Delivering an integrated sexual reproductive health and rights and HIV programme to high-school adolescents in a resource-constrained setting.

Southern Africa remains the epicentre of the human immunodeficiency virus (HIV) epidemic with AIDS the leading cause of death amongst adolescents. Poor policy translation, inadequate programme implementation and fragmentation of services contribute to adolescents' poor access to sexual and reproductive health and rights (SRHR) services. This study assessed an integrated, school-based SRHR and HIV programme, modelled on the South African Integrated School Health Policy in a rural, high HIV-prevalence district. A retrospective cohort study of 1260 high-school learners was undertaken to assess programme uptake, change in HIV knowledge and behaviour and the determinants of barrier-methods use at last sexual intercourse. Programme uptake increased (2%-89%; P�<�0.001) over a 16-month period, teenage-pregnancy rates declined (14%-3%; P�<�0.050) and accurate knowledge about HIV transmission through infected blood improved (78.3%-93.8%; P�<�0.050), a year later. Post-intervention, attending a clinic perceived as adolescent-friendly increased the odds of barrier-methods use during the last sexual encounter (aOR=1.85; 95% CI: 1.31-2.60), whilst being female (aOR=0.69; 95% CI: 0.48-0.99), <15 years (aOR=0.44; 95% CI: 0.24-0.80), or having >5 sexual partners in the last year (aOR=0.59; 95% CI: 0.38-0.91) reduced the odds. This study shows that the unmet SRHR needs of under-served adolescents can be addressed through integrated, school-based SRHR programmes.

Implementation science outcomes of a gender-focused HIV and alcohol risk-reduction intervention in usual-care settings in South Africa.

BACKGROUND: South Africa has the highest HIV prevalence globally, which disproportionately affects women. Hazardous alcohol use reduces antiretroviral adherence which can lead to adverse health. Few evidence-based interventions addressing hazardous alcohol use and HIV have been implemented in real-world settings. This study aimed to evaluate implementation outcomes from the Women's Health CoOp (WHC)-an evidence-based gender-focused HIV intervention-which was implemented in Cape Town. METHODS: We conducted this implementation science trial using a modified stepped-wedge design. Four health clinics were paired with four substance use rehabilitation programs and randomized into four cycles. Women living with HIV and who use alcohol or other drugs were recruited into each cycle (n = 120 each cycle). We assessed adoption, acceptability, appropriateness, cost, and fidelity using a mixed methods approach. RESULTS: Adoption: 100 % of staff trained in the WHC and designated as interventionists delivered one or more workshops. Acceptability: Interventionists found the WHC content beneficial to their patients and the WHC improved connections between clinical units in facilities. Appropriateness: The WHC aligned with facility goals to improve antiretroviral adherence and reduce alcohol use; however, there were implementation challenges, including staff shortages, stigma, and few places to refer women for supportive services. Cost: The cost of implementing the WHC was 20.59 ZAR (1.40 USD) per attendee. Fidelity: Interventionists implemented the WHC with high fidelity and quality. CONCLUSIONS: The findings suggest it is feasible to integrate the WHC into usual-care settings. Future efforts to scale up the intervention will need to address social and structural implementation challenges. TRIAL REGISTRATION: NCT02733003 approved 1/21/2016.

The effectiveness and cost-effectiveness of community-based support for adolescents receiving antiretroviral treatment: an operational research study in South Africa.

