Experiences of traditional health practitioners in the management of female infertility in Harare urban areas: A qualitative study.

Female infertility is a health and social problem that traditional health practitioners (THPs) have been managing in African communities. This study explored the experiences of THPs in the management of female infertility, specifically focusing on their understanding, diagnosis, and treatment methods for female infertility. This was a qualitative study targeting six THPs in Harare urban areas registered with the Traditional Medical Practitioners Council (TMPC) in Zimbabwe. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed in the description of the study design, analysis and presentation of findings. The findings revealed that the etiology of female infertility was attributed to biomedical, lifestyle, spiritual, and male factors. Management of infertility depended on the type of THP. Spirit mediums relied on divination and dreams to diagnose and treat female infertility. Herbalists focused on the physical evidence provided by the client through history taking. THPs had a client referral system within their TMPC network. All THPs ultimately used medicinal plants for treating female infertility. THPs play an important role in the management of female infertility. Understanding their contributions to the management of female infertility provides an opportunity to obtain insight into their practices, thus identifying areas that responsible Ministries can use to strengthen traditional health care systems and ultimately improve reproductive health care for women in African communities.

L'infertilité féminine est un problème sanitaire et social que les tradipraticiens (PTS) gèrent dans les communautés africaines. Cette étude a exploré les expériences des THP dans la gestion de l'infertilité féminine, en se concentrant spécifiquement sur leur compréhension, leur diagnostic et leurs méthodes de traitement de l'infertilité féminine. Il s'agissait d'une étude qualitative ciblant six PTH des zones urbaines de Harare enregistrés auprès du Conseil des médecins traditionnels (TMPC) au Zimbabwe. Les lignes directrices COREQ (Consolidated Criteria for Reporting Qualitative Research) ont été suivies dans la description de la conception de l'étude, de l'analyse et de la présentation des résultats. Les résultats ont révélé que l'étiologie de l'infertilité féminine était attribuée à des facteurs biomédicaux, liés au mode de vie, spirituels et masculins. La prise en charge de l'infertilité dépendait du type de THP. Les médiums spirituels s'appuyaient sur la divination et les rêves pour diagnostiquer et traiter l'infertilité féminine. Les herboristes se sont concentrés sur les preuves matérielles fournies par le client grâce à l'anamnèse. Les THP disposaient d'un système de référencement des clients au sein de leur réseau TMPC. Tous les THP utilisaient finalement des plantes médicinales pour traiter l'infertilité féminine. Les THP jouent un rôle important dans la gestion de l'infertilité féminine. Comprendre leurs contributions à la gestion de l'infertilité féminine offre l'opportunité d'avoir un aperçu de leurs pratiques, identifiant ainsi les domaines que les ministères responsables peuvent utiliser pour renforcer les systèmes de santé traditionnels et, à terme, améliorer les soins de santé reproductive pour les femmes des communautés africaines.

Traditional management of female infertility in Africa: a scoping review protocol.

INTRODUCTION: Infertility adversely affects the sexual reproductive health and overall quality of life of people. Recent estimates show that about one in six people (both men and women) experience infertility in their lifetime. This scoping review will, therefore, map the existing evidence on traditional management of female infertility in Africa including the effectiveness of the traditional healthcare systems, to inform policy and practice. METHODS: The scoping review will be guided by the Arksey and O'Malley framework in conjunction with the Joanna Briggs Institute updated methodological guidance for scoping reviews. A search strategy will be developed, which will target the following databases: PubMed, Scopus, Embase, CINAHL, Google Scholar and Africa-Wide Information including grey literature. The screening of titles, abstracts and full text will be done by two independent reviewers. Data will be extracted, analysed numerically and thematically. The reporting of the scoping review will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. ETHICS AND DISSEMINATION: This scoping review will not require ethical approval as this is secondary analysis of peer-reviewed articles. The findings of the review will be disseminated on various platforms including conferences, meetings to key stakeholders and in a peer-reviewed journal for wider sharing.

Attitudes and perceptions of traditional health practitioners towards documentation of patient health information in their practice in eThekwini Municipality, KwaZulu-Natal, Natal Province, South Africa.

