Evaluation of cancer screening services provided for people living with HIV in Botswana, 2022-2023.

People living with human immunodeficiency virus (PLHIV) have an increased risk of cancers. Currently, Botswana has no screening guidelines for common cancers in PLHIV except cervical cancer. Also, the proportion of PLHIV who are screened for cancer is unknown. This study aimed to evaluate cancer screening services for PLHIV receiving care in the human immunodeficiency virus (HIV) clinics. Resources for cancer screening were assessed and medical records of adults initiating antiretroviral therapy (ART) from 2020 to 2021 in 20 high-volume HIV clinics in Gaborone and Francistown were reviewed. Questionnaires assessing knowledge and practices of cancer screening were administered to health workers. The majority of clinics had the required resources for cancer screening (specifically cervical cancer). Of the 62 health workers working at the HIV clinics, 57 (91.9%) completed the questionnaire: 35 (62.5%) nurses and 22 (37.5%) doctors. Only 26.3% of the health workers were trained in cervical cancer screening. Doctors were more likely to report practicing routine screening of other cancers (e.g. breast) (p = 0.003) while more nurses reported assessing patients for cancer history during follow-up visits (p = 0.036). Most health workers did not perform physical examinations to detect cancer at initial or follow-up visits. Of the 1000 records of PLHIV reviewed, 57.3% were females, and only 38% of these were screened for cervical cancer. Besides cervical cancer, almost all (97.8%) were not screened for any cancer at ART initiation and during follow-up. These findings highlight the need to improve cancer screening services of PLHIV in Botswana through the training of health workers, and the development and enhanced use of screening guidelines.

The Trends and Risk Factors of AIDS-Defining Cancers and Non-AIDS-Defining Cancers in Adults Living with and without HIV: A Narrative Review.

Background: People living with HIV (PLHIV) are at a high-risk of developing AIDS-defining cancers (ADCs) and non-AIDS-defining cancers (NADCs). This review is aimed at exploring available evidence regarding the trends of ADCs and NADCs and the associated risk factors among adult PLHIV. Methods: We conducted a comprehensive search of PubMed, Web of Science, and EBSCO host databases to identify articles published between 2010 and 2023 that reported incidence and mortality rates of cancer, including ADCs and NADCs among PLHIV. We compared trends and rates in PLHIV with HIV-negative adults and further assessed related risk factors. Results: A total of 1886 potentially eligible articles were screened, and of these, 36 were included in this study. More than 50% (n = 20) of these were based in high-income countries. Seventeen studies reported a higher prevalence of NADCs compared to ADCs, with twelve of these conducted in high-income countries. Conversely, eight out of twelve studies reporting a higher prevalence of ADCs versus NADCs were from low-and-middle and upper-middle-income countries. Ten studies indicated a higher incidence of ADCs (6 studies) and NADCs (4 studies) among PLHIV compared to HIV-negative individuals. In contrast, only two studies observed an increase in NADCs among the HIV-negative population. In comparing mortality, seven out of nine studies showed elevated NADC-related deaths compared to ADCs. The main risk factors identified for any cancer, NADCs, and related mortality were advancing age, and longer duration of HIV infection, while lower CD4 cell counts (<200 cells/µl), was associated with both ADC and NADC occurrences. Conclusion: Chronic HIV infection combined with advancing age in PLHIV taking antiretroviral therapy appears to have contributed to increasing cancer burden, particularly the incidence of NADCs and associated mortality. These findings stress the importance of screening for high-risk cancers among PLHIV for early detection and treatment to ensure improved outcomes.

Predictors of stunting among children aged 6-59 months, Zimbabwe.

