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.

Stakeholder Engagement in the Development of Public Health Economic Models: An Application to Modelling of Minimum Unit Pricing of Alcohol in South Africa.

BACKGROUND: Health economic models aim to provide decision makers with information that is contextually relevant, understandable and credible. This requires ongoing engagement throughout the research project between the modeller and end-users. OBJECTIVES: We aim to reflect on how a public health economic model of minimum unit pricing of alcohol in South Africa benefited from, and was shaped by, stakeholders. We outline how engagement activities were used during the development, validation and communication phases of the research with input gathered at each stage to inform future priorities. METHODS: A stakeholder mapping exercise was completed to identify stakeholders with the required knowledge, for example academics with expertise in modelling alcohol harm in South Africa, members of civil society organisations with lived experience of informal alcohol outlets, and policy professionals working at the forefront of alcohol policy development in South Africa. The stakeholder engagement consisted of four phases: developing a detailed understanding of the local policy context; co-producing model focus and structure; scrutinising model development and communication planning; and communicating research evidence to end-users. The first phase utilised 12 individual semi-structured interviews. Phases two to four centred around face-to-face workshops (two online) with both individual and group-based exercises employed to achieve required outputs. RESULTS: Phase one provided key learning on policy context and initiated working relationships. Phases two to four provided a conceptualisation of the problem of alcohol harm in South Africa and the choice of policy to model. Stakeholders chose population subgroups of interest and advised on both economic and health outcomes. They provided input on critical assumptions, data sources, priorities for future work, and communication strategies. The final workshop provided a platform to communicate the results of the model to a largely policy audience. These activities led to the production of highly contextualised research methods and findings that were able to be communicated widely beyond academia. CONCLUSIONS: Our programme of stakeholder engagement was fully integrated into the research programme. It resulted in a number of benefits including creating positive working relationships, guiding modelling decisions, tailoring the research to the context, and providing ongoing opportunities for communication.

Estimating the changing burden of disease attributable to alcohol use in South Africa for 2000, 2006 and 2012.

BACKGROUND: Alcohol use was one of the leading contributors to South Africa (SA)'s disease burden in 2000, accounting for 7% of deaths and disability-adjusted life years (DALYs) in the first South African Comparative Risk Assessment Study (SACRA1). Since then, patterns of alcohol use have changed, as has the epidemiological evidence pertaining to the role of alcohol as a risk factor for infectious diseases, most notably HIV/AIDS and tuberculosis (TB). OBJECTIVES: To estimate the burden of disease attributable to alcohol use by sex and age group in SA in 2000, 2006 and 2012. METHODS: The analysis follows the World Health Organization (WHO)'s comparative risk assessment methodology. Population attributable fractions (PAFs) were calculated from modelled exposure estimated from a systematic assessment and synthesis of 17 nationally representative surveys and relative risks based on the global review by the International Model of Alcohol Harms and Policies. PAFs were applied to the burden of disease estimates from the revised second South African National Burden of Disease Study (SANBD2) to calculate the alcohol-attributable burden for deaths and DALYs for 2000, 2006 and 2012. We quantified the uncertainty by observing the posterior distribution of the estimated prevalence of drinkers and mean use among adult drinkers (≥15 years old) in a Bayesian model. We assumed no uncertainty in the outcome measures. RESULTS: The alcohol-attributable disease burden decreased from 2000 to 2012 after peaking in 2006, owing to shifts in the disease burden, particularly infectious disease and injuries, and changes in drinking patterns. In 2012, alcohol-attributable harm accounted for an estimated 7.1% (95% uncertainty interval (UI) 6.6 - 7.6) of all deaths and 5.6% (95% UI 5.3 - 6.0) of all DALYs. Attributable deaths were split three ways fairly evenly across major disease categories: infectious diseases (36.4%), non-communicable diseases (32.4%) and injuries (31.2%). Top rankings for alcohol-attributable DALYs for specific causes were TB (22.6%), HIV/AIDS (16.0%), road traffic injuries (15.9%), interpersonal violence (12.8%), cardiovascular disease (11.1%), cancer and cirrhosis (both 4%). Alcohol remains an important contributor to the overall disease burden, ranking fifth in terms of deaths and DALYs. CONCLUSION: Although reducing overall alcohol use will decrease the burden of disease at a societal level, alcohol harm reduction strategies in SA should prioritise evidence-based interventions to change drinking patterns. Frequent heavy episodic (i.e. binge) drinking accounts for the unusually large share of injuries and infectious diseases in the alcohol-attributable burden of disease profile. Interventions should focus on the distal causes of heavy drinking by focusing on strategies recommended by the WHO's SAFER initiative.