INTRODUCTION: Adolescents and youth receiving antiretroviral treatment (ART) in sub-Saharan Africa have high attrition and inadequate ART outcomes, and evaluations of interventions improving ART outcomes amongst adolescents are very limited. Sustainable Development Goal (SDG) target 3c is to substantially increase the health workforce in developing countries. We measured the effectiveness and cost-effectiveness of community-based support (CBS) provided by lay health workers for adolescents and youth receiving ART in South Africa. METHODS: A retrospective cohort study including adolescents and youth who initiated ART at 47 facilities. Previously unemployed CBS-workers provided home-based ART-related education, psychosocial support, symptom screening for opportunistic infections and support to access government grants. Outcomes were compared between participants who received CBS plus standard clinic-based care versus participants who received standard care only. Cumulative incidences of all-cause mortality and loss to follow-up (LTFU), adherence measured using medication possession ratios (MPRs), CD4 count slope, and virological suppression were analysed using multivariable Cox, competing-risks regression, generalized estimating equations and mixed-effects models over five years of ART. An expenditure approach was used to determine the incremental cost of CBS to usual care from a provider perspective. Incremental cost-effectiveness ratios were calculated as annual cost per patient-loss (through death or LTFU) averted. RESULTS: Amongst 6706 participants included, 2100 (31.3%) received CBS. Participants who received CBS had reduced mortality, adjusted hazard ratio (aHR) = 0.52 (95% CI: 0.37 to 0.73; p < 0.0001). Cumulative LTFU was 40% lower amongst participants receiving CBS (29.9%) compared to participants without CBS (38.9%), aHR = 0.60 (95% CI: 0.51 to 0.71); p < 0.0001). The effectiveness of CBS in reducing attrition ranged from 42.2% after one year to 35.9% after five years. Virological suppression was similar after three years, but after five years 18.8% CBS participants versus 37.2% non-CBS participants failed to achieve viral suppression, adjusted odds ratio = 0.24 (95% CI: 0.06 to 1.03). There were no significant differences in MPR or CD4 slope. The cost of CBS was US$49.5/patient/year. The incremental cost per patient-loss averted was US$600 and US$776 after one and two years, respectively. CONCLUSIONS: CBS for adolescents and youth receiving ART was associated with substantially reduced patient attrition, and is a low-cost intervention with reasonable cost-effectiveness that can aid progress towards several health, economic and equality-related SDG targets.

Low HIV incidence in pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa.

BACKGROUND: Young Southern African women have the highest HIV incidence globally. Pregnancy doubles the risk of HIV acquisition further, and maternal HIV acquisition contributes significantly to the paediatric HIV burden. Little data on combination HIV prevention interventions during pregnancy and lactation are available. We measured HIV incidence amongst pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa. METHODS: A cohort study that included HIV-uninfected pregnant women was performed. Lay community-based workers provided individualized HIV prevention counselling and performed three-monthly home and clinic-based individual and couples HIV testing. Male partners were referred for circumcision, sexually transmitted infections or HIV treatment as appropriate. Kaplan-Meier analyses and Cox's regression were used to estimate HIV incidence and factors associated with HIV acquisition. RESULTS: The 1356 women included (median age 22.5 years) received 5289 HIV tests. Eleven new HIV infections were detected over 828.3 person-years (PY) of follow-up, with an HIV incidence rate of 1.33 infections/100 PY (95% CI: 0.74-2.40). Antenatally, the HIV incidence rate was 1.49 infections/100 PY (95% CI: 0.64-2.93) and postnatally the HIV incidence rate was 1.03 infections/100 PY (95% CI: 0.33-3.19). 53% of male partners received HIV testing and 66% of eligible partners received referral for circumcision. Women within known serodiscordant couples, and women with newly diagnosed HIV-infected partners, adjusted hazard ratio (aHR) = 32.7 (95% CI: 3.8-282.2) and aHR = 126.4 (95% CI: 33.8-472.2) had substantially increased HIV acquisition, respectively. Women with circumcised partners had a reduced risk of incident HIV infection, aHR = 0.22 (95% CI: 0.03-1.86). CONCLUSIONS: Maternal HIV incidence was substantially lower than previous regional studies. Community-based combination HIV prevention interventions may reduce high maternal HIV incidence in resource-poor settings. Expanded roll-out of home-based couples HIV testing and initiating pre-exposure prophylaxis for pregnant women within serodiscordant couples is needed in Southern Africa.

Improved long-term antiretroviral treatment outcomes amongst patients receiving community-based adherence support in South Africa.