BACKGROUND: Documentation of patient health information in the form of patient medical records (PMRs) is an essential, ethical and regulatory requirement in any healthcare system. African traditional medicine (ATM) exists parallel to biomedicine and continues to play a significant role in primary healthcare of the majority of South Africans. The World Health Organization (WHO) has promoted the integration of ATM into the national health system of South Africa. Patient health information documentation can facilitate this integration, and PMRs promote communication between the two health systems through referrals. Documentation in biomedicine is a clear, compulsory, routine activity, but does not occur regularly or routinely in ATM. OBJECTIVE: To examine the attitudes and perceptions of traditional health practitioners (THPs) towards documentation of patient health information in their practice. METHODS: This quantitative cross-sectional survey involved snowball sampling to recruit THPs in Umlazi Township and rural parts surrounding the township, in Durban, South Africa. A semi-structured questionnaire was used. Quantitative data were analysed using SPSS 25 and the Relative Importance Index (RII) and qualitative data were analysed using Excel for themes. RESULTS: Sampling resulted in 248 THPs of whom 178 (72%) were females. The RII ranked the factors that negatively influenced the participants' attitudes towards documentation of patient health information. Of the 178 females who participated in the study, 129 (72.5%) showed their willingness to introduce documentation in their practice. Of the 127 participants with less than 10 years of practice experience, 126 (99.2%) agreed to the importance of introducing PMRs in their practice. The majority of participants perceived documentation of patient health information as vital to improve their practice. A prominent theme was that the THPs regarded documenting patient health information as important and effective in their practice. CONCLUSION: More than half of participants showed positive attitudes and perceptions towards documenting of patient health information in ATM. The majority of the participants in this study acknowledged the importance of introducing documentation of patient health information in their practice even though they lacked experience and more knowledge. This reflects a need for essential intervention in developing specialised tools to begin promoting documentation of patient health information in ATM.

Anticancer effects of herbal medicine Emelia-M, Mshikazi and Delosma H against human leukaemia cells.

Background: Leukaemia is one of the three major types of blood cancers that lead to the overproduction of abnormal white blood cells. Emelia M (EMB), Mshikazi and Delosma H are herbal medicines that are being used by traditional healers in KwaZulu-Natal, South Africa to treat leukaemia and other diseases. Objectives: To gain insight into the safety (non-toxic effect), anti-cancer activity, mechanisms of action and phytochemical profiles of traditional herbal medicines (Emelia M (EMB), Mshikazi and Delosma H) in South Africa. Methods: The viability of human peripheral blood mononuclear cells (PBMCs), monocytic (THP-1) and T-lymphocyte (Jurkat) cell lines exposed to varying concentrations of aqueous extracts of the three herbal medicines were assessed using adenosine triphosphate (ATP) assay. Results: All three extracts showed a dose-dependent effect on the viability of PBMCs. Cell viability decreased with increasing concentrations of extracts when compared with the untreated cells at 24 and 48 hours. The inhibitory activities (IC50) of the extract were found in the order of Mshikazi > EMB, > Delosma H. All the extracts induced apoptosis with minimal necrosis. Many bioactive compounds that have been previously reported to have anticancer effects were identified in the extracts. Conclusion: Mshikazi extract significantly inhibited the growth of THP-1 and Jurkat cells and induced cell death through apoptosis than the other two extracts.

Characteristics and birth outcomes of pregnant adolescents compared to older women: An analysis of individual level data from 140,000 mothers from 20 RCTs.

BACKGROUND: Adolescence is a critical period of maturation when nutrient needs are high, especially among adolescents entering pregnancy. Using individual-level data from 140,000 participants, we examined socioeconomic, nutrition, and pregnancy and birth outcomes for adolescent mothers (10-19 years) compared to older mothers in low and middle-income countries. METHODS: This study was conducted between March 16, 2018 and May 25, 2021. Data were obtained from 20 randomised controlled trials of micronutrient supplementation in pregnancy. Stratified analyses were conducted by age (10-14 years, 15-17 years, 18-19 years, 20-29 years, 30-39 years, 40+ years) and geographical region (Africa, Asia). Crude and confounder-adjusted means, prevalence and relative risks of pregnancy, nutrition and birth outcomes were estimated using multivariable linear and log-binomial regression models with 95% confidence intervals. FINDINGS: Adolescent mothers comprised 31.6% of our data. Preterm birth, small-for-gestational age (SGA), low birthweight (LBW) and newborn mortality followed a U-shaped trend in which prevalence was highest among the youngest mothers (10-14 years) and then reduced gradually, but increased again for older mothers (40+ years). When compared to mothers aged 20-29 years, there was a 23% increased risk of preterm birth, a 60% increased risk of perinatal mortality, a 63% increased risk of neonatal mortality, a 28% increased risk of LBW, and a 22% increased risk of SGA among mothers 10-14 years. Mothers 40+ years experienced a 22% increased risk of preterm birth and a 103% increased risk of stillbirth when compared to the 20-29 year group. INTERPRETATION: The youngest and oldest mothers suffer most from adverse pregnancy and birth outcomes. Policy and programming agendas should consider both biological and socioeconomic/environmental factors when targeting these populations. FUNDING: Bill and Melinda Gates Foundation (Grant No: OP1137750).

