"It's about time they taught us": a qualitative study evaluating the barriers to finding and screening child contacts under five at risk for TB in Gauteng Province, South Africa from the provider and caregiver perspectives

BACKGROUND

Inadequate numbers of children under five years of age who are exposed to tuberculosis (TB) in the home (child contact) are initiated on TB preventive treatment (TPT) in South Africa. We assessed barriers of initiating isoniazid preventive therapy (IPT) in this age group.

METHODS

We conducted a qualitative study at two primary health clinics in the Ekurhuleni district in Gauteng Province. Between April and July 2019, we enrolled facility managers, TB staff and parents or legal guardians of child contacts (caregivers) attending for care, at the two facilities. Semi-structured questionnaires, facility observations and in-depth interviews using a semi-structured interview guide were used to collect data. Findings from the semi-structured questionnaires with facility staff and facility observations were summarized. Thematic analysis with a deductive approach was used to analyse the data from the in-depth interviews with caregivers.

RESULTS

Two facility managers took part in the study and were assisted to complete the semi-structured questionnaires by TB staff. Fifteen caregivers aged between 18 and 43 years were interviewed of which 13 (87%) were female. Facility managers and TB staff (facility staff) felt that even though caregivers knew of family members who were on TB treatment, they delayed bringing their children for TB screening and TPT. Facility staff perceived caregivers as not understanding the purpose and benefits of TB prevention strategies such as TPT. Caregivers expressed the desire for their children to be screened for TB. However, caregivers lacked knowledge on TB transmission and the value of TB prevention in children at high risk of infection.

CONCLUSION

While facility staff perceived caregivers to lack responsibility, caregivers expressed limited knowledge on the value of screening their children for TB as reasons for not accessing TB preventive services. Health education on TB transmission, screening, and TB prevention strategies at a community level, clinics, creches, schools and via media are important to achieve the global end TB goal of early detection and prevention of TB.

Performance of spirometry assessment at TB diagnosis

BACKGROUND: Spirometry is considered relevant for the diagnosis and monitoring of post-TB lung disease. However, spirometry is rarely done in newly diagnosed TB patients.METHODS: Newly diagnosed, microbiologically confirmed TB patients were recruited for the study. Spirometry was performed within 21 days of TB treatment initiation according to American Thoracic Society/European Respiratory Society guidelines. Spirometry analysis was done using Global Lung Initiative equations for standardisation.RESULTS: Of 1,430 eligible study participants, 24.7% (353/1,430) had no spirometry performed mainly due to contraindications and 23.0% (329/1,430) had invalid results; 52.3% (748/1,430) of participants had a valid result, 82.8% (619/748) of whom had abnormal spirometry. Of participants with abnormal spirometry, 70% (436/619) had low forced vital capacity (FVC), 6.1% (38/619) had a low ratio of forced expiratory volume in 1 sec (FEV1) to FVC, and 19.1% (118/619) had low FVC, as well as low FEV1/FVC ratio. Among those with abnormal spirometry, 26.3% (163/619) had severe lung impairment.CONCLUSIONS: In this population, a high proportion of not performed and invalid spirometry assessments was observed; this was addressed by removing tachycardia as a (relative) contraindication from the study guidance and retraining. The high proportion of patients with severe pulmonary impairment at the time of TB diagnosis suggests a huge morbidity burden and calls for further longitudinal studies on the relevance of spirometry in predicting chronic lung impairment after TB.

Reasons for poor uptake of TB preventive therapy in South Africa

BACKGROUND

South Africa has one the highest TB and HIV burdens globally. TB preventive therapy (TPT) reduces the risk of TB disease and TB-related mortality in adults and children living with HIV and is indicated for use in TB-exposed HIV-negative individuals and children. TPT implementation in South Africa remains suboptimal.

METHODS

We conducted a pragmatic review of TPT implementation using multiple data sources, including informant interviews (n = 134), semi-structured observations (n = 93) and TB patient folder reviews in 31 health facilities purposively selected across three high TB burden provinces. We used case descriptive analysis and thematic coding to identify barriers and facilitators to TPT implementation.

RESULTS

TPT programme implementation was suboptimal, with inadequate monitoring even in health districts with well-functioning TB services. Health workers reported scepticism about TPT effectiveness, deprioritised TPT in practice and expressed divergent opinions about the cadres of staff responsible for implementation. Service- and facility-level barriers included ineffective contact tracing, resource shortages, lack of standardised reporting mechanisms and insufficient patient education on TPT. Patient-level barriers included socio-economic factors.