Unnatural deaths, alcohol bans and curfews: Evidence from a quasi-natural experiment during COVID-19.

BACKGROUND: Coronavirus disease-19 (COVID-19) restrictions, particularly relating to the sale of alcohol and hours of curfew, have had a marked effect on the temporal pattern of unnatural deaths in South Africa. Methods. Death data were collected over 68 weeks from January 2020 to April 2021, together with information on the nature of restrictions (if any) on the sale of alcohol, and hours of curfew. Data were analysed using a simple ordinary least square (OLS) regression model to estimate the relative contribution of restrictions on the sale of alcohol and hours of curfew to the pattern of excess unnatural deaths. Results. The complete restriction on the sale of alcohol resulted in a statistically significant reduction in unnatural deaths regardless of the length of curfew. To the contrary, periods where no or limited restrictions on alcohol were in force had no significant effect, or resulted in significantly increased unnatural deaths. Conclusions. The present study highlights an association between alcohol availability and the number of unnatural deaths and demonstrates the extent to which those deaths might be averted by disrupting the alcohol supply. While this is not a long-term solution to addressing alcohol-related harm, it further raises the importance of implementing evidence-based alcohol control measures.

The effect of lockdown on intentional and nonintentional injury during the COVID-19 pandemic in Cape Town, South Africa: A preliminary report.

BACKGROUND: In response to the coronavirus pandemic, lockdown restrictions and a ban on alcohol sales were introduced in South Africa. Objectives. To investigate the impact of lockdown measures on the number of patients who visited a tertiary urban trauma centre. Methods. The period of investigation was from 1 February to 30 June 2020 and was segmented into three intervals: pre-lockdown (February and March 2020), hard lockdown (April and May 2020) and immediately post lockdown (June 2020). The electronic HECTIS health record registry was interrogated for the total number of patients that were seen per month. These were further categorised according to mechanism of injury (stab, gunshot, blunt assault and road traffic injuries). Penetrating (stab and gunshot) and blunt assault victims were collectively grouped as violent trauma. Results. The mean total number of patients seen decreased by 53% during the hard lockdown period. There was a moderate reduction (15%) in patients with gunshot injuries seen during the hard lockdown phase, but there was an 80% increase in the post-lockdown period. The proportion of patients injured in road traffic collisions pre lockdown, hard lockdown and immediate post lockdown was 16.4%, 8.9% and 11.1%, respectively. Patients injured in road traffic collisions decreased by 74% during the hard lockdown period and maintained a reduction of 32% during the immediate post-lockdown period. The mean total number of patients who visited the trauma unit returned to pre-lockdown levels in June. Conclusions. There was an overall trend of reduced number of patients who visited the trauma unit during the hard lockdown period; however, these numbers returned to pre-lockdown levels during the immediate post-lockdown period. The number of road traffic injury admissions remained reduced during all three phases of lockdown, while the number of gunshot victims increased substantially during the post-lockdown period.

Health promotion: How government can ensure that the National Health Insurance Fund has a fighting chance.