Unravelling the drugability of MSI2 RNA recognition motif (RRM) protein and the prediction of their effective antileukemia inhibitors from traditional herb concoctions.

MSI2 is a homolog 2 of the Musashi RNA binding proteins (MSI) and is known to contribute to acute myeloid leukaemia (AML) and expressed up to 70% in AML patients. High expression of MSI2 has been found to lead to the lower overall survival of patients with AML. This study proposed the potential antagonists of MSI2 RNA-recognition motifs (MSI2 RRM1) derived from the LC-MS analysis of three traditional herbal samples. The LC-MS analysis of the three traditional herbs concoctions yields a total of 271 unique molecules of which 262 were screened against MSI2 RRM1 protein. After the dynamic study of the selected 8 top molecules from the virtual screening, the five most promising ligands emerged as potential MSI2 antagonists compare to the reference experimental molecule. The results show that the dynamic of MSI2 RRM1 protein is accompanied by a rare even of protein chain dissociation and re-association as evident in both the bound and unbound state of the protein. The unbound protein experience earlier chain dissociation compare to ligand-bound protein indicating that ligand binding to the protein slows down the dissociation time but thereafter increases the frequency of alternation between the protein chain association and dissociation after the first experience. Interestingly, the re-association of the protein chain is also accompanied by full restoration of the ligands to the binding site. The drug candidate Methotrexate (M3) and rescinnamine (M9) are listed among the promising antagonist of MSI2 with unique properties compared to a less promising molecule Ergotamine (M6).Communicated by Ramaswamy H. Sarma.

Role of antenatal plasma cytomegalovirus DNA levels on pregnancy outcome and HIV-1 vertical transmission among mothers in the University of Zimbabwe birth cohort study (UZBCS).

INTRODUCTION: Despite being a leading infectious cause of childhood disability globally, testing for cytomegalovirus (CMV) infections in pregnancy is generally not done in Sub-Sahara Africa (SSA), where breastfeeding practice is almost universal. Whilst CMV and human immunodeficiency virus (HIV) are both endemic in SSA, the relationship between antenatal plasma CMV-DNA, HIV-1-RNA levels and HIV-1-mother to child transmission (MTCT) including pregnancy outcomes remains poorly described. METHODS: Pregnant women at least 20 weeks' gestational age at enrolment were recruited from relatively poor high-density suburbs in Harare, Zimbabwe. Mother-infant dyads were followed up until 6 months postpartum. In a case-control study design, we tested antenatal plasma CMV-DNA levels in all 11 HIV-1 transmitting mothers, as well as randomly selected HIV-infected but non-transmitting mothers and HIV-uninfected controls. CMV-DNA was detected and quantified using polymerase chain reaction (PCR) technique. Antenatal plasma HIV-1-RNA load was quantified by reverse transcriptase PCR. Infants' HIV-1 infection was detected using qualitative proviral DNA-PCR. Predictive value of antenatal plasma CMV-DNAemia (CMV-DNA of > 50 copies/mL) for HIV-1-MTCT was analyzed in univariate and multivariate regression analyses. Associations of CMV-DNAemia with HIV-1-RNA levels and pregnancy outcomes were also explored. RESULTS: CMV-DNAemia data were available for 11 HIV-1 transmitting mothers, 120 HIV-infected but non-transmitting controls and 46 HIV-uninfected mothers. In a multivariate logistic regression model, we found a significant association between CMV-DNAemia of > 50 copies/mL and HIV-1 vertical transmission (p = 0.035). There was no difference in frequencies of detectable CMV-DNAemia between HIV-infected and -uninfected pregnant women (p = 0.841). However, CMV-DNA levels were higher in immunosuppressed HIV-infected pregnant women, CD4 < 200 cells/µL (p = 0.018). Non-significant associations of more preterm births (< 37 weeks, p = 0.063), and generally lower birth weights (< 2500 g, p = 0.450) were observed in infants born of HIV-infected mothers with CMV-DNAemia. Furthermore, in a multivariate analysis of HIV-infected but non-transmitting mothers, CMV-DNAemia of > 50 copies/mL correlated significantly with antenatal plasma HIV-1-RNA load (p = 0.002). CONCLUSION: Antenatal plasma CMV-DNA of > 50 copies/mL may be an independent risk factor for HIV-1-MTCT and higher plasma HIV-1-RNA load, raising the possibility that controlling antenatal CMV-DNAemia might improve infant health outcomes. Further studies with larger sample sizes are warranted to confirm our findings.