Retaining high levels of patients in care who are virally suppressed over long treatment periods has been an important challenge for antiretroviral treatment (ART) programmes in sub-Saharan Africa, the region having the highest HIV burden globally. Clinic-linked community-based adherence support (CBAS) programmes provide home-based adherence and psychosocial support for ART patients. However, there is little evidence of their longer-term impact. This study assessed the effectiveness of CBAS after eight years of ART. CBAS workers are lay healthcare personnel providing regular adherence and psychosocial support for ART patients and their households through home visits addressing household challenges affecting adherence. A multicentre cohort study using routinely collected data was undertaken at six public ART sites in a high HIV-prevalence South African district. Patient retention, loss to follow-up (LTFU), viral suppression and CD4 cell restoration were compared between patients with and without CBAS, using competing-risks regression, linear mixed models and log-binomial regression. 3861 patients were included, of whom 1616 (41.9%) received CBAS. Over 14,792 patient-years of observation, the cumulative incidence of LTFU was 37.3% and 46.2% amongst patients with and without CBAS, respectively, following 8 years of ART; adjusted subhazard ratio (CBAS vs. no CBAS) = 0.74 (95% CI: 0.66-0.84; P < .0001). Amongst patients on ART for 6.5-8 years, proportions not achieving viral suppression were 11.4% and 19.4% in patients with and without CBAS, respectively; adjusted risk ratio = 0.47 (95% CI: 0.26-0.86; P = .015). Annual CD4 cell increases from baseline were 62.8 cells/µL/year and 51.5 cells/µL/year amongst patients with and without CBAS, respectively, after 6.5 years or more (P = .034). After adjustment, annual CD4 cell recovery was 15.1 cells/µL/year (95% CI: 2.7-27.6) greater in CBAS patients (P = .017). ART patients who received CBAS had improved long-term patient retention, viral suppression and immunological restoration. CBAS is an intervention that can improve longer-term ART programme outcomes in resource-limited settings.

Effectiveness of community-based support for pregnant women living with HIV: a cohort study in South Africa.

Antiretroviral treatment (ART) initiation in HIV-infected pregnant women in sub-Saharan Africa (SSA) remains inadequate, and there is a severe shortage of professional healthcare workers in the region. The effectiveness of community support programmes for HIV-infected pregnant women and their infants in SSA is unclear. This study compared initiation of maternal antiretrovirals and infant outcomes amongst HIV-infected pregnant women and their infants who received and did not receive community-based support (CBS) in a high HIV-prevalence setting in South Africa. A cohort study, including HIV-infected pregnant women and their infants, was conducted at three sentinel surveillance facilities between January 2009 and June 2012, utilising enhanced routine clinical data. Through home visits, CBS workers encouraged uptake of interventions in the ART cascade, provided HIV-related education, ART initiation counselling and psychosocial support. Outcomes were compared using Kaplan-Meier analyses and multivariable Cox and log-binomial regression. Amongst 1105 mother-infant pairs included, 264 (23.9%) received CBS. Amongst women eligible to start ART antenatally, women who received CBS had a reduced risk of not initiating antenatal ART, 5.4% vs. 30.3%; adjusted risk ratio (aRR) = 0.18 (95% CI: 0.08-0.44; P < .0001). Women who received CBS initiated antenatal ART with less delay after the first antenatal visit, median 26 days vs. 39 days; adjusted hazard ratio (aHR) = 1.57 (95% CI: 1.15-2.14; P = .004). Amongst women who initiated antenatal zidovudine (ZDV) to prevent vertical transmission, women who received CBS initiated ZDV with less delay, aHR = 1.52 (95% CI: 1.18-2.01; P = .001). Women who received CBS had a lower risk of stillbirth, 1.5% vs. 5.4%; aRR = 0.24 (95% CI: 0.07-1.00; P = .050). Pregnant women living with HIV who received CBS had improved antenatal triple ART initiation in eligible women, women initiated ART and ZDV with shorter delays, and had a lower risk of stillbirth. CBS is an intervention that shows promise in improving maternal and infant health in high HIV-prevalence settings.

Implementation and Operational Research: A Comparison of Two Task-Shifting Models of Pharmaceutical Care in Antiretroviral Treatment Programs in South Africa.