Health promotion - keeping people healthy - is critical to ensuring that South Africa (SA)'s National Health Insurance (NHI) services and funding will not be overwhelmed by having to service and pay for large numbers of people with avoidable disease. Although the 2019 NHI Bill mentions health promotion, its lack of emphasis and the narrow approach proposed in the Bill make it unlikely that health promotion will have significant impact on population health or reducing healthcare need. Health promotion experts submit that there is in fact huge potential for carefully planned and researched health promotion to impact on population health. The establishment of a multisectoral National Health Commission or an independent Health Promotion and Development Foundation linked directly to the NHI Fund that includes several relevant government departments and civil society and researchers is proposed. Of the NHI Fund, 2% should be dedicated specifically to promoting health and preventing illness, which must support comprehensive, multisectoral health promotion interventions that go beyond awareness raising and health education. SA's specific realities and needs, including poverty and its related behavioural impacts and health consequences, must be taken into account.

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.

The effect of lockdown on intentional and nonintentional injury during the COVID-19 pandemic in Cape Town, South Africa: A preliminary report.

BACKGROUND: In response to the coronavirus pandemic, lockdown restrictions and a ban on alcohol sales were introduced in South Africa. Objectives. To investigate the impact of lockdown measures on the number of patients who visited a tertiary urban trauma centre. Methods. The period of investigation was from 1 February to 30 June 2020 and was segmented into three intervals: pre-lockdown (February and March 2020), hard lockdown (April and May 2020) and immediately post lockdown (June 2020). The electronic HECTIS health record registry was interrogated for the total number of patients that were seen per month. These were further categorised according to mechanism of injury (stab, gunshot, blunt assault and road traffic injuries). Penetrating (stab and gunshot) and blunt assault victims were collectively grouped as violent trauma. Results. The mean total number of patients seen decreased by 53% during the hard lockdown period. There was a moderate reduction (15%) in patients with gunshot injuries seen during the hard lockdown phase, but there was an 80% increase in the post-lockdown period. The proportion of patients injured in road traffic collisions pre lockdown, hard lockdown and immediate post lockdown was 16.4%, 8.9% and 11.1%, respectively. Patients injured in road traffic collisions decreased by 74% during the hard lockdown period and maintained a reduction of 32% during the immediate post-lockdown period. The mean total number of patients who visited the trauma unit returned to pre-lockdown levels in June. Conclusions. There was an overall trend of reduced number of patients who visited the trauma unit during the hard lockdown period; however, these numbers returned to pre-lockdown levels during the immediate post-lockdown period. The number of road traffic injury admissions remained reduced during all three phases of lockdown, while the number of gunshot victims increased substantially during the post-lockdown period.

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.

Alcohol marketing and adolescent alcohol consumption: Results from the International Alcohol Control study (South Africa).

BACKGROUND: A complete ban on alcohol advertisements has been proposed for South Africa (SA), but there has been limited local research on the association between exposure to alcohol advertisements and alcohol consumption. OBJECTIVES: To examine the role of demographic factors, exposure to alcohol marketing and liking of alcohol advertisements in predicting use of alcohol in the past 6 months among older adolescents in Tshwane, Gauteng Province, SA. METHODS: Participants comprised the adolescent sub-sample (N=869) of the International Alcohol Control study survey that was conducted in SA. They consisted of 408 males and 461 females aged 16 and 17 years who took part in structured interviews on their alcohol consumption and various alcohol-related attitudes and behaviours. A multiple survey logistic regression analysis of the dependent variable alcohol use in the past 6 months on the independent variables age, gender, educational status, socioeconomic status, exposure to alcohol brand marketing and liking of alcohol advertisements was used. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. RESULTS: The prevalence of drinking in the past 6 months was 10.6% (95% CI 5.9 - 18.3). The number of modes of alcohol brand/product advertising to which the adolescents were exposed was positively associated with alcohol use in the past 6 months. An additional mode of alcohol brand/product advertising exposure led to a relative increase of 1.13 (95% CI 1.01 - 1.28) in the odds of alcohol use in the past 6 months (e.g. a participant who was exposed to advertisements via seven different channels was 2.08 times more likely to have used alcohol in the past 6 months than a participant with exposure via a single channel). Having a strong dislike of alcohol advertisements was associated negatively (protective) with alcohol use in the past 6 months, with the odds ratio being 0.35 (95% CI 0.19 - 0.64). Having only a moderate dislike or a liking of alcohol advertisements was positively associated with alcohol use in the past 6 months among the study participants (OR 2.90 and 2.84, respectively). Age, gender, educational status and socioeconomic status were not independently associated with alcohol consumption. CONCLUSIONS: Exposure to alcohol marketing and not being strongly averse to advertisements of alcohol brands and products were associated with alcohol use among adolescents. The results have implications for policies on alcohol marketing in SA.

