Cost and outcomes of routine HIV care and treatment: public and private service delivery models covering low-income earners in South Africa.

BACKGROUND: While South Africa's national HIV program is the largest in the world, it has yet to reach the UNAIDS 95-95-95 targets. To reach these targets, the expansion of the HIV treatment program may be accelerated through the use private sector delivery models. This study identified three innovative non-governmental primary health care models (private sector) providing HIV treatment, as well as two government primary health clinics (public sector) that served similar populations. We estimated the resources used, and costs and outcomes of HIV treatment across these models to provide inputs to inform decisions around how these services might best be provided through National Health Insurance (NHI). METHODS: A review of potential private sector models for HIV treatment in a primary health care setting was conducted. Models actively offering HIV treatment (i.e. in 2019) were considered for inclusion in the evaluation, subject to data availability and location. These models were augmented by government primary health clinics offering HIV services in similar locations. We conducted a cost-outcomes analysis by collecting patient-level resource usage and treatment outcomes through retrospective medical record reviews and a bottom-up micro-costing from the provider perspective (public or private payer). Patient outcomes were based on whether the patient was still in care at the end of the follow up period and viral load (VL) status, to create the following outcome categories: in care and responding (VL suppressed), in care and not responding (VL unsuppressed), in care (VL unknown) and not in care (LTFU or deceased). Data collection was conducted in 2019 and reflects services provided during the 4 years prior to that (2016-2019). RESULTS: Three hundred seventy-six patients were included across the five HIV treatment models. Across the three private sector models there were differences in the costs and outcomes of HIV treatment delivery, two of the models had results similar to the public sector primary health clinics. The nurse-led model appears to have a cost-outcome profile distinct from the others. CONCLUSION: The results show that across the private sector models studied the costs and outcomes of HIV treatment delivery vary, yet there were models that provided costs and outcomes similar to those found with public sector delivery. Offering HIV treatment under NHI through private delivery models could therefore be an option to increase access beyond the current public sector capacity.

Risk Compensation Following Medical Male Circumcision: Results from a 1-Year Prospective Cohort Study of Young School-Going Men in KwaZulu-Natal, South Africa.

PURPOSE: This study sought to assess risk compensation following voluntary medical male circumcision of young school-going men. Risk compensation is defined as an inadvertent increase in sexual risk behaviors and a corresponding decrease in self-perceived risk for contracting HIV following the application of a risk reduction technology. METHODS: This study documented the sexual practices of circumcised (n = 485) and uncircumcised (n = 496) young men in 42 secondary schools at three time points (baseline and 6 and 12 months) in a sub-district of KwaZulu-Natal, South Africa. Study participants were aged from 16 to 24 years old. RESULTS: At the end of the study period, there was no significant difference between the two cohorts concerning learners' perceptions of being at risk of contracting HIV (interaction effect: b = -0.12, p = 0.40). There was also no significant difference in the number of sexual partners in the previous month (interaction effect: b = -0.23, p = 0.15). The proportion of learners who have never used a condom decreased significantly over time (time effect: b = -0.27, p = 0.01), and there was no difference between the circumcised and uncircumcised learners (interaction effect: b = -0.09, p = 0.91). CONCLUSIONS: Risk compensation, as evidenced in this study over a 1-year period, was not associated with undergoing voluntary medical male circumcision (VMMC) in our sample of young school-going men. However, it is of concern that at the end of this study, less than half of the sexually active sample in a high-HIV-prevalence community used condoms consistently in the previous month (39% for both study cohorts). The latter underscores the need to view VMMC as a potential entry point for planned HIV and sexuality education interventions targeting young men in this community.

Community-led monitoring and the role of Ritshidze in improving the quality of primary healthcare in South Africa.

Community-led monitoring (CLM) of health services is a mechanism of community participation and accountability that is increasingly advocated across the globe. In South Africa (SA), a large-scale community-led monitoring initiative called Ritshidze ('saving our lives') was established in 2019. Steered by a coalition of civil society organisations representing people living with HIV, Ritshidze monitors just over 400 primary healthcare (PHC) facilities in 8 provinces on a quarterly basis. In this piece we describe the purposes and design features and the five-step approach to CLM of the Ritshidze model. We also highlight some of the positive changes achieved, and reflect on possible reasons for successes. In doing so, we aim to draw attention to this significant national initiative and its potential as a mechanism of social accountability in SA.

Enhancing styrene monomer recovery from polystyrene pyrolysis: insights from density functional theory.