BACKGROUND: The severe shortage of pharmacists is an important limitation to providing antiretroviral treatment (ART) in resource-limited countries. Two task-shifting pharmaceutical care models have been developed to address this in South Africa, namely indirectly supervised pharmacist assistant (ISPA) and nurse-managed models. This study compared pharmaceutical care quality, patient clinical outcomes, and provider staff costs between these models. METHODS: An analysis of pharmaceutical quality audits, patient clinical data, and staff costing data collected at 7 ISPA and 8 nurse-managed facilities was undertaken. Pharmaceutical audits were conducted by pharmacists using a standardized tool. Routine clinical data were collected prospectively at patient visits, and staff human resources costs were analyzed. RESULTS: Overall pharmaceutical care quality scores were higher at ISPA sites than nurse-managed sites; 88.8% vs. 79.9%, respectively; risk ratio (ISPA vs. nurse) = 1.11 (95% confidence interval: 1.09 to 1.13; P < 0.0001). Mean provider pharmaceutical-related human resources costs per patient visit and per item dispensed were 29% and 49% lower, respectively, at ISPA facilities. At ISPA facilities, patient attrition was observed to be lower and viral suppression higher than at nurse-managed sites. CONCLUSION: The ISPA model had a higher quality of pharmaceutical care and was less costly to implement. Further expansion of this model or integrating it with nurse-managed ART may enhance the cost-efficient scale-up of ART programs in Sub-Saharan Africa.

Improved virological suppression in children on antiretroviral treatment receiving community-based adherence support: a multicentre cohort study from South Africa.

Adherence to antiretroviral treatment (ART) is a challenge in childhood, and children on ART have reduced virological suppression compared to adults. This study evaluated the effect of community-based adherence support (CBAS) on virological outcomes amongst children receiving ART in four South African provinces. Patient Advocates are lay CBAS workers who provide adherence and psychosocial support for patients, undertaking home visits to address household challenges affecting adherence. Patient Advocates provide counselling for children's carers regarding adherence and psychosocial problems. A multicentre cohort study using routinely collected data was conducted at 57 public ART sites including ART-naive children (<16 years) starting ART. Virological suppression until four years of ART was compared between children who received and did not receive CBAS. Analyses were by intention-to-treat, controlling for confounding using multivariable generalised estimating equations. A total of 4853 children were included, of whom 982 (20.2%) received CBAS. The median baseline age was 6.3 years and the baseline CD4 cell percentage was 12.0%; both were equivalent between the two groups. CBAS children had more advanced baseline clinical disease (62.1% vs. 52.6% World Health Organisation stages III or IV; P < 0.0001). A total of 5908 viral load results were analysed. Virological suppression was 65.6% (95% confidence interval [CI]: 62.7-68.4%) vs. 55.5% (95% CI: 54.1-57.0%) in CBAS and non-CBAS children, respectively, at any time-point on treatment (P < 0.0001). In analyses controlling for baseline clinical, demographic, site-related variables and time on ART, children receiving CBAS were more likely to achieve virological suppression, adjusted odds ratio (aOR) 1.60 (95% CI: 1.35-1.89; P < 0.0001). The effect of CBAS increased in magnitude with increasing durations of ART, and CBAS particularly improved virological suppression in a higher-risk subgroup (children younger than two years, aOR 2.47 [95% CI: 1.59-3.84]). CBAS was associated with improved virological suppression in children receiving ART. Expanded implementation of this low-cost intervention should be considered in resource-poor settings.

A clinical study of ectopic pregnancy.

BACKGROUND: The frequency of ectopic pregnancy is increasing throughout the globe and it is the most life threatening emergency in first trimester of pregnancy. Objective of this study was to determine the frequency, risk factors, clinical presentation and management of ectopic pregnancy. METHODS: This prospective descriptive study was conducted in Gynaecology and Obstetrical Unit-II of Liaquat University of Medical and Health Sciences Hospital Hyderabad from 1st May 2009 to 30th April 2012. All women diagnosed with ectopic pregnancy were included in the study. A predesigned pro forma was used to record the details about demographic features, pre-existing risk factors, clinical features at presentation and management of ectopic pregnancy. Data was analysed using SPSS-11. RESULTS: Total numbers of admission during study period were 9600 with 60 cases of ectopic pregnancy, thus representing the frequency of 0.6% (1 in 160). Majority of women 43 (72%) were of 20-30 year age, multigravida 31 (52%) were the most sufferers. Pelvic inflammatory disease 27 (45%), previous abortion 20 (33%), previous surgery 12 (20%) were seen as common risk factors; however no risk factor was identified in 21 (35%) women. Typical history of amenorrhea and abdominal pain was found in 46 (77%) women, 23 (38%) were in a state of shock. Laparotomy was performed in 53 (88%) women. Three (5%) women were treated successfully with methotrexate. Laparoscopic surgery was done in 2 patients and 2 patients were required both Laparoscopy proceeded by laparotomy. No maternal death related to ectopic pregnancy was reported in our study. CONCLUSION: The early diagnosis of an ectopic pregnancy is one of the greatest challenges for obstetricians. The importance of early diagnosis lies in the fact that the lady can be offered a conservative line of management which can definitely have beneficial on her reproductive carrier.