CONCLUSIONS

Improving TPT implementation will require radically simplified and more feasible systems and training for all cadres of health workers. Partnership with communities to stimulate demand driven service uptake can potentially facilitate implementation.

Delivery of TB preventive therapy to incarcerated people living with HIV in southern African correctional facilities

TB preventive treatment (TPT) is recommended for high-risk and hard-to-reach populations such as incarcerated people living with HIV (PLHIV). To assess implementation of TPT delivery in correctional settings, we conducted an exploratory analysis of data from a multisite cohort study in South Africa and Zambia. From 975 participants, 648 were screened for TB, and 409 initiated TPT mostly within a month after initiation of antiretroviral therapy (190/409, 46.5%). We observed a median gap of one month (IQR 0.6-4.7) in TPT delivery to incarcerated PLHIV. Future research should examine standardised quality improvement tools and new strategies such as short-course regimens to improve TPT initiation in this population.

A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2

SUMMARY

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death.

RECOMMENDATIONS

Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.

An economic evaluation of an intervention to increase demand for medical male circumcision among men aged 25-49 years in South Africa

BACKGROUND

Studies estimate that circumcising men between the ages of 20-30 years who have exhibited previous risky sexual behaviour could reduce overall HIV prevalence. Demand creation strategies for medical male circumcision (MMC) targeting men in this age group may significantly impact these prevalence rates.

OBJECTIVES

The objective of this study is to evaluate the cost-effectiveness and cost-benefit of an implementation science, pre-post study designed to increase the uptake of male circumcision for ages 25-49 at a fixed MMC clinic located in Gauteng Province, South Africa.

METHODS

A health care provider perspective was utilised to collect all costs. Costs were compared between the standard care scenario of routine outreach strategies and a full intervention strategy. Cost-effectiveness was measured as cost per mature man enrolled and cost per mature man circumcised. A cost-benefit analysis was employed by using the Bernoulli model to estimate the cases of HIV averted due to medical male circumcision (MMC), and subsequently translated to averted medical costs.

RESULTS

In the 2015 intervention, the cost of the intervention was $9445 for 722 men. The total HIV treatment costs averted due to the intervention were $542,491 from a public care model and $378,073 from a private care model. The benefit-cost ratio was 57.44 for the public care model and 40.03 for the private care model. The net savings of the intervention were $533,046 or $368,628 - depending on treatment in a public or private setting.

CONCLUSIONS

The intervention was cost-effective compared to similar MMC demand interventions and led to statistically significant cost savings per individual enrolled.

Data quality assessment of a South African electronic registry for drug-resistant TB, 2015-2016

SETTING

Assessment of bedaquiline roll-out in South Africa requires accurate patient data in EDRWeb, a national case-based rifampicin-resistant TB (RR-TB) surveillance register.

OBJECTIVE

To ensure EDRWeb data reflect programmatic DR-TB source data, we implemented a data quality improvement initiative.

DESIGN

We conducted data quality assessments of EDRWeb data compared to paper patient folders at two South African RR-TB treatment facilities in 2015 and 2016. We assessed 80 patient records before the intervention for completeness of clinically relevant data fields, and 80 different records after the intervention for completeness and concordance. The intervention involved reviewing and updating EDRWeb along with data quality audits with direct feedback to sites.

RESULTS

At baseline data completeness per site was lowest for variables related to electrocardiogram (ECG) data, adverse events, and concomitant medications (completeness for these fields ranged from 0% to 80%). Post-intervention data completeness and concordance were high for all fields except those related to ECG data (ECG-related field completeness ranged from 10% to 100%).

CONCLUSION

After a data quality initiative, data completeness improved at each site with the exception of ECG data fields. Our findings suggest that data quality interventions may improve patient clinical registries, ultimately enabling better evidence-based decision making for TB programmes.