CONTEXT: Plastic waste pyrolysis offers a potential solution to reduce plastic accumulation, but prioritizing monomer recovery from the process is crucial to effectively address the environmental consequences of plastic accumulation. This study focuses on enhancing the yield of styrene during the pyrolysis of polystyrene by investigating thermal and kinetic data. A comprehensive investigation into the thermal degradation pathways of polystyrene is imperative to overcome the challenges associated with its waste management. The calculated bond dissociation energies reveal that the cleavage of non-terminal carbon-carbon bonds is energetically favorable, resulting in the formation of high molecular weight benzylic radicals. Based on these findings, four pyrolysis pathways are proposed, and the associated thermodynamic and kinetic parameters are determined using the DFT method. The major products identified in this study include styrene, α-methylstyrene, isopropylbenzene, methylbenzene, ethylbenzene, and methane. Furthermore, optimizing the temperature profile of the reactor is shown to enhance the recovery of styrene, thereby contributing to the reduction of plastic waste. This study provides valuable insights into the effective resource recovery from polystyrene waste pyrolysis, emphasizing the significance of managing pyrolysis conditions to achieve maximum yield. By controlling the temperature profile during the pyrolysis process, it is possible to obtain a high yield of styrene, facilitating the efficient recovery of the monomer from waste polystyrene and addressing the environmental concerns associated with plastic accumulation. METHODS: In this study, all calculations were performed using the B3LYP/6-31G(d) level of theory with the Gaussian 16 program package. The proposed model underwent geometry optimization and frequency calculations. Transition states were optimized using the TS Berny method, and energy profiles along reaction pathways were refined using the QST3 method. The IRC method validated proposed mechanisms and investigated energy profiles. Structural models were visualized using GaussView 6.0.

Flourishing During the COVID-19 Pandemic: A Longitudinal Study in South Africa.

In this longitudinal study, we examine changes in psychological distress and multidimensional well-being from before to during the COVID-19 pandemic among South African adults. As a secondary purpose, we explore whether pre-pandemic flourishing is protective against subsequent psychological distress during the public health crisis. The analytic sample (n = 293; Mage = 44.27, SD = 14.28; female = 65.19%) completed measures of anxiety symptoms, depression symptoms, and well-being shortly before the stringent nationwide lockdown started in South Africa (T1). A follow-up assessment was completed approximately 6 months later (T2). Paired samples t-tests supported very small improvements in anxiety (d = -0.09) and depression symptoms (d = -0.13). For domains of well-being, small increases were found in close social relationships (d = 0.25) and financial and material stability (d = 0.19). Positive changes in the domains of character and virtue (d = 0.10) and meaning and purpose (d = 0.07) were very small. Changes in physical and mental health (d = -0.03) and life satisfaction and happiness (d = 0.02) were more negligible. Results from the generalized linear models indicated that continuous scores of secure flourishing assessed before the COVID-19 pandemic were associated with lower subsequent psychological distress (particularly depression symptoms) during the public health crisis. We discuss the implications of the findings for the development and delivery of interventions to promote and sustain human flourishing during public health crises, especially in contexts of social-structural vulnerability.

Primary healthcare delivery models for uninsured low-income earners during the transition to National Health Insurance: Perspectives of private South African providers.

BACKGROUND: The proposed National Health Insurance (NHI) system aims to re-engineer primary healthcare (PHC) provision in South Africa, with strategic purchasing of services from both private and public sector providers by the NHI Fund. Currently, while access to the private sector is primarily restricted to high-income insured earners, an important proportion of the low-income segment is choosing to utilise private PHC providers over public sector clinics. In recent years, a number of private providers in SA have established innovative models of PHC delivery that aim to expand access beyond the insured population and provide affordable access to good-quality PHC services. OBJECTIVES: To describe the current landscape of private PHC clinic models targeting low-income, uninsured earners and the role they might play during the transition to NHI. METHODS: Key informant interviews were conducted with representatives of a sample of private PHC provider organisations providing services to low-income, uninsured earners with clinics - beyond the traditional private sector general practitioner model. Organisations were asked to describe their service delivery model, the population it serves, the PHC services offered and the financing model. Written responses were captured in Excel and coded manually, and the results were thematically analysed. RESULTS: Of the eight organisations identified, most have actively engaged strategies to ensure the provision of affordable quality care. Within these strategies, scale is an important pivot in spreading fixed costs across more paying patients as well as task shifting to lower cadres of healthcare workers. Access to government medicines and laboratory tests is an important factor in achieving lower costs per patient. Together, these strategies support the sustainability of these models. CONCLUSIONS: We have provided an exploratory analysis of private PHC service delivery models serving the low-income, uninsured patient population, establishing factors that increase the efficiency of such service delivery, and delineating combinations of strategies that could make these models successful both during the transition to NHI and during full-scale NHI implementation. A clear regulatory framework would act as a catalyst for further innovation and facilitate contracting. These existing models can enhance and complement government provision and could be scaled up to meet the needs of expanding PHC under NHI. Understanding these models and the space and parameters in which they operate is important.

