A doctor at a PHC clinic: A 'must-have' or 'nice-to-have'?

Background. Many patients have their healthcare needs met at primary healthcare (PHC) clinics in KwaZulu-Natal (KZN), without having to travel to a hospital. Doctors form part of the teams at many PHC clinics throughout KZN, offering a decentralised medical service in a PHC clinic. Objectives. To assess the benefit of having a medical doctor managing patients with more complex clinical conditions at PHC clinic level in uMgungundlovu District, KZN. Two key questions were researched: (i) were the patients whom the clinic doctors managed of sufficient clinical complexity that they warranted a doctor managing them, rather than a PHC nurse clinician? and (ii) what was the spectrum of medical conditions that the clinic doctors managed? Methods. Doctors collected data at all medical consultations in PHC clinics in uMgungundlovu during February 2020. A single-page standardised data tool was used to collect data at every consultation. Results. Thirty-five doctors were working in 45 PHC clinics in February 2020. Twenty-six of the clinic doctors were National Health Insurance (NHI)-employed. The 35 doctors conducted 7 424 patient consultations in February. Staff in the PHC clinics conducted 143 421 consultations that month, mostly by PHC nurse clinicians. The doctors concluded that 6 947 (93.6%) of the 7 424 doctor consultations were of sufficient complexity as to warrant management by a doctor. The spectrum of medical conditions was as follows: (i) consultations for maternal and child health; n=761 (10.2%); (ii) consultations involving non-communicable diseases (NCDs), n=4 372 (58.9%) ­ the six most common NCDs were, in order: hypertension, diabetes, arthritis, epilepsy, mental illness and renal disease; (iii) consultations involving communicable diseases constituted 1 745 (23.5%) of cases; and (iv) consultations involving laboratory result interpretation 1 180 (15.9%).Conclusion. This research showed that at a PHC clinic the more complex patient consultations did indeed require the skills and knowledge of a medical doctor managing these patients. These data support the benefit of a doctor working at every PHC clinic: the doctor is a 'must-have' member of the PHC clinic team, offering a regular, reliable and predictable medical service.

A doctor at a PHC clinic: A 'must-have' or 'nice-to-have'?

BACKGROUND: Many patients have their healthcare needs met at primary healthcare (PHC) clinics in KwaZulu-Natal (KZN), without having to travel to a hospital. Doctors form part of the teams at many PHC clinics throughout KZN, offering a decentralised medical service in a PHC clinic. OBJECTIVES: To assess the benefit of having a medical doctor managing patients with more complex clinical conditions at PHC clinic level in uMgungundlovu District, KZN. Two key questions were researched: (i) were the patients whom the clinic doctors managed of sufficient clinical complexity that they warranted a doctor managing them, rather than a PHC nurse clinician? and (ii) what was the spectrum of medical conditions that the clinic doctors managed? METHODS: Doctors collected data at all medical consultations in PHC clinics in uMgungundlovu during February 2020. A single-page standardised data tool was used to collect data at every consultation. RESULTS: Thirty-five doctors were working in 45 PHC clinics in February 2020. Twenty-six of the clinic doctors were National Health Insurance (NHI)-employed. The 35 doctors conducted 7 424 patient consultations in February. Staff in the PHC clinics conducted 143 421 consultations that month, mostly by PHC nurse clinicians. The doctors concluded that 6 947 (93.6%) of the 7 424 doctor consultations were of sufficient complexity as to warrant management by a doctor. The spectrum of medical conditions was as follows: (i) consultations for maternal and child health; n=761 (10.2%); (ii) consultations involving non-communicable diseases (NCDs), n=4 372 (58.9%) - the six most common NCDs were, in order: hypertension, diabetes, arthritis, epilepsy, mental illness and renal disease; (iii) consultations involving communicable diseases constituted 1 745 (23.5%) of cases; and (iv) consultations involving laboratory result interpretation 1 180 (15.9%). CONCLUSION: This research showed that at a PHC clinic the more complex patient consultations did indeed require the skills and knowledge of a medical doctor managing these patients. These data support the benefit of a doctor working at every PHC clinic: the doctor is a 'musthave' member of the PHC clinic team, offering a regular, reliable and predictable medical service.

Home-based intervention to test and start (HITS) protocol: a cluster-randomized controlled trial to reduce HIV-related mortality in men and HIV incidence in women through increased coverage of HIV treatment.