Prevalence and risk factors of tuberculosis disease in South African correctional facilities in 2015

SETTING: Sixteen South African correctional facilities.OBJECTIVE: To determine the prevalence of and risk factors for tuberculosis (TB) in South African correctional facilities using data collected during a TB screening program in South African correctional facilities in 2015.DESIGN: Inmates in 16 South African correctional facilities were screened for TB from January to December 2015. Inmates reporting ≥1 TB symptom or having an abnormal computer-assisted digital chest X-ray (CXR) provided sputum. Abnormal CXRs were interpreted by a radiologist. Sputum was tested for Mycobacterium tuberculosis using Xpert^® MTB/RIF. Data from 16 South African correctional facilities were used in regression analysis, and prevalence estimates calculated for 12 South African correctional facilities with >30% screening coverage.RESULTS: In 12 South African correctional facilities included in the prevalence estimates, 837 inmates had TB disease (2653/100 000) as indicated by current TB treatment or screening-identified TB by radiologist or Xpert. Previous TB was associated with increased odds of screening-identified TB in HIV-positive inmates (OR 4.3, 95%CI 2.5-7.3). For HIV-negative inmates, previous TB (adjusted OR [aOR] 4.9, 95%CI 1.7-14.1) and self-reported symptoms vs. none (1 symptom, aOR 8.8, 95%CI 1.2-67.7; >2 symptoms, aOR 21.7, 95%CI 3.0-158.8) were independently associated with increased odds of screening-identified TB.CONCLUSIONS: Routine TB screening, including CXR, is needed in South African correctional facilities to identify and refer inmates with active TB.

'They are inconveniencing us' - exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: perspectives from patients and clinicians in the Free State Province, South Africa

BACKGROUND

Tuberculosis (TB) treatment loss to follow up (LTFU) plays an important contributory role to the staggering TB epidemic in South Africa. Reasons for treatment interruption are poorly understood. Treatment interruption appears to be the culmination of poor health literacy of patients and inadequate health education provided by clinicians. We explored clinician and patient perspectives of the gaps in TB messaging that influence TB treatment LTFU.

METHODS

We conducted semi-structured in-depth interviews between January and May 2018 with a sample of 15 clinicians managing TB and 7 patients identified as LTFU in public clinics in the Free State Province, South Africa. Thematic analysis using a mixed deductive/inductive thematic approach was used.

RESULTS

Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Patients felt that the TB messaging received was inadequate. Many of the clinicians interviewed felt that improving patient's TB knowledge would reinforce adherence to treatment and thus focused on sharing information on treatment completion, side effects and infection control. However, the inability of clinicians to establish rapport with patients or to identify social support challenged TB treatment adherence by patients. Clinicians perceived this as patients not following their instructions despite what they considered lengthy TB education. Having said this, clinicians concurred that their medical management of TB lacked the psycho-social dimension to treat a social disease of this magnitude.

CONCLUSIONS

Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Clinicians concurred that poor patient understanding of TB and that biomedical management lacking a psycho-social dimension further exacerbated the poor treatment outcome. TB remains a social disease, the successful management of which hinges on patient-centred care.

Symptom and digital chest X-ray TB screening in South African prisons: yield and cost-effectiveness

BACKGROUND: Correctional inmates are at a high risk of tuberculosis (TB). The optimal approach to screening this population is unclear.METHODS: We retrospectively reviewed records from TB screening in 64 correctional facilities in South Africa between January 2015 and July 2016. Inmates received symptom screening (any of cough, fever, weight loss, or night sweats) combined with digital chest X-ray (CXR), when available. CXRs were assessed as 'abnormal' or with no abnormalities. Inmates with either a symptom or an 'abnormal' CXR were asked to provide a single spot sputum for Xpert^® MTB/RIF testing. We estimated the incremental cost-effectiveness ratio (ICER) per additional TB case detected using CXR screening among asymptomatic inmates.RESULTS: Of 61 580 inmates, CXR screening was available for 41 852. Of these, 19 711 (47.1%) had TB symptoms. Among 22 141 inmates without symptoms, 1939/19 783 (9.8%) had an abnormal CXR, and 8 (1.2%) were Xpert-positive among those with Xpert tests done. Of 14 942 who received symptom screening only and had symptoms, 84% (12 616) had an Xpert result, and 105 (0.8%) were positive. The ICER for CXR screening was US$22 278.CONCLUSION: Having CXR in addition to symptom screening increased yield but added considerable cost. A major limitation of screening was the low specificity of the symptom screen.

