapy, and in the treatment of infectious diseases. However, the development of antimicrobial resistance and the slow rate of discovery of new agents with novel mechanisms of actions represent a threat to modern medicine. INCLUSION CRITERIA: This scoping review considered papers that described medical school curricula that focused on the teaching and learning of the prescription of antimicrobial medication. Studies that described this concept in the curricula of other health profession students, such as nursing, pharmacy, or dentistry students, were excluded. METHODS: The JBI three-step process was followed and conducted by two reviewers. The scoping review followed an a priori published protocol. Eight databases were searched for both published and unpublished literature and gray literature. Only studies published in English from 1996 onwards were included. Full texts of selected citations were assessed against the inclusion criteria by two independent reviewers. Data were independently extracted by two reviewers. Disagreements were resolved through discussion, and the need for a third reviewer was not required. Data extraction was undertaken using a modified charting table developed for the review objectives. The findings are presented using the narrative synthesis. RESULTS: Thirteen studies were included in the review, with most of the papers originating from the United States of America and Europe, with one from developing countries. Didactic lectures and web-based distance learning were the most common modes of instruction used in the included papers. Six of the included papers presented the outcomes of their interventions; different methods of assessment were used to evaluate students, which included baseline and post-instruction assessment or a series of short exams. Some of the concepts in the teaching material included the use of antimicrobial agents, prevention of antimicrobial resistance, antimicrobial stewardship, and infection prevention control. The programs (ranging from 75 minutes to 100 hours) were implemented from second to fourth year of study. CONCLUSIONS: A wide range of interventions were used to teach the principles of antimicrobial stewardship to medical students. There is a need to further evaluate these programs through follow-up of students after graduation to determine whether the skills learned are retained.

Knowledge and perceptions about antibiotic resistance and prudent antibiotic prescribing among final year medical students in two African countries.

OBJECTIVES: The objectives of this study were to assess the knowledge and perceptions of final year medical students about antibiotic resistance and antibiotic use to assist in the development of an antibiotic stewardship curriculum for teaching medical students in South Africa and Nigeria and the principles of prudent antibiotic prescribing. METHODS: A cross-sectional study was conducted to determine the knowledge and perceptions of final year medical students in one South African and three Nigerian universities about prudent antibiotic use, antibiotic resistance and antibiotic stewardship. A 26-item questionnaire was administered electronically to students in three medical schools and a paper-based copy in the fourth. KEY FINDINGS: A difference in the gap in knowledge between the two countries was identified; however, respondents from both countries had a similar understanding of antibiotic use and antibiotic resistance. Most respondents in South Africa (94.8%) and Nigeria (91.4%) agreed that antibiotics are overused in their countries. There was a significant difference between the number of respondents in the two countries who thought that there are new antibiotics available to treat resistant pathogens; 45.4% of Nigerian respondents agreed with the statement as compared to 9.6% of the South African respondents. Of the 10 vignettes answered correctly, South African respondents scored an average of 62.4% in the knowledge segment compared to 31.9% scored by the Nigerian respondents (P = 0.001). All of the South African (100%) and 98.3% of the Nigerian respondents indicated their desire for more education on appropriate antibiotic use. CONCLUSIONS: Although students from both countries had the same perception of antibiotic resistance, there was, however, a difference in their level of knowledge, which could have been improved in both countries. This should be addressed at an undergraduate curriculum level; as well as with continued education to reinforce antibiotic knowledge.

Cost-effectiveness analysis of flucytosine as induction therapy in the treatment of cryptococcal meningitis in HIV-infected adults in South Africa.