The significance of cytomegalovirus in children with pneumonia admitted for mechanical ventilation.

BACKGROUND: The pathogenic role of cytomegalovirus (CMV) among children with pneumonia is not clear. OBJECTIVES AND DESIGN: We describe the outcome of children on mechanical ventilation with 'probable' CMV-related pneumonitis (CMV DNA polymerase chain reaction [PCR] positive as well as clinical and imaging features of CMV on ganciclovir) and children with pneumonia and CMV infection (CMV DNA PCR-positive without clinical and imaging features of CMV and not on ganciclovir therapy) at a paediatric intensive care unit in South Africa between 2011 and 2013. CMV viral loads were measured in non-bronchoscopic bronchoalveolar lavage fluid (NBBALF), plasma and whole-blood samples. RESULTS: Of the 97 children enrolled, 38 had CMV-related pneumonitis, 27 had pneumonia and CMV infection and 32 had pneumonia without CMV infection (negative CMV DNA PCR). Survival in the three groups was respectively 73.7% (P < 0.05), 92.6% (P < 0.05) and 88.0%. The difference in outcome could be accounted for by variance in the prevalence of human immunodeficiency virus (HIV) infection (respectively 60.5% and 29.6%, P < 0.05). A higher CMV viral load in NBBALF and plasma was seen in cases of CMV-related pneumonitis than in pneumonia with CMV infection: respectively log 5.20 vs. log 4.10 (P < 0.05) and 4.56 vs. 3.47 (P < 0.05). CONCLUSIONS: HIV-infected children on mechanical ventilation with CMV-related pneumonitis on ganciclovir have poor outcomes. Randomised placebo-controlled studies on ganciclovir are required.

Aetiology of male urethritis in patients recruited from a population with a high HIV prevalence.

The aetiology of urethritis, the significance of potential pathogens and the relation of urethritis to HIV infection were determined in 335 men (cases) with and 100 men (controls) without urethral symptoms. Urethral swab specimens were tested for different organisms by PCR or by culture for Neisseria gonorrhoeae. The prevalence of N. gonorrhoeae and Chlamydia trachomatis was 52 and 16%, respectively. The potential pathogens: Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis and herpes simplex virus (HSV), were present in 5, 36, 6 and 6% of the cases respectively. M. genitalium was the only potential pathogen associated with microscopic urethritis. After excluding gonococcal infections, U. urealyticum was more frequent in symptomatic patients, while the prevalence of T. vaginalis was similar among cases and controls. These results strongly suggest an a etiological role for M. genitalium in male urethritis, a possible role for U. urealyticum, but not for T. vaginalis. The control group, with 97% genital ulcer disease patients, was not suitable for the investigation of the role of HSV. The sero-prevalence of HIV was 45%. Current infections were not associated with HIV. However, a history of previous urethral discharge was associated with HIV in a multivariate analysis and supported the hypothesis that non-ulcerative sexually transmitted diseases facilitate HIV transmission.

A group-based counselling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: a randomized controlled pilot study.

BACKGROUND: Co-morbid depression in HIV-positive patients on anti-retroviral (ART) treatment poses a public health threat. It compromises treatment adherence and accelerates disease progression. This study aimed to assess the feasibility of a group-based counselling intervention for depressed HIV-positive patients in primary health care (PHC) in South Africa using a task shifting approach. METHODS: Using a randomized control design, 76 HIV-positive patients with co-morbid depression were initially recruited. This reduced to 34 in the final cohort. Participants were assessed using the Patient Health Questionnaire (PHQ9), Hopkins Symptom Checklist (HSCL-25) and Multidimensional Scale of Perceived Social Support (MSPSS) at baseline and 3-month follow-up. The intervention was adapted from a local group-based Interpersonal Therapy (IPT) intervention. Process evaluation interviews were held with the HIV counsellors who delivered the intervention and a sub-sample of participants. RESULTS: Repeated measures ANOVA analysis showed significantly greater improvement on depression scores on the PHQ9 in the intervention group compared to the control group. A significant decline in the mean scores on the HSCL-25 was found for both groups although this was more pronounced for the intervention group. There was no significant improvement in the MSPSS scores. LIMITATIONS: The small sample size of the final cohort affected the power of the study to detect significant differences between the intervention and control groups on the MSPSS. Longer term impact of the intervention is unknown. CONCLUSIONS: These preliminary findings suggest that group-based counselling for depression in HIV-positive patients can potentially be effectively delivered by appropriately trained and supported lay HIV counsellors. The need for a larger trial is indicated.