Lessons learnt conducting minimally invasive autopsies in private mortuaries as part of HIV and tuberculosis research in South Africa

Current estimates of the burden of tuberculosis (TB) disease and cause-specific mortality in human immunodeficiency virus (HIV) positive people rely heavily on indirect methods that are less reliable for ascertaining individual-level causes of death and on mathematical models. Minimally invasive autopsy (MIA) is useful for diagnosing infectious diseases, provides a reasonable proxy for the gold standard in cause of death ascertainment (complete diagnostic autopsy) and, used routinely, could improve cause-specific mortality estimates. From our experience in performing MIAs in HIV-positive adults in private mortuaries in South Africa (during the Lesedi Kamoso Study), we describe the challenges we faced and make recommendations for the conduct of MIA in future studies or surveillance programmes, including strategies for effective communication, approaches to obtaining informed consent, risk management for staff and efficient preparation for the procedure.

Cost of point-of-care lateral flow urine lipoarabinomannan antigen testing in HIV-positive adults in South Africa

INTRODUCTION:

The World Health Organization recommends point-of-care (POC) lateral flow urine lipoarabinomannan (LF-LAM) for tuberculosis (TB) diagnosis in selected human immunodeficiency virus (HIV) positive people. South Africa had 438 000 new TB episodes in 2016, 58.9% of which were contributed by HIV-positive people. LF-LAM is being considered for scale-up in South Africa.

METHODS:

We estimated the costs of using LF-LAM in HIV-positive adults with CD4 counts ⩽ 150 cells/μl enrolled in the TB Fast Track Trial in South Africa. We also estimated costs of POC haemoglobin (Hb), as this was used in the study algorithm. Data on clinic-level (10 intervention clinics) and above-clinic-level costs were collected.

RESULTS:

A total of 1307 LF-LAM tests were performed at 10 clinics over 24 months. The mean clinic-level costs were US$12.80 per patient for LF-LAM and POC Hb; LF-LAM costs were US$11.49 per patient. The mean above-clinic-level unit costs for LF-LAM were US$12.06 for clinic preparation, training, coordination and mentoring. The mean total cost of LF-LAM was US$23.55 per patient.

CONCLUSION:

At clinic level, the cost of LF-LAM was comparable to other TB diagnostics in South Africa. It is important to consider above-clinic-level costs for POC tests, as these may be required to support roll-out and ensure successful implementation.

Evidence-informed policy making at country level: lessons learned from the South African Tuberculosis Think Tank

BACKGROUND:

National Tuberculosis Programmes (NTPs) require specialist input to support the development of policy and practice informed by evidence, typically against tight deadlines.

OBJECTIVE:

To describe lessons learned from establishing a dedicated tuberculosis (TB) think tank to advise the South African NTP on TB policy.

INTERVENTION AND EVALUATION METHODS:

A national TB think tank was established to advise the NTP in support of evidence-informed policy. Support was provided for activities, including meetings, modelling and regular telephone calls, with a wider network of unpaid expert advisers under an executive committee and working groups. Intervention evaluation used desktop analysis of documentary evidence, interviews and direct observation.

RESULTS:

The TB Think Tank evolved over time to acquire three key roles: an ‘institution’, a ‘policy dialogue forum’ and an ‘interface’. Although enthusiasm was high, motivating participation among the NTP and external experts proved challenging. Motivation of working groups was most successful when aligned to a specific need for NTP decision making. Despite challenges, the TB Think Tank contributed to South Africa's first ever TB and human immunodeficiency virus (HIV) investment case, and the decision to create South Africa's first ever ring-fenced grant for TB. The TB Think Tank also assisted the NTP in formulating strategy to accelerate progress towards reaching World Health Organization targets.

DISCUSSION:

With partners, the TB Think Tank achieved major successes in supporting evidence-informed decision making, and garnered increased funding for TB in South Africa. Identifying ways to increase the involvement of NTP staff and other experts, and keeping the scope of the Think Tank well defined, could facilitate greater impact. Think tank initiatives could be replicated in other settings to support evidence-informed policy making.

What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations?

OBJECTIVE:

To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa.

METHODS:

A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation.

RESULTS:

Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm³. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each).

CONCLUSION:

PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.

An intervention to optimise the delivery of integrated tuberculosis and HIV services at primary care clinics: results of the MERGE cluster randomised trial

OBJECTIVES

To evaluate the effect of an intervention to optimize TB/HIV integration on patient outcomes.

