Project ASPIRE: A feasibility randomized controlled trial of a brief intervention for reducing risk of depression and alcohol-related harms among South African adolescents.

OBJECTIVE: Brief interventions could reduce adolescents' risk of depression and alcohol-related harms, but evidence of their feasibility and acceptability for low-and middle-income countries is lacking. To address this gap, we conducted a feasibility trial of the ASPIRE intervention, a four-session multi-component counselling intervention for South African adolescents. METHOD: We recruited 117 adolescents who met our inclusion criteria. Participants were randomly assigned to the ASPIRE intervention or a comparison condition. Outcomes were assessed at baseline, six-week, and three-month post-randomization time points. Primary outcomes were based on feasibility of study procedures and intervention delivery (assessed on seven predetermined progression criteria). Clinical outcomes (risk of depression and alcohol harms) were secondary. RESULTS: Despite modifications to all study procedures arising from Covid-19 restrictions, five of the seven key progression criteria were fully met, including: feasibility of data collection and outcome measures, counsellor competencies, randomization and blinding, adverse advents, and acceptability of the intervention. The progression criterion for recruitment and intervention retention were not fully met. CONCLUSION: Findings suggest that the ASPIRE intervention was generally feasible to deliver and acceptable to adolescents. However, modifications to the trial design and intervention delivery are needed to optimize the validity of a definitive randomized controlled trial of the ASPIRE intervention.

Depression and post-traumatic stress symptoms two years post-rape and the role of early counselling: Rape Impact Cohort Evaluation (RICE) study.

Background: Survivors of sexual violence are at higher risk of adverse mental health outcomes compared to those exposed to other interpersonal traumas.Objective: To examine the trajectory of both post-traumatic stress disorder (PTSD) and depression as well as the role of early counselling over 24 months among rape survivors.Method: The South African Rape Impact Cohort Evaluation (RICE) study enrolled women aged 16-40 years attending post-rape care services within 20 days of a rape incident (n = 734), and a comparison group (n = 786) was recruited from primary health care. Women were followed for 24 months; the main study outcomes were depression and PTSD. Reports of early supportive counselling by the exposed group were also included. The analysis included an adjusted joint mixed model with linear splines to account for correlated observations between the outcomes.Results: At 24 months, 45.2% of the rape-exposed women met the cut-off for depression and 32.7% for PTSD. This was significantly higher than levels found among the unexposed. Although a decline in depression and PTSD was seen at 3 months among the women who reported a rape, mean scores remained stable thereafter. At 24 months mean depression scores remained above the depression cut-off (17.1) while mean PTSD scores declined below the PTSD cut-off (14.5). Early counselling was not associated with the trajectory of either depression or PTSD scores over the two years in rape-exposed women with both depression and PTSD persisting regardless of early counselling.Conclusion: The study findings highlight the importance to find and provide effective mental health interventions post-rape in South Africa.

Smoked drug use in patients with TB is associated with higher bacterial burden.

BACKGROUND: Smoking of illicit drugs may lead to more rapid TB disease progression or late treatment presentation, yet research on this topic is scant. We examined the association between smoked drug use and bacterial burden among patients newly initiated on drug-susceptible TB (DS-TB) therapy.METHODS: Data from 303 participants initiating DS-TB treatment in the Western Cape Province, South Africa, were analyzed. Smoked drug use was defined as self-reported or biologically verified methamphetamine, methaqualone and/or cannabis use. Proportional hazard and logistic regression models (adjusted for age, sex, HIV status and tobacco use) examined associations between smoked drug use and mycobacterial time to culture positivity (TTP), acid-fast bacilli sputum smear positivity and lung cavitation.RESULTS: People who smoked drugs (PWSD) comprised 54.8% (n = 166) of the cohort. TTP was faster for PWSD (hazard ratio 1.48, 95% CI 1.10-1.97; P = 0.008). Smear positivity was higher among PWSD (OR 2.28, 95% CI 1.22-4.34; P = 0.011). Smoked drug use (OR 1.08, 95% CI 0.62-1.87; P = 0.799) was not associated with increased cavitation.CONCLUSIONS: PWSD had a higher bacterial burden at diagnosis than those who do not smoke drugs. Screening for TB among PWSD in the community may facilitate earlier linkage to TB treatment and reduce community transmission.