Phytochemical profile and in vitro antioxidant activity of Emelia M (EMB), Mshikazi and Delosma H herbal medicines as demonstrated in THP-1 and Jurkat leukaemia cell lines.

Background: Three decoctions, namely Emelia M (EMB), Mshikazi and Delosma H are used by traditional health practitioners in KwaZulu-Natal, South Africa to treat and manage leukaemia and related conditions. Objectives: This study evaluated the in vitro antioxidant activity and phytochemical profile of the aqueous extracts of Emelia M (EMB), Mshikazi and Delosma H decoctions. Methods: Antioxidant activity of the extracts was evaluated using1-diphenyl-2-picrylhydrazyl (DPPH), glutathione (GSH), phosphomolybdate and thiobarbituric acid reactive substance (TBARS) assays. Phytochemical screening was used to determine the presence of compounds. Results: The DPPH radical scavenging activity was similar to ascorbic acid for EMB and Delosma H, but not for Mshikazi. At 24 h, EMB increased GSH in both THP-1 and Jurkat cells similar to Delosma H while Mshikazi demonstrated the lowest activity. At 48 h, EMB and Delosma H revealed increased GSH in THP-1 cells with no significant decrease in GSH levels in Jurkat cells. However, EMB showed the lowest lipid peroxidation activity compared to Delosma H and Mshikazi after 24 h treatment of both cells. Phenols, flavonoids, terpenoids, saponins were present in all extracts. Conclusion: Extracts of the three decoctions possess both antioxidant and prooxidant properties through high scavenging activity and increased in lipid peroxidation.

Knowledge and documentation of patient health information among traditional health practitioners in urban and peri-urban areas of eThekwini Municipality, KwaZulu-Natal Province, South Africa.

BACKGROUND: Documentation of patient health information (PHI) is a regulatory requirement and hence a standard procedure in allopathic healthcare practice. The opposite is true for African traditional medicine (ATM) in most African countries, including South Africa, despite legal and policy frameworks that recognise and mandate the institutionalisation of ATM. Developing good practice standards for PHI documentation is an essential step in the institutionalisation of ATM. OBJECTIVE: This study examined the knowledge and practices of documentation of PHI by traditional health practitioners (THPs) in Durban, eThekwini Municipality, KwaZulu-Natal Province, South Africa. METHODS: In this quantitative cross-sectional study, snowball sampling was used to identify and recruit THPs. An interviewer-administered questionnaire was used to gather data. Chi-square tests and logistic regression were used to assess associations of knowledge and practice of documentation of PHI with potential predictors; age, gender, education, type of practitioner, experience, number of patients seen per day and location of the practice. RESULTS: Of the 248 THPs who participated, 71.8% were female. Mean (SD) age was 47.4 (14.2), ranging 18-81 years. The majority (65.7%) were Izangoma (diviners). Overall, 42.9% of the THPs reported knowledge of patient medical records (PMRs). In logistic regression, only number of patients seen per day remained a significant predictor of knowledge about PMR. THPs who reported seeing 6-10 patients were five times more likely (Odds Ratio (OR): 5.164, 95% Confidence Interval (CI): 1.270-20.996; p = 0.022) to report knowledge of PMR than those seeing <6 patients per day. Overall, 25.0% of THPs reported that they were documenting some PHI. Documentation was associated with having knowledge of PMR (OR: 29.323, 95% CI: 10.455-82.241; p < 0.0001) and being an Isangoma (OR: 3.251, 95% CI: 1.092-9.679; p = 0.02). Not knowing what (56.5%) and how (50.5%) to record were the most commonly cited reasons for not documenting. CONCLUSION: Knowledge of PMR is low, and the practice of documenting PHI is even lower among THPs in eThekwini. That knowledge of PMR was a strong predictor of documentation practice, and the most common reason for not documenting was lack of knowledge about what and how to document suggests that training could improve PHI documentation in traditional medicine practice.