BACKGROUND: Cryptococcal meningitis in HIV-infected patients in sub-Saharan Africa accounts for three-quarters of the global cases and 135,000 deaths per annum. Current treatment includes the use of fluconazole and amphotericin B. Recent evidence has shown that the synergistic use of flucytosine improves efficacy and reduces toxicity, however affordability and availability has hampered access to flucytosine in many countries. This study investigated the evidence and cost implications of introducing flucytosine as induction therapy for cryptococcal meningitis in HIV-infected adults in South Africa. METHODS: A decision analytic cost-effectiveness and cost impact model was developed based on survival estimates from the ACTA trial and local costs for flucytosine as induction therapy in HIV-infected adults with cryptococcal meningitis in a public sector setting in South Africa. The model considered five treatment arms: (a) standard of care; 2-week course amphotericin B/fluconazole (2wk AmBd/Flu), (b) 2-week course amphotericin B/flucytosine (2wk AmBd/5FC), (c) short course; 1-week course amphotericin B/flucytosine (1wk AmBd/5FC) (d) oral course; 2-week oral fluconazole/flucytosine (oral) and e) 1-week course amphotericin B/fluconazole (1wk AmBd/Flu). A sensitivity analysis was conducted on key variables. RESULTS: The highest total treatment costs are in the 2-week AmBd/5FC arm followed by the 2-week oral regimen, the 1-week AmBd/5FC, then standard of care with the lowest cost in the 1-week AmBd/Flu arm. Compared to the lowest cost option the 1-week flucytosine course is most cost-effective at USD119/QALY. The cost impact analysis shows that the 1-week flucytosine course has an incremental cost of just over USD293 per patient per year compared to what is currently spent on standard of care. Sensitivity analyses suggest that the model is most sensitive to life expectancy and hospital costs, particularly infusion costs and length of stay. CONCLUSIONS: The addition of flucytosine as induction therapy for the treatment of cryptococcal meningitis in patients infected with HIV is cost-effective when it is used as a 1-week AmBd/5FC regimen. Savings could be achieved with early discharge of patients as well as a reduction in the price of flucytosine.

Fast-track treatment initiation counselling in South Africa: A cost-outcomes analysis.

INTRODUCTION: In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider's perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC). METHODS: This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome. RESULTS: A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome. CONCLUSION: The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment. TRIAL REGISTRATION: Clinical Trial Number: NCT02536768.

Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa.

We aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30-39.9 vs 18-29.9 years, 95% confidence intervals (CI): 1.0-2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4-3.6) and HIV testing history (aRR 1.7 for > 12 months vs < 12 months/no prior test, 95% CI: 1.0-2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4-3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2-18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2-0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2-3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.

Community health worker models in South Africa: a qualitative study on policy implementation of the 2018/19 revised framework.

South Africa has a long history of community health workers (CHWs). It has been a journey that has required balancing constrained resources and competing priorities. CHWs form a bridge between communities and healthcare service provision within health facilities and act as the cornerstone of South Africa's Ward-Based Primary Healthcare Outreach Teams. This study aimed to document the CHW policy implementation landscape across six provinces in South Africa and explore the reasons for local adaptation of CHW models and to identify potential barriers and facilitators to implementation of the revised framework to help guide and inform future planning. We conducted a qualitative study among a sample of Department of Health Managers at the National, Provincial and District level, healthcare providers, implementing partners [including non-governmental organizations (NGOs) who worked with CHWs] and CHWs themselves. Data were collected between April 2018 and December 2018. We conducted 65 in-depth interviews (IDIs) with healthcare providers, managers and experts familiar with CHW work and nine focus group discussions (FGDs) with 101 CHWs. We present (i) current models of CHW policy implementation across South Africa, (ii) facilitators, (iii) barriers to CHW programme implementation and (iv) respondents' recommendations on how the CHW programme can be improved. We chronicled the differences in NGO involvement, the common facilitators of purpose and passion in the CHWs' work and the multitude of barriers and resource limitations CHWs must work under. We found that models of implementation vary greatly and that adaptability is an important aspect of successful implementation under resource constraints. Our findings largely aligned to existing research but included an evaluation of districts/provinces that had not previously been explored together. CHWs continue to promote health and link their communities to healthcare facilities, in spite of lack of permanent employment, limited resources, such as uniforms, and low wages.