OBJECTIVE: Stunted children have an increased risk of diminished cognitive development, diabetes, degenerative and CVD later in life. Numerous modifiable factors decrease the risk of stunting in children. This study aimed to assess the role of the individual, household and social factors on stunting in Zimbabwean children. DESIGN: A 1:2 unmatched case-control study. SETTING: This study was conducted in two predominantly rural provinces (one with the highest national prevalence of stunting and one with the lowest prevalence) in Zimbabwe. PARTICIPANTS: Data were obtained from the caregivers of 150 children aged between 6 and 59 months with stunting and from the caregivers of 300 children without stunting. RESULTS: Multiple (39) correlates of stunting were identified. Child's age, birth length, birth weight, and weight-for-age outcome (child-related factors), caregiver's age, maternal HIV status, occupation, and education (parental factors), breast-feeding status, number of meals, and dietary quality (dietary factors), child's appetite, diarrhoeal and worm infection (childhood illnesses), income status, access to safe water, access to a toilet, health clubs and maternal support in infant feeding (household, socio-cultural factors) were all found to be significant predictors of childhood stunting. CONCLUSION: Nearly all aspects under review from the individual-, household- to social-level factors were significantly associated with childhood stunting. These findings add to the growing body of evidence supporting the WHO stunting framework and strengthen the need to focus interventions on a multi-sectoral approach to effectively address stunting in high prevalence countries.

Dietary patterns and childhood stunting in Zimbabwe.

BACKGROUND: Diet is one important predictor of children's growth, and often dietary interventions can assist with reversing adverse nutrition outcomes. Traditionally research has focused on individual food items or food classes to generate an understanding of disease risk. Dietary patterns provide a holistic approach to understanding the relationship between exposure and outcome. METHOD: A matched case-control study was conducted. Caregivers of 450 children (225 cases, 225 controls) aged 6-59 months were asked to describe the diet their children had consumed in the previous 7 days using a Food Frequency Questionnaire. Dietary patterns were developed using factor analysis and regression analysis was conducted to assess which dietary pattern was associated with childhood stunting. RESULTS: Three dietary patterns were identified: modern (n = 181), low animal-source (n = 158), and traditional (n = 111). Children with the low animal source dietary pattern had increased odds of being stunted (AOR 1.03, p < 0.05). Three demographic factors (Child's age, father's age and having a sibling < 24 months apart) were identified as significant predictors of consumption of any of the traditional and low animal source diet (P < 0.001). CONCLUSION: Nutrition intervention such as health education, counselling and supplementary feeding should include a holistic approach to dietary education not only focusing on promoting a balanced diet but improvement strengthening the upgrading of child's dietary pattern taking into cognisant both quantity, and quality of nutrients provided to the child.

Development of a Zimbabwean child growth curve and its comparison with the World Health Organization child growth standards.

BACKGROUND: There is limited research that describes the growth trajectories of African children. The development of World Health Organization (WHO) growth standards considered a sample of children who lived in environments optimum for human growth. AIM: This study aimed to develop weight-for-age and height-for-age growth curves from the Zimbabwean 2018 National Nutrition Survey and compare them with the WHO growth standards. SETTING: Study participants were recruited from all districts in Zimbabwe. METHODS: Height-for-age and weight-for-age data collected from 32 248 children were used to develop the Zimbabwean references. Smooth growth curves (height, weight and body mass index [BMI]-for-age) were estimated with the Lambda Mu Sigma (LMS) method and compared with the WHO growth standards. RESULTS: Zimbabwean children were shorter and weighed less in comparison with the WHO growth standards. The -2 standard deviation (s.d.) Z-score curves (height-for-age) for Zimbabwean children (boys and girls) were below the -1 s.d. Z-score curves of the WHO growth standards. The Zimbabwean Z-scores (BMI-for-age) values above -1 s.d. were significantly higher in comparison with the corresponding WHO growth standards. CONCLUSION: Utilising the WHO growth standards would diagnose a higher proportion of Zimbabwean children as stunted whilst underestimating the proportion at risk of obesity. The WHO growth standards lack a consideration of the geographical, economic, political and environmental constraints existing between countries.