The University of Zimbabwe College of Health Sciences (UZ-CHS) BIRTH COHORT study: rationale, design and methods.

BACKGROUND: Commencing lifelong antiretroviral therapy (ART) immediately following HIV diagnosis (Option B+), has greatly improved maternal-infant health. Thus, large and increasing numbers of HIV-infected women are on ART during pregnancy, a situation concurrently increasing numbers of HIV-exposed-uninfected (HEU) infants. Compared to their HIV-unexposed-uninfected (HUU) counterparts, HEU infants show higher rates of adverse birth outcomes, mortality, infectious/non-communicable diseases including impaired growth and neurocognitive development. There is an urgent need to understand the impact of HIV and early life ART exposures, immune-metabolic dysregulation, comorbidities and environmental confounders on adverse paediatric outcomes. METHODS: Six hundred (600) HIV-infected and 600 HIV-uninfected pregnant women ≥20 weeks of gestation will be enrolled from four primary health centres in high density residential areas of Harare. Participants will be followed up as mother-infant-pairs at delivery, week(s) 1, 6, 10, 14, 24, 36, 48, 72 and 96 after birth. Clinical, socio-economic, nutritional and environmental data will be assessed for adverse birth outcomes, impaired growth, immune/neurodevelopment, vertical transmission of HIV, hepatitis-B/C viruses, cytomegalovirus and syphilis. Maternal urine, stool, plasma, cord blood, amniotic fluid, placenta and milk including infant plasma, dried blood spot and stool will be collected at enrolment and follow-up visits. The composite primary endpoint is stillbirth and infant mortality within the first two years of life in HEU versus HUU infants. Maternal mortality in HIV-infected versus -uninfected women is another primary outcome. Secondary endpoints include a range of maternal and infant outcomes. Sub-studies will address maternal stress and malnutrition, maternal-infant latent tuberculosis, Helicobacter pylori infections, immune-metabolomic dysregulation including gut, breast milk and amniotic fluid dysbiosis. DISCUSSION: The University of Zimbabwe-College of Health-Sciences-Birth-Cohort study will provide a comprehensive assessment of risk factors and biomarkers for HEU infants' adverse outcomes. This will ultimately help developing strategies to mitigate effects of maternal HIV, early-life ART exposures and comorbidities on infants' mortality and morbidity. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT04087239 . Registered 12 September 2019.

Mental health research capacity building in sub-Saharan Africa: the African Mental Health Research Initiative.

Mental, neurological and substance use (MNS) disorders are a leading, but neglected, cause of morbidity and mortality in sub-Saharan Africa. The treatment gap for MNS is vast with only 10% of people with MNS disorders in low-income countries accessing evidence-based treatments. Reasons for this include low awareness of the burden of MNS disorders and limited evidence to support development, adaptation and implementation of effective and feasible treatments. The overall goal of the African Mental Health Research Initiative (AMARI) is to build an African-led network of MNS researchers in Ethiopia, Malawi, South Africa and Zimbabwe, who are equipped to lead high quality mental health research programs that meet the needs of their countries, and to establish a sustainable career pipeline for these researchers with an emphasis on integrating MNS research into existing programs such as HIV/AIDS. This paper describes the process leading to the development of AMARI's objectives through a theory of change workshop, successes and challenges that have been faced by the consortium in the last 4 years, and the future role that AMARI could play in further building MNS research capacity by brining on board more institutions from low- and middle-income countries with an emphasis on developing an evidence-based training curriculum and a research-driven care service.

Effectiveness of an HIV-risk reduction intervention to reduce HIV transmission among serodiscordant couples in Durban, South Africa. A randomized controlled trial.

Lack of condom use by married or cohabiting couples in populations with high rates of HIV infection has become a significant public health issue. This study investigated whether an HIV risk-reduction intervention (RRI) would increase condom use when delivered to serodiscordant couples as a unit. Of the 62 couples that were screened, 30 serodiscordant couples were enrolled in the study, and randomized 2:1 to an immediate intervention-waitlist control study. The 12-week intervention focused on communication, problem-solving, and negotiation skills. Participants were assessed at baseline, three and six months after the intervention. The main outcome measures were consistent condom use, HIV seroconversion and fidelity to the programme. The use of condoms increased for both the intervention and control groups after receiving a 12-week RRI. Group comparisons showed a significant difference at three months, with a significantly higher mean proportion of condom-protected sex acts (p = 0.0119) between the control and intervention groups, the later showing an increase in condom use. No seroconversion was detected, and the overall retention rate of participants was 83.33%. Counselling heterosexual couples as a unit prompted an increase in condom use, but sustained condom use remains a challenge.