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.

Reducing substance use and risky sexual behaviour among drug users in Durban, South Africa: Assessing the impact of community-level risk-reduction interventions.

Alcohol and other drug (AOD) use is increasingly recognised as having a direct and indirect effect on the transmission of human immunodeficiency virus (HIV). However, there is evidence to suggest that drug- and sex-related HIV risk-reduction interventions targeted at drug users within drug treatment centres or via community outreach efforts can lead to positive health outcomes. This study aimed to test whether a community-level intervention aimed at AOD users has an impact on risky AOD use and sexual risk behaviour. In 2007, in collaboration with a local non-governmental organisation (NGO) in Durban, an initiative was begun to implement a number of harm reduction strategies for injection and non-injection drug users. The NGO recruited peer outreach workers who received intensive initial training, which was followed by six-monthly monitoring and evaluation of their performance. Participants had to be 16 years of age or older, and self-reported alcohol and/or drug users. Peer outreach workers completed a face-to-face baseline questionnaire with participants which recorded risk behaviours and a risk-reduction plan was developed with participants which consisted of reducing injection (if applicable) and non-injection drug use and sex-related risks. Other components of the intervention included distribution of condoms, risk-reduction counselling, expanded access to HIV Testing Services, HIV/sexually transmitted infection care and treatment, and referrals to substance abuse treatment and social services. At follow-up, the baseline questionnaire was completed again and participants were also asked the frequency of reducing identified risk behaviours. Baseline information was collected from 138 drug users recruited into the study through community-based outreach, and who were subsequently followed up between 2010 and 2012. No injection drug users were reached. The data presented here are for first contact (baseline) and the final follow-up contact with the participants. There were no decreases in drug use practices such as use of cannabis, heroin, cocaine and Ecstasy after the intervention with drug users; however, there was a significant reduction in alcohol use following the intervention. While there was a substantial increase in the proportion of participants using drugs daily as opposed to more often, the reduction in the frequency of drug use was not statistically significant. Following the intervention, drug users had significantly fewer sexual partners, but there were no significant differences following the intervention with regard to frequency of sex or use of condoms. Substance use in general and during sex was, however, decreased. While the findings were mixed, the study shows that it is possible to provide HIV risk-reduction services to a population of substance users who are less likely to receive services through community outreach, and provide risk-reduction information, condoms and condom demonstration and other services. More intensive interventions might be needed to have a substantial impact on substance use and substance use-related HIV risk behaviours.

Addressing the intersection between alcohol consumption and antiretroviral treatment: needs assessment and design of interventions for primary healthcare workers, the Western Cape, South Africa.

