Micronutrient gaps during the complementary feeding period in 6 countries in Eastern and Southern Africa: a Comprehensive Nutrient Gap Assessment.

Insufficient quantity and inadequate quality of foods in early life are key causes of all forms of malnutrition. Identification of nutrient and dietary gaps in the diets of infants and young children is essential to inform policies and programs designed to improve child diets. A Comprehensive Nutrient Gap Assessment was used to assess the public health significance of nutrient gaps during the complementary feeding period and to identify evidence gaps in 6 countries in Eastern and Southern Africa. Important gaps were identified in iron, vitamin A, zinc, and calcium and, to a lesser extent, vitamin B12 and folate. The best whole-food sources of these micronutrients available in part or all of the countries studied include beef liver, chicken liver, small dried fish, beef, and eggs. Investment is needed in many countries to collect data on micronutrient biomarkers and dietary intake. Strategic actions to improve child diets will require engagement and intervention across relevant systems to accelerate progress on improving the diets of infants and young children.

Moderate levels of pre-therapy drug resistance (PDR) in a generalised epidemic: time for better first-line ART?

BACKGROUND: The WHO-recommended first-line antiretroviral therapy (ART) as a fixed dose combination (FDC) of efavirenz (EFV) and tenofovir disoproxil fumarate (TDF) with lamivudine (3TC) or emtricitabine (FTC) has been preferred in the large scale unprecedented ART roll out in Southern Africa. Models and recent reports suggest that pre-ART HIV drug resistance (PDR) is increasing with high treatment coverage. METHOD: We therefore investigated PDR and any local transmission clusters in a setting where high treatment coverage was further enhanced by universal test and treat (UTT). Surveillance drug resistance mutations (SDRMs) were identified with an in-house PCR and population sequencing method and calibrated population resistance (CPR) tool. RESULTS: Of 60 patients, six (10%) had an SDRM mutation: five (8.3%) had nonnucleoside reverse transcriptase (NNRT) mutations, one had an nucleos(t)ide reverse transcriptase inhibitor mutation and none had protease inhibitor (PI) mutations. Phylogenetic analysis revealed no large transmission clusters. CONCLUSION: An increase to the current moderate PDR levels and the better tolerability and durability, may support a recent drive to avail FDC integrase strand transfer inhibitor (ISTI)-based regimens as the new preferred first-line ART in the Southern African region for individual benefit and to contribute to limiting transmission of infection and drug resistant virus.

High-dose vitamin D3 reduces deficiency caused by low UVB exposure and limits HIV-1 replication in urban Southern Africans.

Cape Town, South Africa, has a seasonal pattern of UVB radiation and a predominantly dark-skinned urban population who suffer high HIV-1 prevalence. This coexistent environmental and phenotypic scenario puts residents at risk for vitamin D deficiency, which may potentiate HIV-1 disease progression. We conducted a longitudinal study in two ethnically distinct groups of healthy young adults in Cape Town, supplemented with vitamin D3 in winter, to determine whether vitamin D status modifies the response to HIV-1 infection and to identify the major determinants of vitamin D status (UVB exposure, diet, pigmentation, and genetics). Vitamin D deficiency was observed in the majority of subjects in winter and in a proportion of individuals in summer, was highly correlated with UVB exposure, and was associated with greater HIV-1 replication in peripheral blood cells. High-dosage oral vitamin D3 supplementation attenuated HIV-1 replication, increased circulating leukocytes, and reversed winter-associated anemia. Vitamin D3 therefore presents as a low-cost supplementation to improve HIV-associated immunity.

Learning from HIV: exploring migration and health in South Africa.

Southern Africa is associated with high HIV prevalence and diverse population movements, including temporary, circular movements between rural and urban areas within countries (internal migration), and movements across borders (international migration). Whilst most migration in southern Africa is associated with the search for improved livelihood opportunities in urban areas a small--but significant--number of people are forced to migrate to escape persecution or civil war. This paper utilises recent empirical studies conducted in South Africa to explore linkages between migration into urban areas and health, focusing on HIV. It is shown that the relationship between migration and HIV is complex; that both internal and international migrants move to urban areas for reasons other than healthcare seeking; and that most migratory movements into urban areas involve the positive selection of healthy individuals. Whilst healthy migration has economic benefits for rural sending households, the data uncovers an important process of return migration (internally or across borders) in times of sickness, with the burden of care placed on the rural, sending household. There is an urgent need for a comprehensive response that maintains the health of migrants in urban areas, and provides support to rural areas in times of sickness.

Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa.

Voluntary medical male circumcision (VMMC) reduces female-to-male HIV transmission by approximately 60%; modeling suggests that scaling up VMMC to 80% of men 15- to 49-years-old within five years would avert over 3.3 million new HIV infections in 14 high priority countries/regions in southern and eastern Africa by 2025 and would require 20.33 million circumcisions. However, the shortage of health professionals in these countries must be addressed to reach these proposed coverage levels. To identify human resource approaches that are being used to improve VMMC volume and efficiency, we looked at previous literature and conducted a program review. We identified surgical efficiencies, non-surgical efficiencies, task shifting, task sharing, temporary redeployment of public sector staff during VMMC campaign periods, expansion of the health workforce through recruitment of unemployed, recently retired, newly graduating, or on-leave health care workers, and the use of volunteer medical staff from other countries as approaches that address human resource constraints. Case studies from Kenya, Tanzania, and Swaziland illustrate several innovative responses to human resource challenges. Although the shortage of skilled personnel remains a major challenge to the rapid scale-up of VMMC in the 14 African priority countries/regions, health programs throughout the region may be able to replicate or adapt these approaches to scale up VMMC for public health impact.

Traditional male circumcision in eastern and southern Africa: a systematic review of prevalence and complications.

OBJECTIVE: to systematically review studies on the prevalence and complications of traditional male circumcision (i.e. circumcision by a traditional provider with no formal medical training), whose coverage and safety are unclear. METHODS: we systematically searched databases and reports for studies on the prevalence and complications of traditional male circumcision in youth 10-24 years of age in eastern and southern Africa, and also determined the ages at which traditional circumcision is most frequently performed. FINDINGS: six studies reported the prevalence of traditional male circumcision, which had been practised in 25-90% of all circumcised male study participants. Most circumcisions were performed in boys 13-20 years of age. Only two of the six studies on complications reported overall complication rates (35% and 48%) following traditional male circumcision. The most common complications were infection, incomplete circumcision requiring re-circumcision and delayed wound healing. Infection was the most frequent cause of hospitalization. Mortality related to traditional male circumcision was 0.2%. CONCLUSION: published studies on traditional male circumcision in eastern and southern Africa are limited; thus, it is not possible to accurately assess the prevalence of complications following the procedure or the impact of different traditional practices on subsequent adverse events. Also, differences in research methods and the absence of a standard reporting format for complications make it difficult to compare studies. Research into traditional male circumcision procedures, practices and complication rates using standardized reporting formats is needed.

Impact of HIV treatment scale-up on women's reproductive health care and reproductive rights in Southern Africa.

The HIV epidemic has changed the face of women's reproductive health across southern Africa. In some circles, there have been calls for restrictions on women's reproductive rights, focusing particularly on the spread of HIV between sexual partners and from mother to child. However, during the past decade, public health attention and resources for the clinical care of HIV-infected individuals living in Africa have led to advances in women's reproductive health services. As many programs have recognized that effective HIV care and treatment services must link to other areas of primary care, key reproductive health services such as those providing contraception and barrier methods are commonly integrated into antiretroviral therapy services. In much of the region, this programmatic focus has helped increase attention on the ground to women's reproductive rights. However, in many settings, policies explicitly supporting the reproductive rights of HIV-infected women have lagged. Important gaps remain both in policy development and in the design, evaluation, and implementation of interventions promoting women's reproductive health and rights at the service delivery level.

Multiple stressors in Southern Africa: the link between HIV/AIDS, food insecurity, poverty and children's vulnerability now and in the future.