Annona stenophylla aqueous extract stimulate glucose uptake in established C2Cl2 muscle cell lines.

BACKGROUND: Annona stenophylla is a folk medicine popularly used in Zimbabwe for the treatment of many ailments. This study was carried out to determine some of the possible anti diabetic mechanisms of its action using in vitro cell culturing methods. METHODS: A. stenophylla's effects on glucose uptake were tested using muscle cells (C2Cl2). Expression of glucose 4 transporters was determined by treating cell lines with plant extract. Total RNA was isolated and using RT-PCR, GLUT 4 expression levels were quantified. Translocation of GLUT 4 was assessed using FITC fluorescence measured by flow cytometry. RESULTS: Treatment of cells with plant extract significantly increased glucose uptake in a concentration dependent manner, with the highest concentration (250 µg/ml) giving 28% increased uptake compared to the negative control. The increase in glucose uptake (2.5 times more than control) was coupled to increase in GLUT 4 mRNA and subsequently GLUT 4 translocation. Wortmannin expunged the A. stenophylla induced increase in GLUT 4 mRNA and glucose uptake. CONCLUSION: The results suggest that A. stenophylla aqueous extract increases glucose uptake partly through increasing the GLUT 4 mRNA and translocation potentially acting via the PI-3-K pathway. This study confirms the ethnopharmacological uses of A. stenophylla indicating potential for anti-diabetic products formulation.

Core competencies acquired in indigenous training of traditional health practitioners in Kwazulu-Natal.

INTRODUCTION: Despite the recognition of Traditional Medicine systems as a critical component of health care by the WHO and the African Union, its integration into the health care mainstream remains very subdued in South Africa. This is partly due to the lack of empirical data pertinent to traditional healer training that could inform the accreditation process. OBJECTIVE: To determine core competencies acquired by Traditional Health Practitioners (THP) of KwaZulu-Natal Province, South Africa during their apprenticeship. MATERIALS AND METHODS: Purposeful, convenient and snowballing sampling and the sequential data collection methods of questionnaires, journaling and focus groups was used to collect data from the THP tutors and their trainees in rural, peri-urban and urban areas of eThekwini and uThungulu Districts of Kwa Zulu Natal (KZN). RESULTS: Eleven core competencies were identified: consultation, diagnoses, holistic patient care and treatment, integrative and holistic healing, application of healing procedures and cultural rituals, spiritual development, ethical competencies, problem solving, herbalism, ancestral knowledge and end of life care. CONCLUSION: The apprenticeship of THPs in KZN is based on eleven core competencies. These competencies are fundamental pillars for critical health care provided by THPs and are crucial for setting standards for the accreditation of traditional training in South Africa if the THP Act 22 of 2007 is to achieve its purpose of providing for the management of and control over the registration, training and conduct of the practitioners. Hence, the appointed interim THP Council should include the identified competencies when articulating bases for accreditation of the training and assessments.

Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries.