Evaluation of the child growth monitoring programme in two Zimbabwean provinces.

BACKGROUND:  The child growth monitoring (CGM) programme is an important element of nutrition programmes, and when combined with other child health programmes, it can assist in successful management and control of malnutrition in children. AIM:  This study aimed to assess the extent to which the CGM programme is able to identify instances of childhood malnutrition and how much this contributes towards malnutrition reduction in Zimbabwe. SETTING:  The study was conducted in Manicaland and Matabeleland South provinces of Zimbabwe. The two provinces were purposively selected for having the highest and least proportion of children affected by stunting in the country. METHODS:  The CGM programme in Zimbabwe was evaluated using the logic model to assess the ability of the programme to identify growth faltering and link children to appropriate care. RESULTS:  Records from 60 health facilities were reviewed. Interviews were conducted with 60 nurses, 100 village health workers (VHWs) and 850 caregivers (300 health facility exit interviews, 450 community based). Nearly all (92%) health facilities visited had functional measuring scales. Twelve health facilities (20%) had no functional height board, with five using warped height boards for measuring children's height. Less than a quarter (21%) of the children had complete records for weight for age and height for age. A large proportion of children eligible for admission for the management of moderate (83%) and severe malnutrition (84%) were missed. CONCLUSION:  The CGM programme in Zimbabwe is not well equipped for assessing child height for age and management of children identified with malnutrition, thus failing to timely identify and manage childhood stunting.

Validation of growth standards and growth references: A review of literature.

The World Health Organization (WHO) growth standards provide the most recognized and widely accepted way of assessing child growth. To ensure its applicability, accuracy, and reliability, studies have validated WHO growth standards against local populations and other internationally recognized growth references. We reviewed outcomes of evaluations done on WHO growth standards and assess the appropriateness of using these growth standards on a global level. We undertook a systematic quantitative review of studies published from 2011 to 2020 from multiple databases. Studies were included if they considered children aged 59 months and below and reported on validation of growth standards. There was an agreement in studies that validated WHO growth standards against international growth references of its superiority in identifying stunted, overweight, and obese children. However, they were less likely to identify underweight children. None of the studies reviewed reported similar growth trajectories to WHO standards in all indicators considered. Regional differences in child growth were observed in comparison to WHO growth standards. Adoption of regional-specific standards increases the sensitivity of identifying children with adverse nutrition outcomes.

Factors influencing patients' choice of clinic at Inanda, KwaZulu-Natal.

BACKGROUND: In South Africa, patients are meant to attend the clinic close to their place of residence. However, patients often choose which clinic to attend, which results in overcrowding. AIM: This study aimed to investigate the structural and process factors influencing patients' choice to attend a community health centre (CHC) in KwaZulu-Natal, South Africa. SETTING: The study was conducted at the Inanda C Community Health Centre (CHC). METHODS: Systematic random sampling was used to select study participants. A structured questionnaire was used to collect socio-demographic data and assess the factors influencing patients' choice to attend this CHC. RESULTS: There were 400 patients who participated. The commonest structural indicator that patients agreed on as the reason they attend Inanda C CHC was because it has enough medication (126, 73.3%). There was a significant difference in the proportion of patients who agreed that seeing a doctor instead of nurse was a reason for attending this clinic with 118 (68.6%) patients from within the catchment area and 170 (74.6%) from outside the catchment area. The commonest process indicators that patients from within and outside the catchment area agreed on as reasons for attending Inanda C CHC were 'the doctor or nurse explains my sickness and treatment to me' and 'I get good quality of care'. CONCLUSION: The structural and process indicators that influence patients' choice of clinic may need to be improved at other clinics in this area in order to decrease the overcrowding at this clinic.

Training and assessing undergraduate medical students' research: Learning, engagement and experiences of students and staff.