BACKGROUND: To realize the full benefits of treatment as prevention in many hyperendemic African contexts, there is an urgent need to increase uptake of HIV testing and HIV treatment among men to reduce the rate of HIV transmission to (particularly young) women. This trial aims to evaluate the effect of two interventions - micro-incentives and a tablet-based male-targeted HIV decision support application - on increasing home-based HIV testing and linkage to HIV care among men with the ultimate aim of reducing HIV-related mortality in men and HIV incidence in young women. METHODS/DESIGN: This is a cluster randomized trial of 45 communities (clusters) in a rural area in the uMkhanyakude district of KwaZulu Natal, South Africa (2018-2021). The study is built upon the Africa Health Research Institute (AHRI)'s HIV testing platform, which offers annual home-based rapid HIV testing to individuals aged 15 years and above. In a 2 × 2 factorial design, individuals aged ≥15 years living in the 45 clusters are randomly assigned to one of four arms: i) a financial micro-incentive (food voucher) (n = 8); ii) male-targeted HIV specific decision support (EPIC-HIV) (n = 8); iii) both the micro incentives and male-targeted decision support (n = 8); and iv) standard of care (n = 21). The EPIC-HIV application is developed and delivered via a tablet to encourage HIV testing and linkage to care among men. A mixed method approach is adopted to supplement the randomized control trial and meet the study aims. DISCUSSION: The findings of this trial will provide evidence on the feasibility and causal impact of two interventions - micro-incentives and a male-targeted HIV specific decision support - on uptake of home-based HIV testing, linkage to care, as well as population health outcomes including population viral load, HIV related mortality in men, and HIV incidence in young women (15-30 years of age). TRIAL REGISTRATION: This trial was registered on 28 November 2018 on, identifier https://clinicaltrials.gov/ .

The association between a detectable HIV viral load and non-communicable diseases comorbidity in HIV positive adults on antiretroviral therapy in Western Cape, South Africa.

BACKGROUND: Past studies have found a relationship between detectable HIV viral load and non-communicable diseases (NCDs) in HIV-infected individuals on antiretroviral therapy in high-income settings, however there is little research in South Africa. Our objective was to investigate the association between detectable HIV viral load and prevalent NCDs in a primary health centre in peri-urban South Africa. METHODS: HIV-infected adults (aged ≥25) who had been on antiretroviral therapy for ≥ six months and attended the HIV clinic within a primary health centre in Khayelitsha, Cape Town, were recruited. We recorded participants' demographics, HIV characteristics, the presence of NCDs via self-report, from clinic folders and from measurement of their blood pressure on the day of interview. We used logistic regression to estimate the association between a detectable HIV viral load and NCD comorbidity. RESULTS: We recruited 330 adults. We found no association between a detectable HIV viral load and NCD comorbidity. Within our multivariable model, female gender (OR3·26; p = 0·02) age > 35 (OR 0·40; p = 0·02) low CD4 count (compared to CD4 < 300 (reference category): CD4:300-449 OR 0·28; CD4:450-599 OR 0·12, CD4:≥600 OR 0·12; p = < 0·001), and ever smoking (OR 3·95; p = < 0·001) were associated with a detectable HIV viral load. We found a lower prevalence of non-communicable disease in clinic folders than was self-reported. Furthermore the prevalence of hypertension measured on the day of interview was greater than that reported on self-report or in the clinic folders. CONCLUSIONS: The lack of association between detectable viral load and NCDs in this setting is consistent with previous investigation in South Africa but differs from studies in high-income countries. Lower NCD prevalence in clinic records than self-report and a higher level of hypertension on the day than self-reported or recorded in clinic folders suggest under-diagnosis of NCDs in this population. This potential under-detection of NCDs may differ from a high-income setting and have contributed to our finding of a null association. Our findings also highlight the importance of the integration of HIV and primary care systems to facilitate routine monitoring for non-communicable diseases in HIV-infected patients.

Social support, disclosure and stigma and the association with non-adherence in the six months after antiretroviral therapy initiation among a cohort of HIV-positive adults in rural KwaZulu-Natal, South Africa.