METHODS

Cluster randomised control trial at 18 primary care clinics in South Africa. The intervention was placement of a nurse (TB/HIV integration officer) to facilitate provision of integrated TB/HIV services, and a lay health worker (TB screening officer) to facilitate TB screening for 24 months. Primary outcomes were i) incidence of hospitalisation/death among individuals newly diagnosed with HIV, ii) incidence of hospitalisation/death among individuals newly diagnosed with TB and iii) proportion of HIV-positive individuals newly diagnosed with TB who were retained in HIV care 12 months after enrolment.

RESULTS

Of 3328 individuals enrolled, 3024 were in the HIV cohort, 731 in TB cohort and 427 in TB-HIV cohort. For the HIV cohort, the hospitalisation/death rate was 12.5 per 100 person-years (py) (182/1459py) in the intervention arm vs. 10.4/100py (147/1408 py) in the control arms respectively (Relative Risk (RR) 1.17 [95% CI 0.92-1.49]).For the TB cohort, hospitalisation/ death rate was 17.1/100 py (67/ 392py) vs. 11.1 /100py (32/289py) in intervention and control arms respectively (RR 1.37 [95% CI 0.78-2.43]). For the TB-HIV cohort, retention in care at 12 months was 63.0% (213/338) and 55.9% (143/256) in intervention and control arms (RR 1.11 [95% 0.89-1.38]).

CONCLUSIONS

The intervention as implemented failed to improve patient outcomes beyond levels at control clinics. Effective strategies are needed to achieve better TB/HIV service integration and improve TB and HIV outcomes in primary care clinics.

TRIAL REGISTRATION

South African Register of Clinical Trials (registration number DOH-27-1011-3846).

Tuberculosis among HIV-infected population: incidence and risk factors in rural Tanzania

BACKGROUND

The incidence of tuberculosis among HIV-infected populations with high CD4 count in high burden countries has not been well studied.

OBJECTIVE

To assess the TB incidence in HIV-infected adults and its associated risk factors.

METHOD

A cohort study with retrospective review of medical records and prospective follow-up of HIV-infected adult participants attending CTC who were 18-55 years old, had CD4 count more than 250 cells/mm³ in the period of 2008-2010 and were not on ART at enrolment. Cox proportional hazard regression was used to explore the predictors of incident TB.

RESULTS

Overall 777 (24%) of 3,279 CTC enrolled HIV-infected adults fulfilled the inclusion criteria of the study. The incidence of TB in the study population ranged from 0.8/100 per person years (PY) at risk (95% CI 0.5-1.3) in the main analysis to 1.7/100 PY at risk (95% CI 1.0-2.6) in sensitivity analyses. Only prior history of TB disease was found to have a significant association with an increased risk of TB, hazard ratio 5.7 (95% CI 2.0-16.4, p value 0.001).

CONCLUSION

Tuberculosis incidence among HIV-infected adults with medium/high CD4 count in Bagamoyo is lower than in other high TB burden countries. Previously TB treated patients have a much higher risk of getting TB again than those who never had TB before.

Isoniazid preventive therapy use among patients on antiretroviral therapy: a missed opportunity

Isoniazid preventive therapy (IPT) with antiretroviral therapy (ART) reduces incident tuberculosis among patients infected with the human immunodeficiency virus. We describe IPT use among patients on ART at two primary care clinics in South Africa. Of 597 participants interviewed, 100 (16.8%) reported IPT use; 73.4% (365/497) with no reported IPT use were eligible for IPT. IPT use was associated with age <35 years (aOR 1.90, 95%CI 1.18-3.06), and receiving care at one clinic as opposed to the other (aOR 4.72, 95%CI 2.69-7.93). The high proportion of patients on ART eligible for IPT represents a missed opportunity for IPT scale-up.

Willingness to participate in trials and to be vaccinated with new tuberculosis vaccines in HIV-infected adults

BACKGROUND

New tuberculosis (TB) vaccines are required to meet global targets for TB control.

OBJECTIVES

To determine willingness to participate (WTP) in new TB vaccine trials, willingness to be vaccinated with a newly licensed TB vaccine and associated factors among human immunodeficiency virus (HIV) infected persons.

SETTING

Two primary care clinics in South Africa.

DESIGN

Cross-sectional study design. Participants were asked about WTP and willingness to be vaccinated. Demographic, clinical, knowledge of TB and perception of risk information were collected. Log binomial regression was used to determine associated factors.