BACKGROUND: The development of research skills is an important aspect of undergraduate medical training that facilitates the practice of evidence-based medicine. The inclusion of research training into undergraduate medical curricula can take various formats and is compulsory for all students at the Nelson R. Mandela School of Medicine (NRMSM). The evaluation of this training is important, both to ensure that students obtain the required research skills and to improve the quality of the training. AIM: The aim of this study was to evaluate undergraduate medical students' and staff learning, engagement and experiences in the training and assessment of third-year research projects. SETTING: This research was conducted at NRMSM, South Africa. METHODS: Questionnaires were administered to third-year medical students after they completed their research project poster presentations and to the staff who assessed the presentations. Responses to the learning process, group work, alignment between module outcomes and assessment and the benefits of poster presentations were assessed. RESULTS: A total of 215 students and 10 staff completed the questionnaire. Many students reported having enjoyed learning about research (78%) and that the training activities facilitated their understanding of the research process (84%). The majority of students (86%) and staff (80%) perceived the posters as an effective way to demonstrate students' ability to collect, analyse and interpret data. CONCLUSION: Staff and students viewed the research process positively and reported that the poster presentations were an effective way to assess research.

An evaluation of infection control in private and public sector intensive care units in South Africa.

BACKGROUND: Appropriate infection control policies and practices are key to reducing the risk of healthcare-associated infections in patients in intensive care units (ICUs). OBJECTIVE: To evaluate infection control in ICUs using the Infection Control Assessment Tool (ICAT). METHODS: Six public and five private adult ICUs were included. Seven modules from the ICAT were administered including ICU, hand hygiene, and isolation and standard precautions. Modules were scored on a quantitative scale as per the tool guidelines and trained independent nurses observed practices. RESULTS: All ICUs reported to have a 1:1 nurse-to-patient ratio. One public ICU did not have the required 1:2 hand wash basin-to-bed ratio. We observed 100% adherence to handwashing or alcohol rub at each of the five moments of hand hygiene; however, the correct amount of alcohol rub was used in only 2% (n = 2) of the 117 observations. The median score for isolation and standard precautions was 79%. DISCUSSION: There was good infection control practice in ICUs. However, ICUs did not have isolation policies for all the infections listed in the ICAT and did not screen visitors to the ICU. We identified shortcomings in the ICAT and a more suitable tool is required for our healthcare setting.

Challenges with Surveillance of Healthcare-Associated Infections in Intensive Care Units in South Africa.

BACKGROUND: The incidence of healthcare-associated infections (HAIs) in the public health sector in South Africa is not known due to the lack of a surveillance system. We report on the challenges experienced in the implementation of a surveillance system for HAIs in intensive care units (ICUs). METHODS: A passive, paper-based surveillance system was piloted in eight ICUs to measure the incidence of ventilator-associated pneumonia, catheter-associated urinary tract infection, and central line-associated bloodstream infection. Extensive consultation with the ICU clinical and nursing managers informed the development of the surveillance system. The Plan-Do-Study-Act method was utilized to guide the implementation of the surveillance. RESULTS: The intended outputs of the surveillance system were not fully realized due to incomplete data. The organizational culture did not promote the collection of surveillance data. Nurses felt that the surveillance form added to their workload, and the infection control practitioners were unable to adequately supervise the process due to competing work demands. CONCLUSIONS: A manual system that adds to the administrative workload of nurses is not an effective method of measuring the burden of HAIs. Change management is required to promote an organizational culture that supports accurate data collection for HAIs.

Molecular Characterization of Corynebacterium diphtheriae Outbreak Isolates, South Africa, March-June 2015.