Pathways to adverse pregnancy outcomes: exploring the mediating role of intimate partner violence and depression: results from a South African rape cohort study.

Adverse pregnancy outcomes (APOs) are common occurrences that contribute to negative maternal and child health outcomes. Our aim was to test the hypothesis that trauma exposure and depression are drivers of the better-recognised risk factors for miscarriage, abortion and stillbirths. Our comparative cohort study based in Durban, South Africa recruited women who reported a recent rape (n = 852) and those who had never experienced rape (n = 853), with follow-up for 36 months. We explored APOs (miscarriage, abortion or stillbirth) among those having a pregnancy during follow-up (n = 453). Potential mediators were baseline depression, post-traumatic stress symptoms, substance abuse, HbA1C, BMI, hypertension and smoking. A structural equation model (SEM) was used to determine direct and indirect paths to APO. Overall, 26.6% of the women had a pregnancy in the follow-up period and 29.4% ended in an APO, with miscarriage (19.9%) the most common outcome, followed by abortion (6.6%) and stillbirths (2.9%). The SEM showed two direct pathways from exposure to childhood trauma, rape and other trauma, to APO which were ultimately mediated by hypertension and/or BMI, but all paths to BMI were mediated by depression and IPV-mediated pathways from childhood and other trauma to hypertension. Food insecurity mediated a pathway from experiences of trauma in childhood to depression. Our study confirms the important role of trauma exposure, including rape, and depression on APOs, through their impact on hypertension and BMI. It is critical that violence against women and mental health are more systematically addressed in antenatal, pregnancy and postnatal care.

Mandrax use, sexual risk, and opportunities for pre-exposure prophylaxis among out-of-school adolescent girls and young women in Cape Town, South Africa.

BACKGROUND: In South Africa (SA), adolescent girls and young women (AGYW) aged 15 - 24 years account for nearly 25% of all new HIV infections in the country. The intersection of substance use and sexual risk continues to drive the HIV epidemic among AGYW. For example, methaqualone, also known as Mandrax, has sedative effects that may affect women's ability to negotiate condom use during sex, refuse sex without a condom, or consent to sex, thereby increasing their risk for HIV. Consequently, it is critical to understand how Mandrax use affects HIV risk among AGYW and to assess awareness of and willingness to use biomedical HIV prevention methods, such as pre-exposure prophylaxis (PrEP), among AGYW who use Mandrax. OBJECTIVES: To examine the role of Mandrax use in sexual behaviours and investigate the extent to which AGYW who use Mandrax are aware of and willing to initiate PrEP. METHODS: Data for this report were derived from baseline and 6-month follow-up data provided by 500 AGYW participating in a cluster-randomised trial assessing the efficacy of a young woman-focused intervention to reduce substance use and HIV risk. AGYW who self-identified as black African or coloured, reported using substances, reported condomless sex in the past 3 months, and had discontinued school early were recruited from 24 community clusters across Cape Town, SA. Following consent/assent, participants provided biological specimens to test for recent drug use (including Mandrax) and completed the self-report questionnaire. RESULTS: Logistic regression analysis revealed that the AGYW who had a positive test result for Mandrax use were less likely to use a condom with their main partner (p=0.01), and almost three times more likely to use alcohol and/or other drugs before or during their last act of sexual intercourse (p<0.001), compared with the AGYW who had a negative Mandrax test result. Mandrax use was not significantly related to PrEP awareness (p>0.10) or willingness to use PrEP (p>0.10), but 70% of AGYW who used Mandrax were willing to initiate PrEP. CONCLUSION: The study findings highlight how Mandrax use may contribute to HIV risk among SA AGYW. Key decision-makers should consider incorporating substance use prevention efforts into existing HIV reduction programmes and equip youth-friendly clinics with the resources to identify AGYW who use Mandrax and offer them PrEP.