RESULTS

A total of 827 participants were included in the analysis: 80.4% female, 72.2% on antiretroviral therapy, median age 35 years (interquartile range [IQR] 29-42 years), CD4 count 523 cells/µl (IQR 427-659 cells/µl). WTP and willingness to be vaccinated were high, at 84.5% and 92.6%, respectively. WTP was associated with knowledge about TB (prevalence ratio [PR] 1.10, 95% confidence interval [CI] 1.03-1.17) and perception of risk (PR 1.07, 95%CI 1.01-1.13). Willingness to be vaccinated was associated with employment (PR 1.04, 95%CI 1.01-1.08) and perception of risk (PR 1.05, 95%CI 1.01-1.09).

CONCLUSIONS

There was high WTP in TB vaccine trials and willingness to be vaccinated among HIV-infected patients with good TB knowledge and high perceived risk of contracting TB.

Pooling sputum from multiple individuals for Xpert® MTB/RIF testing: a strategy for screening high-risk populations

SETTING

Symptom-based screening for tuberculosis (TB) disease is limited by poor performance of symptom screening in several key populations. We tested the hypothesis that pooling sputum from multiple individuals for Xpert(®) MTB/RIF testing would reduce the number of tests required while retaining an acceptable sensitivity, thus allowing the use of Xpert for TB screening.

METHODS

We compared pooling ratios that would require the least number of assays using Xpert and determined that for a population with a TB prevalence of approximately 3%, a 1:5 pooling ratio is optimal. To evaluate sensitivity, we generated pools of one specimen with known Mycobacterium tuberculosis culture positivity (smear microscopy-positive or -negative) with four culture-negative specimens.

RESULTS

All 20 of the pools generated from a smear- and culture-positive sputum sample were positive using Xpert. Of the 22 pools with a smear-negative, culture-positive sample, we included 17 in the analysis, of which 13 (76%) were Xpert-positive.

CONCLUSIONS

Pooling of sputum samples using Xpert achieved reasonable sensitivity and warrants further evaluation of the systematic screening of high TB prevalence populations.

How important are human immunodeficiency virus (HIV) clinical markers to the long-term formal employment among people living with HIV in developing countries? A study in South Africa

OBJECTIVE

To examine the relationship of Human Immunodeficiency Virus (HIV) clinical markers and socio-demographic characteristics with long-term formal employment among people living with HIV (PLHIV).

PARTICIPANTS

554 adults, 55% females, on HIV treatment for at least two years at two public hospitals in Johannesburg, South Africa.

METHODS

A retrospective cohort design, tracing changes in study participants' formal employment status since the first HIV-positive diagnosis. Data collection included historical medical records review and interviewer-administered questionnaires.

RESULTS

44% of all study participants (39% and 49% among males and females, respectively) were formally employed at the time of the study, primarily in low-skilled jobs in the private sector. The majority (83%) of males and 60% of females remained in formal employment since being diagnosed as HIV-positive. Female gender, education to grade 12 or higher, a smaller household size and being married were significantly associated with current formal employment. Formal employment was unrelated to HIV treatment indicators (CD4 count, viral load and duration since diagnosis). Of those in formal employment, 68 (28%) were aware of HIV policies at their workplaces, which was also positively associated with the duration in their current employment.

CONCLUSIONS AND RECOMMENDATIONS

PLHIV in developing country contexts can enter into and maintain formal employment, especially when treatment and workplace support are available. Thus, employer organisations should implement effective workplace HIV policies to enhance employment experiences of their workforce living with HIV. Care and support services for people on HIV treatment should also address their career development needs.

A cluster randomised trial to evaluate the effect of optimising TB/HIV integration on patient level outcomes: the "merge" trial protocol

INTRODUCTION

We describe the design of the MERGE trial, a cluster randomised trial, to evaluate the effect of an intervention to optimise TB/HIV service integration on mortality, morbidity and retention in care among newly-diagnosed HIV-positive patients and newly-diagnosed TB patients.

DESIGN

Eighteen primary care clinics were randomised to either intervention or standard of care arms. The intervention comprised activities designed to optimise TB and HIV service integration and supported by two new staff cadres-a TB/HIV integration officer and a TB screening officer-for 24 months. A process evaluation to understand how the intervention was perceived and implemented at the clinics was conducted as part of the trial. Newly-diagnosed HIV-positive patients and newly-diagnosed TB patients were enrolled into the study and followed up through telephonic interviews and case note abstractions at six monthly intervals for up to 18 months in order to measure outcomes. The primary outcomes were incidence of hospitalisations or death among newly diagnosed TB patients, incidence of hospitalisation or death among newly diagnosed HIV-positive patients and retention in care among HIV-positive TB patients. Secondary outcomes of the study included measures of cost-effectiveness.