Several countries in Southern Africa now see large numbers of their population barely subsisting at poverty levels in years without shocks, and highly vulnerable to the vagaries of the weather, the economy and government policy. The combination of HIV/AIDS, food insecurity and a weakened capacity for governments to deliver basic social services has led to the region experiencing an acute phase of a long-term emergency. "Vulnerability" is a term commonly used by scientists and practitioners to describe these deteriorating conditions. There is particular concern about the "vulnerability" of children in this context and implications for children's future security. Through a review of literature and recent case studies, and using a widely accepted conceptualisation of vulnerability as a lens, we reflect on what the regional livelihoods crisis could mean for children's future wellbeing. We argue that an increase in factors determining the vulnerability of households - both through greater intensity and frequency of shocks and stresses ("external" vulnerability) and undermined resilience or ability to cope ("internal" vulnerability) - are threatening not only current welfare of children, but also their longer-term security. The two specific pathways we explore are (1) erosive coping strategies employed by families and individuals; and (2) their inability to plan for the future. We conclude that understanding and responding to this crisis requires looking at the complexity of these multiple stressors, to try to comprehend their interconnections and causal links. Policy and programme responses have, to date, largely failed to take into account the complex and multi-dimensional nature of this crisis. There is a misfit between the problem and the institutional response, as responses from national and international players have remained relatively static. Decisive, well-informed and holistic interventions are needed to break the potential negative cycle that threatens the future security of Southern Africa's children.

Oculocutaneous albinism in southern Africa: population structure, health and genetic care.

BACKGROUND: People with oculocutaneous albinism (OCA) have reduced levels of melanin in their hair, skin and eyes, with associated visual impairment and extreme sun sensitivity requiring lifelong monitoring. This genetic condition is surrounded by myth, superstition and fear in Africa, where affected individuals and their families may be rejected, shunned and excluded from their community. OBJECTIVE: This review reports population studies in southern Africa to determine the distribution of people with OCA in this predominantly rural and relatively impoverished area-crucial information for health and education providers. Health and genetic care studies document the range of eye and skin problems experienced and suggest effective and sustainable ways to manage these needs in a low resource setting. CONCLUSION: Innovative genetic care programmes in northern South Africa facilitate low-cost management of albinism, raise self-esteem and promote community awareness, helping to improve the long-term health prospects and social integration of those affected. This holistic approach of dealing with albinism from both a medical and a sociological perspective could be applied in other areas of Africa where this condition is prevalent.

HIV/AIDS symptom management in Southern Africa.

We describe self-reported strategies used by persons living with HIV/AIDS in Botswana, Lesotho, South Africa, and Swaziland to manage common HIV-related symptoms. A questionnaire asked participants to list three to six symptoms they had recently experienced, the care strategies they had used to make them better, where they had learned the strategy, and to rate the perceived effectiveness of the strategy. Data were collected in 2002 from 743 persons. The self-care management strategies were coded into eight categories: medications, complementary treatments, self-comforting, changing diet, seeking help, exercise, spiritual care, and daily thoughts/activities. Overall, participants reported medications as the most frequently occurring management strategy and the most effective. A very small inventory of behavioral strategies was available to participants to help them manage their HIV-related symptoms.

Catha edulis, an international socio-medical problem with considerable pharmacological implications.

It is evident from the mentioned studies that the medical and psychosocial effects of khat chewing are hazardous both to the individual and the community. The habituation of khat chewing seriously effects the psychoeconomic structure of the subject. Being aware of the increasing prevalence of khat chewing (often together with other drugs), it is essential to assess the health and socio-economic problems of khat habituation in order to take further, appropriate medical and social measures.

Aspects of poisoning with traditional medicines in southern Africa.

During 1981-1985, 1306 patients were admitted to Ga-Rankuwa Hospital due to acute poisoning. The major causes were paraffin (59.0%) and traditional medicines (15.8%). The mortality from paraffin was low (2.1%), but poisoning from traditional medicine resulted in a high mortality (15.2%) and accounted for 51.7% of all deaths. The traditional healer was the main source (83.4%), of traditional medicines, while 11.6% was bought from African medicine shops. The rest was acquired from other sources. In 82.5% of cases traditional medicines were taken orally, and in 10.5% of cases they were administered as an enema. Poisoning by traditional medicines was always accidental and probably due to overdosage. Vomiting, diarrhea, and abdominal pain were the most frequently encountered symptoms while the lungs, liver, and central nervous system were commonly affected. Treatment consisted of ventilation, intravenous fluids, and other palliative measures. A great deal of secrecy still surrounds traditional medicine, hampering rational therapy. Questioning of patients and interviews with traditional healers facilitated the identification of a number of major etiological agents. This elucidated the problem and should promote effective treatment.