BACKGROUND: Micronutrient deficiencies are common among women in low-income and middle-income countries. Data from randomised trials suggest that maternal multiple micronutrient supplementation decreases the risk of low birthweight and potentially improves other infant health outcomes. However, heterogeneity across studies suggests influence from effect modifiers. We aimed to identify individual-level modifiers of the effect of multiple micronutrient supplements on stillbirth, birth outcomes, and infant mortality in low-income and middle-income countries. METHODS: This two-stage meta-analysis of individual patient included data from 17 randomised controlled trials done in 14 low-income and middle-income countries, which compared multiple micronutrient supplements containing iron-folic acid versus iron-folic acid alone in 112 953 pregnant women. We generated study-specific estimates and pooled subgroup estimates using fixed-effects models and assessed heterogeneity between subgroups with the χ2 test for heterogeneity. We did sensitivity analyses using random-effects models, stratifying by iron-folic acid dose, and exploring individual study effect. FINDINGS: Multiple micronutrient supplements containing iron-folic acid provided significantly greater reductions in neonatal mortality for female neonates compared with male neonates than did iron-folic acid supplementation alone (RR 0·85, 95% CI 0·75-0·96 vs 1·06, 0·95-1·17; p value for interaction 0·007). Multiple micronutrient supplements resulted in greater reductions in low birthweight (RR 0·81, 95% CI 0·74-0·89; p value for interaction 0·049), small-for-gestational-age births (0·92, 0·87-0·97; p=0·03), and 6-month mortality (0·71, 0·60-0·86; p=0·04) in anaemic pregnant women (haemoglobin <110g/L) as compared with non-anaemic pregnant women. Multiple micronutrient supplements also had a greater effect on preterm births among underweight pregnant women (BMI <18·5 kg/m2; RR 0·84, 95% CI 0·78-0·91; p=0·01). Initiation of multiple micronutrient supplements before 20 weeks gestation provided greater reductions in preterm birth (RR 0·89, 95% CI 0·85-0·93; p=0·03). Generally, the survival and birth outcome effects of multiple micronutrient supplementation were greater with high adherence (≥95%) to supplementation. Multiple micronutrient supplements did not significantly increase the risk of stillbirth or neonatal, 6-month, or infant mortality, neither overall or in any of the 26 examined subgroups. INTERPRETATION: Antenatal multiple micronutrient supplements improved survival for female neonates and provided greater birth-outcome benefits for infants born to undernourished and anaemic pregnant women. Early initiation in pregnancy and high adherence to multiple micronutrient supplements also provided greater overall benefits. Studies should now aim to elucidate the mechanisms accounting for differences in the effect of antenatal multiple micronutrient supplements on infant health by maternal nutrition status and sex. FUNDING: None.

Use of Proviral DNA to Investigate Virus Resistance Mutations in HIV-infected Zimbabweans.

BACKGROUND: Antiretroviral therapy (ART) to suppress HIV replication has reduced morbidity and mortality yet effectiveness of current HIV drugs is threatened by HIV drug resistance (HIVDR) mutations. OBJECTIVE: To determine HIVDR mutations using proviral DNA from specimens of patients presenting to an HIV treatment clinic. METHODS: DNA from 103 patients, 86 treatment-experienced, 17 treatment-naïve, were genotyped for the HIV-1C reverse transcriptase gene (RT; codons 21-304) using Sanger sequencing and sequences analyzed using Sequencher software. Resistance mutations were interpreted using Stanford HIVDR reference database. RESULTS: Median age was 39 (IQR, 33-46) years and 80% of patients were female. Six-percent (n=6) had at least one HIVDR mutation, comprising NRTI-associated mutations, (M184V, T69D, T69N and V75I); NNRTI-associated mutations (G190A, K103N, V106M, Y181C) and thymidine analogue associated mutations (D67N, K70R, K219Q, L210W, M41L, T215Y). Of the six participants, with at least one HIVDR mutation, all were treatment experienced, five were on tenofovir, lamivudine and nevirapine and one was on tenofovir, lamivudine and atazanavir. There was no difference in median CD4 count and viral loads when patients were compared by presence of HIVDR mutations. CONCLUSION: We demonstrated the use of proviral DNA in HIVDR testing in adult patients and present that all the patients with various kinds of HIVDR mutations were treatment experienced, pointing to the role of drug regimens in driving viral mutations. Thus, the use of proviral DNA has potential to help provide surveillance on risk of HIVDR in HIV-infected individuals who are on treatment, which may assist in corrective treatment.

Prevalence of and Factors Associated with Nephropathy in Diabetic Patients Attending an Outpatient Clinic in Harare, Zimbabwe.

There is limited information on the burden of diabetic nephropathy in developing countries. This study aimed to determine the prevalence of and factors associated with nephropathy among diabetic patients attending an outpatient clinic in Harare, Zimbabwe. In an analytical cross-sectional study, diabetic patients were consecutively enrolled and a questionnaire administered, clinical assessment conducted, and blood samples collected for human immunodeficiency virus testing and measurement of lipids, creatinine, fructosamine, and glycosylated hemoglobin levels. Urine samples were collected for determination of albumin and creatinine levels, which were used to categorize albuminuria. A total of 344 diabetic patients were enrolled. Overall, just over a third (35.8%) of patients had moderately increased albuminuria and 9.0% had severely increased albuminuria giving an overall prevalence of nephropathy of 44.8%. Prevalence of moderately increased albuminuria was slightly higher (36.5% versus 33.3%) and severely increased albuminuria slightly lower (8.8% versus 9.5%) in type 2 than type 1 diabetes patients, but the difference was not statistically significant (P = 0.866). Higher fructosamine and retinopathy were associated with nephropathy in both univariate and multivariate analysis {higher fructosamine (odds ratio [OR] = 1.00, confidence interval [CI] = 1.00-1.01), and retinopathy (OR = 2.80, CI = 1.64-4.97)}. We report a higher prevalence of moderately increased albuminuria and a lower prevalence of severely increased albuminuria compared with findings reported a decade ago among type 1 and type 2 diabetes mellitus patients attending the same clinic. High fructosamine and retinopathy were independent predictors of nephropathy.