Outcome of primigravida with high head at term.

OBJECTIVE: To determine the progress of labour, need of medical and surgical intervention and foetal and maternal outcome in primigravida with high head at term METHODS: The prospective descriptive study was conducted at the Department of Obstetrics and Gynaecology, Peoples University of Medical and Health Sciences, Nawabshah, Pakistan, from Jan 1 to June30, 2011, and comprised 100 primigravida with unengaged head at term and at onset of labour. Detailed history was taken in each case and general, systemic and obstetric examination was done. Pelvic assessment and ultrasonography was performed. SPSS 16 was used for statistical analysis. RESULT: Of the 100 women in the study, 70 (70%) were aged between 20-30 years.The most common identified cause of non-engaged head was deflexed head in 28 (28%), while no cause was found in 45(45%) women. Further, 45 (45%) women presented with spontaneous labour, while labour had to be induced with prostaglandin in the rest. Vaginal delivery occurred in 59 (59%) cases and caesarean section was performed in 41 (41%).The duration of labour was < 12 hours in 32 (32%) cases. Postpartum haemorrhage affected 10 (10%) patients, wound infection was seen in 7 (7%), and perineal tear in 2 (2%). Apgar score at 5 minutes was 7-10 in 75 (75%), 4-6 in (20%), 3 and below in 5 (5%) of neonates.

Local-level mortality surveillance in resource-limited settings: a case study of Cape Town highlights disparities in health.

OBJECTIVE: To identify the leading causes of mortality and premature mortality in Cape Town, South Africa, and its subdistricts, and to compare levels of mortality between subdistricts. METHODS: Cape Town mortality data for the period 2001-2006 were analysed by age, cause of death and sex. Cause-of-death codes were aggregated into three main cause groups: (i) pre-transitional causes (e.g. communicable diseases, maternal causes, perinatal conditions and nutritional deficiencies), (ii) noncommunicable diseases and (iii) injuries. Premature mortality was calculated in years of life lost (YLLs). Population estimates for the Cape Town Metro district were used to calculate age-specific rates per 100,000 population, which were then age-standardized and compared across subdistricts. FINDINGS: The pattern of mortality in Cape Town reflects the quadruple burden of disease observed in the national cause-of-death profile, with HIV/AIDS, other infectious diseases, injuries and noncommunicable diseases all accounting for a significant proportion of deaths. HIV/AIDS has replaced homicide as the leading cause of death. HIV/AIDS, homicide, tuberculosis and road traffic injuries accounted for 44% of all premature mortality. Khayelitsha, the poorest subdistrict, had the highest levels of mortality for all main cause groups. CONCLUSION: Local mortality surveillance highlights the differential needs of the population of Cape Town and provides a wealth of data to inform planning and implementation of targeted interventions. Multisectoral interventions will be required to reduce the burden of disease.

Morbidity and mortality associated with obstetric hysterectomy.