SWATH-MS identification of CXCL7, LBP, TGFß1 and PDGFRß as novel biomarkers in human systemic mastocytosis.

Mastocytosis is a rare myeloproliferative disease, characterised by accumulation of neoplastic mast cells in one or several organs. It presents as cutaneous or systemic. Patients with advanced systemic mastocytosis have a median survival of 3.5 years. The aetiology of mastocytosis is poorly understood, patients present with a broad spectrum of varying clinical symptoms that lack specificity to point clearly to a definitive diagnosis. Discovery of novel blood borne biomarkers would provide a tractable method for rapid identification of mastocytosis and its sub-types. Moving towards this goal, we carried out a clinical biomarker study on blood from twenty individuals (systemic mastocytosis: n = 12, controls: n = 8), which were subjected to global proteome investigation using the novel technology SWATH-MS. This identified several putative biomarkers for systemic mastocytosis. Orthogonal validation of these putative biomarkers was achieved using ELISAs. Utilising this workflow, we identified and validated CXCL7, LBP, TGFß1 and PDGF receptor-ß as novel biomarkers for systemic mastocytosis. We demonstrate that CXCL7 correlates with neutrophil count offering a new insight into the increased prevalence of anaphylaxis in mastocytosis patients. Additionally, demonstrating the utility of SWATH-MS for the discovery of novel biomarkers in the systemic mastocytosis diagnostic sphere.

Stormwater runoff reduction benefits of distributed curbside infiltration devices in an urban catchment.

Distributed infiltration systems can benefit downstream water bodies by reducing the runoff flowrate and volume discharges from the catchment. Investigating their runoff flowrate and volume reduction potential at the catchment scale will inform decision makers regarding their efficacy for managing catchment outflows. To this end, we conducted field investigations at the residential catchment scale for three years. The study monitored the catchment for one year before the installation of leaky well systems (preinstallation) and two years after installation (postinstallation). The hydrological model, calibrated to preinstallation catchment outflows, acted as a virtual control tool. Runoff flow outputs from the control model and two years of monitored runoff flow data from the postinstallation period were analysed using statistical methods. The statistical tests showed a significant 13% reduction in average flowrates in storms with a corresponding runoff flowrate of up to 50 L/s. The study further reported the ability of infiltration systems to reduce runoff volume in the catchment by 9%. This reduction was not significant, however, as per the results of the statistical analysis. We then fitted the generalized linear model (GLM) to the monitored and simulated runoff volume data. This enabled us to break down the effect of curbside infiltration systems on runoff volume according to corresponding peak flowrates during the storm. The results of the two-way ANOVA performed to detect significant differences in the regression slopes of the GLM indicated that curbside infiltration systems significantly reduced runoff volume for storms when the runoff flowrates remained below 100 L/s.

LOW PREVALENCE OF HAEMOSPORIDIANS IN BLOOD AND TISSUE SAMPLES FROM HUMMINGBIRDS.

Hummingbirds are vital members of terrestrial ecosystems, and because of their high metabolic requirements, they serve as indicators of ecosystem health. Monitoring the parasitic infections of hummingbirds is thus especially important. Haemosporidians, a widespread group of avian blood parasites, are known to infect hummingbirds, but little is known about the prevalence and diversity of these parasites in hummingbirds. The prevalence of haemosporidians in several hummingbird species was examined and we compared 4 different tissue types in detecting parasites by polymerase chain reaction (PCR). Blood samples from 339 individuals of 3 different hummingbird species were tested, and 4 individuals were found positive for haemosporidian infection, a prevalence of 1.2%. Hummingbird carcasses (n = 70) from 5 different hummingbird species were also sampled to assess differences in detection success of haemosporidians in heart, kidney, liver, and pectoral muscle tissue samples. Detection success was similar among tissue types, with haemosporidian prevalence of 9.96% in heart tissue, 9.52% in kidney tissue, 10.76% in liver tissue, and 11.76% in pectoral muscle tissue. All tissue samples positive for haemosporidian infection were from the Black-chinned Hummingbird (Archilochus alexandri). Possible reasons for low prevalence of these blood parasites could include low susceptibility to insect vectors or parasite incompatibility in these hummingbirds.