Apolipoprotein B Gene Polymorphisms and Dyslipidemia in HIV Infected Adult Zimbabweans.

BACKGROUND: Dyslipidemia does not occur in all HIV-infected or antiretroviral therapy-experienced patients suggesting role of host genetic factors but there is paucity of data on association between dyslipidemia and gene polymorphisms in Zimbabwe. OBJECTIVE: To determine association of lipoprotein levels and apolipoprotein B polymorphisms in HIV-infected adults. METHOD: Demographic data were collected from 103 consenting patients; lipoprotein levels were determined and blood samples were successfully genotyped for both apolipoprotein B 2488C>T Xba1 and apolipoprotein B 4154G>A p.Gln4154Lys EcoR1 polymorphisms by real time polymerase chain reaction. RESULTS: Mean age of genotyped patients was 40.3 ± 10.1 years, 68% were female; prevalence of dyslipidemia was 67.4%. Of 103 samples genotyped for apolipoprotein B Xba1 polymorphism, 76 (74%) were homozygous C/C, 24 (23%) were heterozygous C/T and only three (3%) were homozygous T/T. Apolipoprotein B EcoR1 polymorphism showed little variability, one participant had rare genotype A/A, 68.3% had wild type genotype G/G. CONCLUSION: Observed frequencies of apolipoprotein B XbaI and EcoRI polymorphisms matched other African studies. In spite of low numbers of rare variants, there was positive association between both total cholestrol and high density lipoprotein with ECoR1 wild type G/G genotype, suggesting that ECoRI 4154 G allele could be more protective against coronary heart disease than EcoR1 4154 A allele. There is need for further research at population level to confirm whether apolipoprotein B ECoR1 genotyping is useful for predicting risk of dyslipidemia in HIV patients in our setting.

HIV-1 Disease Progression and Survival in an Adult Population in Zimbabwe: Is There an Effect of the Mannose Binding Lectin Deficiency?

HIV infection remains a major global health burden since its discovery in 1983. Sub-Saharan Africa is the region hardest hit by the HIV/AIDS pandemic where 63% of the 33 million infected people live. While there is marked person-to-person variability in susceptibility, progression, and survival with HIV infection, there is a paucity of predictive diagnostics associated with these clinical endpoints. In this regard, the deficiency in plasma Mannose Binding Lectin (MBL) is a common opsonic defect reported to increase susceptibility infections, including HIV. To the best of our knowledge, we report here the first study on the putative role of MBL deficiency on HIV progression and survival in an African adult population. We hypothesized that MBL deficiency has a role to play in HIV infection by increasing HIV disease progression and decreasing survival. We assessed the role of MBL deficiency on HIV disease progression and survival in a Zimbabwean adult population enrolled in the Mupfure Schistosomiasis and HIV (MUSH) cohort. We analyzed blood samples for MBL levels, MBL2 genotypes, HIV-1 status, viral load, and CD4(+) T cell counts. Participants were followed for 3 years wherein the endpoints were measured at baseline, 6 weeks, and 3, 6, 12, 24, and 36 months. Disease progression was measured as the rate of decline in CD4(+) T cell counts and the rate of increase in HIV viral load. We assessed 197 HIV positive adults where 83% (164) were women with a median age of 31 years. Prevalence of plasma MBL deficiency (less than 100 µg/L) and MBL2 deficient genetic variants (A/O and O/O genotypes) was 21% (42 out of 197) and 39% (74 out of 190), respectively. We did not observe a significant role to explain individual variation in mortality, change of CD4(+) T cell count, and viral load by MBL plasma deficiency or MBL2 genetic variants from baseline to 3 years follow up period in this adult population. We suggest the need for global OMICS research and that the present findings attest to the large between-population variability in a host of factors that can predispose individuals susceptible to HIV progression and mortality. We therefore cannot recommend at this time the use of plasma MBL levels or MBL2 genetic variants as a prognostic marker in HIV infection, disease progression, and survival in this adult population in Africa.