BACKGROUND: At the points where an infectious disease and risk factors for poor health intersect, while health problems may be compounded, there is also an opportunity to provide health services. Where human immunodeficiency virus (HIV) infection and alcohol consumption intersect include infection with HIV, onward transmission of HIV, impact on HIV and acquired immunodeficiency syndrome (AIDS) disease progression, and premature death. The levels of knowledge and attitudes relating to the health and treatment outcomes of HIV and AIDS and the concurrent consumption of alcohol need to be determined. This study aimed to ascertain the knowledge, attitudes and practices of primary healthcare workers concerning the concurrent consumption of alcohol of clinic attendees who are prescribed antiretroviral drugs. An assessment of the exchange of information on the subject between clinic attendees and primary healthcare providers forms an important aspect of the research. A further objective of this study is an assessment of the level of alcohol consumption of people living with HIV and AIDS attending public health facilities in the Western Cape Province in South Africa, to which end, the study reviewed health workers' perceptions of the problem's extent. A final objective is to contribute to the development of evidence-based guidelines for AIDS patients who consume alcohol when on ARVs. The overall study purpose is to optimise antiretroviral health outcomes for all people living with HIV and AIDS, but with specific reference to the clinic attendees studied in this research. METHODS: Overall the research study utilised mixed methods. Three group-specific questionnaires were administered between September 2013 and May 2014. The resulting qualitative data presented here supplements the results of the quantitative data questionnaires for HIV and AIDS clinic attendees, which have been analysed and written up separately. This arm of the research study comprised two, separate, semi-structured sets of interviews: one face-to-face with healthcare workers at the same primary healthcare clinics from which the clinic attendees were sampled, and the other with administrators from the local government health service via email. The qualitative analysis from the primary healthcare worker interviews has been analysed using thematic content analysis. RESULTS: The key capacity gaps for nurses include the definition of different patterns and volumes of alcohol consumption, resultant health outcomes and how to answer patient questions on alcohol consumption while on antiretroviral treatment. Not only did the counsellors lack knowledge regarding alcohol abuse and its treatment, but they were also they were unclear on their role and rights in relation to their patients. Doctors highlighted the need for additional training for clinicians in diagnosing alcohol use disorders and information on the pharmacological interventions to treat alcoholism. CONCLUSION: Pertinent knowledge regarding patient alcohol consumption while taking ARVs needs to be disseminated to primary healthcare workers.

Codeine misuse and dependence in South Africa--learning from substance abuse treatment admissions.

BACKGROUND: Misuse of prescription and over-the-counter codeine-containing products is a global public health issue. OBJECTIVES: To investigate the extent of treatment demand related to the misuse of codeine or codeine dependence in South Africa (SA) and the profile of patients seeking treatment, so as to understand the nature and extent of the problem. METHOD: Data were collected from centres participating in the South African Community Epidemiology Network on Drug Use in 2014. A total of 17 260 admissions were recorded. RESULTS: There were 435 recorded treatment admissions for codeine misuse or dependence as a primary or secondary substance of abuse (2.5% of all admissions). Of treatment admissions, 137 (0.8%) involved codeine as the primary substance of abuse; 74.9% of patients were males, with an even spread across population groups. Ages ranged from 11 to 70 years, with the highest proportion aged 20 - 29 years; >40% were referred by self, family and/or friends, and 26.7% by health professionals; and 36.8% had received treatment previously. The majority reported misuse of tablets/capsules, with 17.6% reporting misuse of syrups. Oral use comprised 96.6% and daily use 63.1%. CONCLUSIONS: Data from treatment admissions related to codeine misuse and dependence are informative, but provide an incomplete picture of the nature and extent of codeine-related problems in SA. Other data sources must be considered before further regulatory/policy changes regarding codeine are implemented.

Hazardous and harmful use of alcohol and/or other drugs and health status among South African patients attending HIV clinics.

There is growing recognition of the influence of substance use, particularly alcohol use, on HIV disease progression. This study investigated how hazardous/harmful use of alcohol and drugs impacts the health status of 1503 patients attending HIV clinics. Of the sample, 37 % indicated hazardous/harmful drinking and 13 % indicated a drug problem. Hazardous/harmful use of alcohol and drugs was significantly related to health status, with participants using substances more likely to have TB-positive status (χ(2) = 4.30, p < 0.05), less likely to be on ARVs (χ(2) = 9.87, p < 0.05) and having lower CD4 counts (t = 4.01, p < 0.05). Structural equation modelling confirmed the centrality of hazardous/harmful use of alcohol as a direct and indirect determinant of disease progression. Based on these findings it is recommended that patients attending HIV clinics be routinely screened for problematic alcohol and/or drug use, with strong emphasis on ensuring ARV adherence in those with problematic alcohol use.