BACKGROUND: Obstetric hysterectomy still complicates a substantial number of pregnancies in third world countries and is a significant cause of obstetric morbidity and mortality. This study was carried out to evaluate in our setup the frequency of obstetric hysterectomy, its indication, risk factors, complication, morbidity, mortality and avoidable factors. METHODS: A descriptive study of all patients who under went obstetric hysterectomy was conducted from 1st May, 2004 to 31st October, 2005 at Gynaecology and Obstetric Unit-II, III of Liaquat University of Medical and Health Science Hospital, Hyderabad. After collecting the data on pre-designed proforma the data was fed to SPSS in the form of frequency distribution tables and percentages were calculated. Statistical analysis of data was performed by using Chi-square test. The level of significance was taken as p<0.05. RESULTS: During the study time period there were total 6495 deliveries and 41 cases of obstetric hysterectomy were identified, giving a frequency of 0.63% or 1 in 158 deliveries. Most of patients were from rural areas (82.92%), un-booked 73.17%), uneducated (95%), lower socioeconomical class (92.69%), 25-29 years age (48.78%) multiparae (56.10%), have to travel a distance of <100 km to reach hospital and referred late (51%) by healthcare providers (doctors). Majority of hysterectomies were performed due to ruptured uteri (51.21%). There were 5 maternal and 26 perinatal deaths; all were due to severity of conditions necessitating hysterectomy. CONCLUSION: Incidence of obstetric hysterectomy in our woman is very high. The reason being many avoidable factors such as high parity, inadequate maternity and family planning services, lack of proper referral system, un-booked status, mismanaged labour, illiteracy on the part of woman herself, family and health care providers are not taken care of during pregnancy, labour and puerperium.

Acid aspiration prophylaxis during anaesthesia for caesarean section: a survey among anaesthetists at Hyderabad.

BACKGROUND: Pulmonary aspiration of gastric contents leading to acid aspiration syndrome (AAS) is a well recognized risk factor during general anaesthesia (GA) for Caesarean section (CS). The cross sectional observational study was conducted during July 2008 to October 2008 at Department of Anaesthesiology and Intensive Care, Liaquat University of Medical & Health Sciences Jamshoro, Sindh, Pakistan. The objective was to assess anaesthetic practice patterns and measures to prevent aspiration of acid gastric contents in full-term pregnant women undergoing anaesthesia for Caesarean section. METHODS: A structured questionnaire regarding practice of anaesthesia for Caesarean section was distributed among anaesthetists working and practicing at Hyderabad. Results from the completed questionnaires were transferred to a Microsoft Excel spreadsheet and the responses represented as percentages. RESULTS: General anaesthesia was preferred by 75.4% anaesthetists for caesarean section, 83.6% anaesthetists used rapid sequence induction with cricoid pressure during general anaesthesia, 29.5% respondents restricted clear fluids for 2-3 hours. Antacids were used by 90% of the anaesthetists, while about 50% anaesthetists performed extubation when patients were fully awake. CONCLUSION: Recommended practice patterns and measures to prevent aspiration of acid gastric contents during anaesthesia for caesarean section are not observed by most of the anaesthetists working at Hyderabad.

Masking through averages--intraprovincial heterogeneity in HIV prevalence within the Western Cape.

OBJECTIVE: To measure HIV prevalence at health-district level in the Western Cape (WC) and to compare these findings with those of the National HIV Antenatal Surveys (NHASs). This investigation aimed to estimate the degree of heterogeneity of HIV prevalence within the province in order to inform the design of appropriate and targeted HIV interventions. METHOD: Annual cross-sectional, unlinked district HIV antenatal surveys were implemented in all 25 health districts of the WC for the years 2001 - 2004, concurrently with the NHAS. A stratified proportional sample was drawn for each district, involving all 344 antenatal clinics in the province, and the anonymous screening method as described by the World Health Organization (WHO) was applied. RESULTS: The NHAS revealed a significant increase in HIV prevalence in the WC from 8.6% (95% confidence interval (CI): 5.6 - 11.6) in 2001 to 15.4% (95% CI: 12.5 - 18.2) in 2004. The district-level HIV surveys showed wide variation in HIV prevalence across the health districts, which increased progressively during this period (a range of 0.6 - 22% for the year 2001 increased to 1 - 33% in 2004). Spatial analysis of HIV prevalence by health district for this period also revealed progressive spatial growth of the sub-epidemics, with the highest prevalence observed in districts located in the Cape metropole region. CONCLUSIONS: These concurrent surveys highlight the fact that examining a provincial estimate of HIV prevalence alone has the potential to mask epicentres within the province. This underscores the importance of expanding the surveillance systems to detect heterogeneity sub-provincially, in order to link with local-level planning and resource allocation.