In 2015, a cluster of respiratory diphtheria cases was reported from KwaZulu-Natal Province in South Africa. By using whole-genome analysis, we characterized 21 Corynebacterium diphtheriae isolates collected from 20 patients and contacts during the outbreak (1 patient was infected with 2 variants of C. diphtheriae). In addition, we included 1 cutaneous isolate, 2 endocarditis isolates, and 2 archived clinical isolates (ca. 1980) for comparison. Two novel lineages were identified, namely, toxigenic sequence type (ST) ST-378 (n = 17) and nontoxigenic ST-395 (n = 3). One archived isolate and the cutaneous isolate were ST-395, suggesting ongoing circulation of this lineage for >30 years. The absence of preexisting molecular sequence data limits drawing conclusions pertaining to the origin of these strains; however, these findings provide baseline genotypic data for future cases and outbreaks. Neither ST has been reported in any other country; this ST appears to be endemic only in South Africa.

Delays in switching patients onto second-line antiretroviral treatment at a public hospital in eThekwini, KwaZulu-Natal.

BACKGROUND: South Africa has one of the largest antiretroviral treatment (ART) programmes globally. In addition to increasing access to ART, it is important that the health system also focuses on the appropriate management of patients who fail first-line ART. Delays in switching patients onto second-line ART can adversely affect patient outcomes. AIM: To identify the patient-related and programmatic factors that delay switching patients onto second-line ART, and to assess whether these delays contribute to subsequent virological failure. METHODS: Clinical records of adult patients switched onto second-line ART between 2011 and 2014 at a public antiretroviral clinic were used to collect demographic, clinical, laboratory and programmatic data (availability of viral load results, inadequate patient follow-up, insufficient notes for effective follow-up). Data were analysed using univariate and multivariate logistic regression. RESULTS: The median duration from the date of first and confirmatory documented high viral load (VL > 1000 copies/mL) to being switched to second-line ART was 13.2 months [interquartile range (IQR) 1.1-52.7 months] and 6.4 months (IQR 0-43.3 months), respectively. Inadequate prescriber notes for appropriate follow-up (p = 0.01) and unavailability of patients' viral load results (p = 0.02) were significantly associated with delays in switching to second-line ART. There was no significant association between the time taken to switch to second-line ART and subsequent virological failure. CONCLUSION: We observed lengthy delays in switching patients to second-line ART. Modifiable programmatic factors were found to be significantly associated with delays in switching to second-line ART.

Teaching research: a programme to develop research capacity in undergraduate medical students at the University of KwaZulu-Natal, South Africa.

BACKGROUND: Improved research ability is a core competency to achieve in health professionals. The Selectives is a three-year, longitudinal, community-based programme within the undergraduate curriculum which aims to develop research capacity in all medical students during the prescribed curriculum. In relation to the programme, the authors describe the types of studies conducted by students, conditions that facilitated their learning, how the experience improved students' knowledge of research and public health and their development of reflective learning practices. METHODS: A cohort of 212 students completed the Selectives Programme in 2014, and 69 (32 %) completed an anonymous online evaluation thereafter. Data collected include students' perceptions of the research component of Selectives; its impact on their knowledge of research and a documentary analysis of their research protocols and posters. Ethical approval for the ongoing evaluation of the Selectives was sought and obtained from the institutional Biomedical Research Ethics Committee. RESULTS: During Selectives, 75 groups of 2-4 students conducted research studies of primary health care problems in community settings. Each group is assessed on their presentation of research findings as a scientific poster. The Selectives facilitated learning for the majority of the cohort. Students reported positive learning experiences about the research process, including ethics; protocol writing; data processing; dissemination of findings and results; and their use in informing a health promotion intervention. Students reported having gained a better understanding of their strengths and weaknesses through reflective learning from this academic activity. The Selectives is scheduled adjacent to the students' mid-year vacation. This scheduling together with the placement in the students' home community minimizes travel and accommodation costs associated with working outside the academic teaching platform and therefore makes it a cost-effective model in a low resource context. CONCLUSIONS: The Selectives has proven beneficial to develop a range of generic and practical research competencies for a full cohort of students enrolled in the undergraduate medical curriculum. The Selectives research process is integrated with learning about population health and the social determinants of health in a primary health care setting.