Associations Between Patterns of Alcohol Use and Viral Load Suppression Amongst Women Living with HIV in South Africa.

This study aimed to identify alcohol use patterns associated with viral non-suppression among women living with HIV (WLWH) and the extent to which adherence mediated these relationships. Baseline data on covariates, alcohol consumption, ART adherence, and viral load were collected from 608 WLWH on ART living in the Western Cape, South Africa. We defined three consumption patterns: no/light drinking (drinking ≤ 1/week and ≤ 4 drinks/occasion), occasional heavy episodic drinking (HED) (drinking > 1 and ≤ 2/week and ≥ 5 drinks/occasion) and frequent HED (drinking ≥ 3 times/week and ≥ 5 drinks/occasion). In multivariable analyses, occasional HED (OR 3.07, 95% CI 1.78-5.30) and frequent HED (OR 7.11, 95% CI 4.24-11.92) were associated with suboptimal adherence. Frequent HED was associated with viral non-suppression (OR 2.08, 95% CI 1.30-3.28). Suboptimal adherence partially mediated the relationship between frequent HED and viral non-suppression. Findings suggest a direct relationship between frequency of HED and viral suppression. Given the mediating effects of adherence on this relationship, alcohol interventions should be tailored to frequency of HED while also addressing adherence.

Addressing the mental health needs of adolescents in South African communities: a protocol for a feasibility randomized controlled trial.

BACKGROUND: Like many low- and middle-income countries, almost half of the proportion of the South African population is under the age of 25. Given the peak age of onset for most mental health problems is in adolescence, it is vital that adolescents have access to mental health counselling. There are several initiatives to increase access to mental health counselling in South Africa, primarily through the integration of counselling for common mental disorders (CMD) into primary health care services, but adolescents (15-18 years of age) generally do not utilize these services. To address this gap, we will undertake a study to explore the feasibility of conducting a trial of the effectiveness of a community-based mental health counselling intervention for adolescents at-risk for a CMD. METHODS: The study is a feasibility trial of the ASPIRE intervention, a four-session blended multi-component counselling intervention adapted for South African adolescents at risk for depression and alcohol use disorders. We will enrol 100 adolescents from community settings and randomly assign them to the ASPIRE intervention or a comparison condition. Feasibility measures, such as rates of recruitment, consent to participate in the trial and retention, will be calculated. Qualitative interviews with participants and counsellors will explore the acceptability of the intervention. The primary outcomes for a subsequent trial would be reductions in symptoms of depression and days of heavy drinking which will be measured at baseline, 6 weeks, and 3 months post-randomization. DISCUSSION: This feasibility trial using a mixed-methods design will allow us to determine whether we can move forward to a larger effectiveness trial of the ASPIRE intervention. TRIAL REGISTRATION: The trial is registered with the Pan African Clinical Trials Registry (PACTR20200352214510). Registered 28 February 2020-retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9795.

A novel brief treatment for methamphetamine use disorders in South Africa: a randomised feasibility trial.

BACKGROUND: Effective brief treatments for methamphetamine use disorders (MAUD) are urgently needed to complement longer more intensive treatments in low and middle income countries, including South Africa. To address this gap, the purpose of this randomised feasibility trial was to determine the feasibility of delivering a six-session blended imaginal desensitisation, plus motivational interviewing (IDMI) intervention for adults with a MAUD. METHODS: We enrolled 60 adults with a MAUD and randomly assigned them 1:1 to the IDMI intervention delivered by clinical psychologists and a control group who we referred to usual care. Feasibility measures, such as rates of recruitment, consent to participate in the trial and retention, were calculated. Follow-up interviews were conducted at 6 weeks and 3 months post-enrollment. RESULTS: Over 9 months, 278 potential particiants initiated contact. Following initial screening 78 (28%) met inclusion criteria, and 60 (77%) were randomised. Thirteen of the 30 participants assigned to the treatment group completed the intervention. Both psychologists were highly adherent to the intervention, obtaining a fidelity rating of 91%. In total, 39 (65%) participants completed the 6-week follow-up and 40 (67%) completed the 3-month follow-up. The intervention shows potential effectiveness in the intention-to-treat analysis where frequency of methamphetamine use was significantly lower in the treatment than in the control group at both the 6 week and 3-month endpoints. No adverse outcomes were reported. CONCLUSIONS: This feasibility trial suggests that the locally adapted IDMI intervention is an acceptable and safe intervention as a brief treatment for MAUD in South Africa. Modifications to the study design should be considered in a fully powered, definitive controlled trial to assess this potentially effective intervention. Trial registration The trial is registered with the Pan African Clinical Trials Registry (Trial ID: PACTR201310000589295).