The World Health Organisation (WHO) recommends antiretroviral treatment (ART) initiation at human immunodeficiency virus (HIV) diagnosis. As ART programmes expand, addressing barriers to adherence is vital. Past mixed findings on the association between social support, stigma and non-disclosure with ART adherence highlights the need for further research. The primary aim of this study was to examine how these factors are associated with ART non-adherence in the six months after ART initiation. The secondary aim was to explore how other factors are associated with non-adherence. We conducted secondary analysis of prospective data from HIV-positive adults initiating ART. Social support, disclosure patterns, perceived stigma and other demographic factors were collected at ART initiation and six months follow-up. Logistic regression models were used to examine factors associated with self-reported ART non-adherence in the last six months and the last month before the six month follow-up ("recent"). Non-adherence in the last six months was twenty-five percent and recent non-adherence was nine percent. There was no association between non-adherence and social support, stigma or non-disclosure of HIV status. In the final model the odds of non-adherence in the last six months were significantly higher for those: with incomplete ART knowledge (aOR 2.10, 95%CI 1.21-3.66); who visited a healthcare provider for conditions other than HIV (aOR1.98, 95%CI 1.14-3.43); had higher CD4 counts at ART initiation (CD4 100-199:aOR 2.50, 95%CI 1.30-4.81; CD4 ≥ 200:aOR 2.85, 95%CI 1.10-7.40;referent CD4 < 100 cells/mm3); had tested HIV-positive in the last year (aOR 2.00, 95%CI 1.10-3.72; referent testing HIV-positive outside the last year); experienced a rash/itching secondary to ART (aOR 2.48, 95%CI 1.37-4.52); and significantly lower for those ≥48 years (aOR 0.65, 95%CI 0.46-0.90). Early non-adherence remains a concern. Incorporation of adherence monitoring and ART knowledge enhancement into appointments for ART collection may be beneficial.

Postoperative healing and behaviour when surgical swabs are applied to calf dehorning wounds.

OBJECTIVE: To assess the effect on healing and pain-associated behaviours of covering exposed sinuses after horn amputation under extensive production conditions in northern Australia. METHODS: Horned, weaned Brahman-cross heifers (n = 50) aged approximately 6 months were alternately allocated to have their dehorning wounds either patched with a dry, non-sterile gauze swab or left untreated. Adherence of swabs and growth rates, healing and pain-associated behaviour were monitored for 88 days post-surgery. RESULTS: Half of the patches were lost by 24 h post-surgery, with most of the rest falling off 2-6 weeks later. Patching resulted in healing 5.5 days earlier (P = 0.018). Sealing of exposed frontal sinuses occurred in most heifers within 3 weeks and full healing occurred within 13 weeks. Patching reduced haemorrhage (P < 0.01) regardless of when the patches were dislodged, prevented insect invasion of the wound and reduced the incidence of secondary infection (P < 0.01). Wound patches did not affect behaviour in the weeks following surgery. In the days after surgery, the heifers did not eat and showed a high incidence of behaviours indicating pain. Behaviour was relatively normal by 2 weeks after surgery, although the heifers avoided social interaction with other unbranded calves for 4 weeks. CONCLUSION: The application of gauze swabs to dehorning wounds advanced healing, reduced the incidence of haemorrhage and secondary infections, and may reduce deaths. Efficacy is expected to improve if high rates of 24-h retention of patches can be achieved. The prolonged time to healing and the pain-associated behaviours highlight the need for better welfare of dehorned calves through improvements in analgesia, surgical procedures and post-surgical care.

Paediatric Type 2 Diabetes Still Rare in an Irish Tertiary Referral Unit.

While Type 2 Diabetes in childhood has become increasingly prevalent throughout the world, in our service we found that only 2% (7/320) of children and adolescents with diabetes aged <16 years had type 2 diabetes. All type 2 subjects were overweight or obese and six of seven were non-Caucasian. Mean age at presentation was 12.8 years. Six patients (85%) had complications, most commonly hypertension. Although Type 2 Diabetes in children remains relatively rare in our cohort, identification of these children is important as management differs from Type 1 Diabetes.

Time to eligibility for antiretroviral therapy in adults with CD4 cell count > 500 cells/µL in rural KwaZulu-Natal, South Africa.

OBJECTIVES: Understanding of progression to antiretroviral therapy (ART) eligibility and associated factors remains limited. The objectives of this analysis were to determine the time to ART eligibility and to explore factors associated with disease progression in adults with early HIV infection. METHODS: HIV-infected adults (≥ 18 years old) with CD4 cell count > 500 cells/µl were enrolled in the study at three primary health care clinics, and a sociodemographic, behavioural and partnership-level questionnaire was administered. Participants were followed 6-monthly and ART eligibility was determined using a CD4 cell count threshold of 350 cells/µl. Kaplan - Meier and Cox proportional hazard regression modelling were used in the analysis. RESULTS: A total of 206 adults contributed 381 years of follow-up; 79 (38%) reached the ART eligibility threshold. Median time to ART eligibility was shorter for male patients (12.0 months) than for female patients (33.9 months). Male sex [adjusted hazard ratio (aHR) 3.13; 95% confidence interval (CI) 1.82-5.39], residing in a household with food shortage in the previous year (aHR 1.58; 95% CI 0.99-2.54), and taking nutritional supplements in the first 6 months after enrolment (aHR 2.06; 95% CI 1.11-3.83) were associated with shorter time to ART eligibility. Compared with reference CD4 cell count ≤ 559 cells/µl, higher CD4 cell count was associated with longer time to ART eligibility [aHR 0.46 (95% CI 0.25-0.83) for CD4 cell count 560-632 cells/µl; aHR 0.30 (95% CI 0.16-0.57) for CD4 cell count 633-768 cells/µl; and aHR 0.17 (95% CI 0.08-0.38) for CD4 cell count > 768 cells/µl]. CONCLUSIONS: Over one in three adults with CD4 cell count > 500 cells/µl became eligible for ART at a CD4 cell count threshold of 350 cells/µl over a median of 2 years. The shorter time to ART eligibility in male patients suggests a possible need for sex-specific pre-ART care and monitoring strategies.