Establishing a health promotion and development foundation in South Africa.

South Africa has a 'quadruple burden of disease'. One way to reduce this burden, and address the social determinants of health and social inequity, could be through health promotion interventions driven by an independent Health Promotion and Development Foundation (HPDF). This could provide a framework to integrate health promotion and social development into all government and civil society programmes. On priority issues, the HPDF would mobilise resources, allocate funding, develop capacity, and monitor and evaluate health promotion and development work. Emphasis would be on reducing the effects of poverty, inequity and unequal development on disease rates and wellbeing. The HPDF could also decrease the burden on the proposed National Health Insurance (NHI) system. We reflect on such foundations in other countries, and propose a structure for South Africa's HPDF and a dedicated funding stream to support its activities. In particular, an additional 2% levy on alcohol and tobacco products is proposed to be utilised to fund the HPDF.

Monitoring the prevalence of methamphetamine-related presentations at psychiatric hospitals in Cape Town, South Africa.

OBJECTIVE: This study aimed to determine a demographic profile of methamphetamine (MA)-related admissions to major psychiatric services in Cape Town, obtain a substance use profile from admitted patients, a profile of common MA-related symptoms encountered during the assessment of the patients presenting with MA-related problems, and a brief profile of the psychiatric diagnoses made. METHOD: Staff in six psychiatric hospitals or wards in Cape Town collected data on methamphetamine related admissions between July and December 2008 using a one-page record review form. The data collection form consisted of the patient's demographic details, presenting symptoms, previous admission details, current MA and other substance use information, and DSM-IV diagnosis. RESULTS: A total of 235 forms were completed. Most patients were male (69%) and the mean age was 25 years. The most common presenting symptoms were aggressive behaviour (74%), followed by delusions (59%) and hallucinations (57%). Males were two times more likely to present with aggression as compared to females, while females were significantly more likely to present with depressed mood or euphoric/elevated mood. The majority of patients had substance-induced psychotic disorder (41%), followed by schizophrenia (31%). Twelve percent (12%) had bipolar mood disorder. CONCLUSION: MA-related psychiatric admissions pose serious challenges to all health services dealing with these patients. Further training and treatment protocol development and distribution is indicated.

A preliminary investigation of the AUDIT and DUDIT in comparison to biomarkers for alcohol and drug use among HIV-infected clinic attendees in Cape Town, South Africa.

OBJECTIVE: There is growing concern about the effect of substance use on HIV treatment outcomes. The study objectives included: (i) evaluating whether the use of validated questionnaires (AUDIT and DUDIT) provide useful and consistent information of alcohol and drug consumption when compared with the use of biomarkers of alcohol in (urine and hair) and drugs in (urine) and (ii) assessing the feasibility of using self-report measures compared with urine and hair tests. METHOD: Participants were HIV positive patients attending an HIV community health clinic in Kraaifontein, Cape Town. Hair and urine samples were collected and analysed for alcohol, in Fatty Acid Ethyl Esters (FAEE) and in Ethyl Glucuronide and (EtG), and drugs. Biological markers were compared with self-report measures of alcohol and drug consumption in terms of sensitivity, specificity. Forty-three participants completed the self-report measures, while 30 provided hair and urine samples. RESULTS: On the AUDIT, 18 (41.9%) participants screened positive for harmful and hazardous drinking and 13 (30.2%) participants on the DUDIT screened positive for having a drug-related problem. Two of 30 participants (7%) tested positive for alcohol abuse on FAEE analysis. For EtG, 6 of 24 (25%) participants tested positive for alcohol abuse. On hair drug analysis, all 30 participants tested negative for cannabis, amphetamines, opiates, cocaine, PCP and methaqualone. On the urinalysis, 1 of 30 participants tested positive for cannabis and everyone tested negative for all other drugs included in the screening. CONCLUSION: Substance use among patients attending HIV clinics appears to be a problem, especially alcohol. Self-report measures seem to be a more cost effective option for screening of alcohol and drug abuse in resource poor settings.