Task Sharing or Task Dumping: Counsellors Experiences of Delivering a Psychosocial Intervention for Mental Health Problems in South Africa.

Given task-sharing mental health counselling to non-specialist providers is a recognised strategy to increase service capacity, ensuring that their training, supervision, and support needs are met is necessary to facilitate the sustainable delivery of a high-quality service. Using in-depth interviews, we qualitatively explored the experiences of 18 facility-based counsellors (FBCs) tasked with delivering a counselling intervention within chronic disease services offered within primary care facilities participating in the project MIND cluster randomised controlled trial. Findings show that project MIND training with a strong emphasis on role playing and skills rehearsal improved FBCs' confidence and competence, complemented by highly structured supervision and debriefing provided by a registered counsellor, were key strategies for supporting the implementation of task-shared mental health counselling. FBCs perceived many benefits to providing mental health counselling in primary healthcare but systemic interventions are needed for sustained implementation.

The impact of alcohol use on tuberculosis treatment outcomes: a systematic review and meta-analysis.

Alcohol use is associated with increased risk of developing tuberculosis (TB) disease, yet the impact of alcohol use on TB treatment outcomes has not been summarized. We aimed to quantitatively review evidence of the relationship between alcohol use and poor TB treatment outcomes. We conducted a systematic review of PubMed, EMBASE, and Web of Science (January 1980-May 2018). We categorized studies as having a high- or low-quality alcohol use definition and examined poor treatment outcomes individually and as two aggregated definitions (i.e., including or excluding loss to follow-up [LTFU]). We analyzed drug-susceptible (DS-) and multidrug-resistant (MDR-) TB studies separately. Our systematic review yielded 111 studies reporting alcohol use as a predictor of DS- and MDR-TB treatment outcomes. Alcohol use was associated with increased odds of poor treatment outcomes (i.e., death, treatment failure, and LTFU) in DS (OR 1.99, 95% CI 1.57-2.51) and MDR-TB studies (OR 2.00, 95% CI 1.73-2.32). This association persisted for aggregated poor treatment outcomes excluding LTFU, each individual poor outcome, and across sub-group and sensitivity analyses. Only 19% of studies used high-quality alcohol definitions. Alcohol use significantly increased the risk of poor treatment outcomes in both DS- and MDR-TB patients. This study highlights the need for improved assessment of alcohol use in TB outcomes research and potentially modified treatment guidelines for TB patients who consume alcohol.

Characteristics and drinking behaviour of patients on antiretroviral therapy who drink and attend HIV clinics in Tshwane, South Africa: Implications for intervention.

BACKGROUND: Patients on antiretroviral therapy (ART) who drink alcohol are at risk of poor medication adherence and negative health outcomes. OBJECTIVES: To explore the drinking behaviour of patients on ART and assess the associations between drinking, adherence to ART and viral load, and in particular factors associated with binge drinking (≥6 drinks per occasion) at least monthly. METHODS: We recruited 623 HIV patients from six hospitals in the Tshwane metropole who scored positive on the Alcohol Use Disorders Identification Test (AUDIT-C) but were 'non-dependent' drinkers into a randomised controlled trial. This article reports on baseline data. RESULTS: Of the patients, 51% reported drinking in the past week, 60% of men and 33% of women consumed ≥6 standard drinks on a typical drinking day, and 19% of men and 5% of women were identified as drinking at harmful levels. Over a quarter reported having a friend or relative, or a doctor or other healthcare worker, express concern about their drinking or suggest that they cut down. AUDIT total scores were significantly negatively correlated with self-reported adherence to ART and positively correlated with viral load. Number of years on ART was not significantly associated with binge drinking. Persons who were employed part time (odds ratio (OR) 1.474) or were self-employed (OR 2.135) were more likely to binge-drink than unemployed persons. Beer drinkers (OR 1.716) were more at risk for binge drinking than non-beer drinkers, and persons who drank monthly or less (OR 0.053) or 2 - 4 times a month (OR 0.168) were less at risk for bingeing than those who drank ≥4 times per week. CONCLUSIONS: The high volume of alcohol consumed per occasion by patients on ART, especially beer and spirits drinkers, is a concern. Interventions that address structural drivers of heavy drinking and target HIV patients at risk of heavy drinking are needed.