Declining child mortality in northern Malawi despite high rates of infection with HIV.

OBJECTIVE: To determine whether routine surveys, such as the Demographic and Health Surveys (DHS), have underestimated child mortality in Malawi. METHODS: Rates and causes of child mortality were obtained from a continuous-registration demographic surveillance system (DSS) in Malawi for a population of 32 000. After initial census, births and deaths were reported by village informants and updated monthly by project enumerators. Cause of death was established by verbal autopsy whenever possible. The likely impact of human immunodeficiency virus (HIV) infection on child mortality was also estimated from antenatal clinic surveillance data. Overall and age-specific mortality rates were compared with those from the 2004 Malawi DHS. FINDINGS: Between August 2002 and February 2006, 38 617 person-years of observation were recorded for 20 388 children aged < 15 years. There were 342 deaths. Re-census data, follow-up visits at 12 months of age and the ratio of stillbirths to neonatal deaths suggested that death registration by the DSS was nearly complete. Infant mortality was 52.7 per 1000 live births, under-5 mortality was 84.8 per 1000 and under-15 mortality was 99.1 per 1000. One-fifth of deaths by age 15 were attributable to HIV infection. Child mortality rates estimated with the DSS were approximately 30% lower than those from national estimates as determined by routine surveys. CONCLUSION: The fact that child mortality rates based on the DSS were relatively low in the study population is encouraging and suggests that the low mortality rates estimated nationally are an accurate reflection of decreasing rates.

Lap belt injuries in children.

The use of adult seat belts without booster seats in young children may lead to severe abdominal, lumbar or cervical spine and head and neck injuries. We describe four characteristic cases of lap belt injuries presenting to a tertiary children's hospital over the past year in addition to a review of the current literature. These four cases of spinal cord injury, resulting in significant long-term morbidity in the two survivors and death in one child, arose as a result of lap belt injury. These complex injuries are caused by rapid deceleration characteristic of high impact crashes, resulting in sudden flexion of the upper body around the fixed lap belt, and consequent compression of the abdominal viscera between the lap belt and spine. This report highlights the dangers of using lap belts only without shoulder straps. Age-appropriate child restraint in cars will prevent these injuries.

Hearing loss after lumbar puncture.

We report a 63-year-old man who developed transient acute on chronic hearing loss after a lumbar puncture performed to investigate raised intracranial pressure. He was subsequently found to have stenosis of the distal left transverse sinus, which was treated with stenting.

Declining child mortality in northern Malawi despite high rates of infection with HIV

Objective:To determine whether routine surveys; such as the Demographic and Health Surveys (DHS); have underestimated child mortality in Malawi : Methods :Rates and causes of child mortality were obtained from a continuous-registration demographic surveillance system (DSS) in Malawi for a population of 32 000. After initial census; births and deaths were reported by village informants and updated monthly by project enumerators. Cause of death was established by verbal autopsy whenever possible. The likely impact of human immunodeficiency virus (HIV) infection on child mortality was also estimated from antenatal clinic surveillance data. Overall and age-specific mortality rates were compared with those from the 2004 Malawi DHS. Findings:Between August 2002 and February 2006; 38 617 person-years of observation were recorded for 20 388 children aged 15 years. There were 342 deaths. Re-census data; follow-up visits at 12 months of age and the ratio of stillbirths to neonatal deaths suggested that death registration by the DSS was nearly complete. Infant mortality was 52.7 per 1000 live births; under-5 mortality was 84.8 per 1000 and under-15 mortality was 99.1 per 1000. One-fifth of deaths by age 15 were attributable to HIV infection. Child mortality rates estimated with the DSS were approximately 30 lower than those from national estimates as determined by routine surveys Conclusion: The fact that child mortality rates based on the DSS were relatively low in the study population is encouraging and suggests that the low mortality rates estimated nationally are an accurate reflection of decreasing rates