Looking back, moving forward: 50 years of South African Medical Research Council alcohol-related publications.

BACKGROUND: Alcohol is one of the highest risk factors for death and disability in South Africa (SA). Objective. To explore the trajectory of empirical research on alcohol in SA between 1969 and 2019, with an emphasis on South African Medical Research Council (SAMRC) authored publications. Methods. We reviewed published research (Pubmed and Africa-Wide Information) using systematic methods, clear inclusion and exclusion criteria, and defined search terms. The search was not limited by language. Data synthesis was carried out by the first and last authors. Results. A total of 867 journal articles met the inclusion criteria, with 243 (28.0%) authored or co-authored by SAMRC researchers. For the latter group, three-quarters had an SAMRC researcher as first or last author. Over three-quarters (78.6%) of the SAMRC author positions ('first', 'last' or 'other, counting researchers from a unit only once, but counting authors across different units on a single publication) were from intramural units. Over half the articles authored by SAMRC researchers focused on non-communicable diseases (55.9%), 23.8% focused on communicable diseases, and 10% on crime, violence or injury. Few articles focused on alcohol and tuberculosis (TB), alcohol and cancer, or alcohol policy. Over three-quarters (76.9%) were epidemiological in nature, and 65.3% were cross-sectional studies. There were 17 reviews (7 systematic) and 11 randomised controlled trials (RCTs). There was an increase in the annual number of publications over the 50-year period for both SAMRC and non-SAMRC researchers. Over time, there has been a trend towards publishing on alcohol research in journals published outside SA, but the SAMJ still remains a popular journal choice. Conclusion. The SAMRC has contributed substantially to the growing field of alcohol research in SA, but gaps in areas such as alcohol policy evaluation, alcohol and its association with TB and cancer, and interventional research, are evident.

Acceptability of obtaining hair samples for assessing antiretroviral therapy (ART) exposure amongst alcohol drinking ART recipients in Tshwane, South Africa.

To achieve the maximal therapeutic benefits of antiretroviral therapy (ART), high adherence is required. In South Africa, ART recipients are usually counselled by their health care providers to stop drinking alcohol, as heavy alcohol use compromises ART adherence. Patients who continue drinking alcohol tend to hide their alcohol-related adherence challenges from their health care providers. Objective measures of ART adherence/exposure may help to better identify drinkers who could benefit from ART adherence enhancement interventions. To evaluate the acceptability of collecting hair samples to objectively assess ART exposure among alcohol drinkers, we conducted four mixed-gender focus group discussions (FGDs) with alcohol drinking ART recipients at two ART sites in Tshwane, South Africa. Data were analysed using content analysis. ART recipients found hair sample testing for ART exposure to be novel and therefore expected that some ART recipients would initially be hesitant to provide a sample. Participants thought that the acceptability of hair sample collection could be enhanced by providing a full explanation of how the hair sample would be obtained and what the testing would entail. Participants also viewed hair sample testing as a viable and desirable alternative to blood sample testing for ART exposure. Some worries about the possible use of hair samples for witchcraft and the symbolic nature of hair were brought up, but these were not seen as insurmountable concerns. In conclusion, hair sample testing is a potentially acceptable method of assessing ART exposure amongst ART recipients who drink alcohol.