DISCUSSION

Methodological challenges of the trial such as implementation of a complex multi-faceted health systems intervention, the measurement of integration at baseline and at the end of the study and an evolving standard of care with respect to TB and HIV are discussed. The trial will contribute to understanding whether TB/HIV service integration affects patient outcomes.

An evaluation of 'Ribolola': a household tuberculosis contact tracing programme in North West Province, South Africa

SETTING

Rural/peri-urban community, South Africa.

OBJECTIVES

To examine the yield of tuberculosis (TB) cases, TB preventive therapy (TBPT) initiation and human immunodeficiency virus (HIV) diagnoses from household TB contact tracing.

DESIGN

Retrospective programme analysis.

METHODS

Households of index TB cases were visited and their contacts screened for TB and HIV. TB suspects provided sputum or were referred for assessment. Contacts aged <5 years were referred for assessment for TBPT initiation.

RESULTS

There were 732 index TB cases (67.1% HIV-positive). Among 3627 household contacts, 3573 (98.5%) had known outcomes, of which 183 (5.0%) were already on appropriate treatment. Among 3390 remaining contacts, 361 (10.6%) were aged <5 years, of whom 34 (9.4%) started anti-tuberculosis treatment and 286 (79.2%) started TBPT. Among 3029 contacts aged ≥5 years, 93 (3.1%) started anti-tuberculosis treatment: 19 (20.4%) were smear-positive and 71 (76.3%) were culture-positive. Among contacts aged ≥14 years, 794/2133 (37.2%) underwent HIV testing, of whom 208/794 (26.2%) tested positive.

CONCLUSIONS

Household active case finding in this high TB and HIV prevalence setting obtained high yields of TB, particularly in those aged <5 years, and facilitated assessment for TBPT. There was a good yield of new HIV diagnoses, and a gain in efficiency due to integration within one programme.

Factors influencing uptake of HIV care and treatment among children in South Africa - a qualitative study of caregivers and clinic staff

Despite antiretroviral therapy rollout in South Africa, fewer children than expected are accessing HIV care services. Our objectives were to describe barriers and facilitators of uptake of HIV care among children. Our study involved six private-sector clinics which provide HIV care free-of-charge in and around Gauteng province, South Africa. In-depth interviews were conducted in July 2008 with 21 caregivers of HIV-infected children attending these clinics, 21 clinic staff members and three lead members of staff from affiliated care centres. Many children were only tested for HIV after being recurrently unwell. The main facility-related barriers reported were long queues, negative staff attitudes, missed testing opportunities at healthcare facilities and provider difficulties with paediatric counselling and venesection. Caregivers reported lack of money for transport, food and treatments for opportunistic infections, poor access to welfare grants and lack of coordination amongst multiple caregivers. Misperceptions about HIV, maternal guilt and fear of negative repercussions from disclosure were common. Reported facilitators included measures implemented by clinics to help with transport, support from family and day-care centres/orphanages, and seeing children's health improve on treatment. Participants felt that better public knowledge about HIV would facilitate uptake. Poverty and the implications of children's HIV infection for their families underlie many of these factors. Some staff-related and practical issues may be addressed by improved training and simple measures employed at clinics. However, changing caregiver attitudes may require interventions at both individual and societal levels. Healthcare providers should actively promote HIV testing and care-seeking for children.

Pyeloureteritis cystica

Pyeloureteritis cystica is a rare situation of the renal pelvis and ureters, characterized by cystical formations of the epithelium. The etiology is unknown and there is no specific treatment. It is usually diagnosed accidently during imaging of the upper urinary tract for different reasons. We present a case of pyeloureteritis cystica.

Shockwave lithotripsy and endourological management of urinary calculi in children: a single-center 10-year experience

PURPOSE

Shock wave lithotripsy (SWL) and endourological techniques revolutionized the management of pediatric urolithiasis. We sought to assess the impact of new technology and local practice in the treatment of pediatric urolithiasis during a 10-year period.

MATERIALS AND METHODS

Between 1997 and 2006, 125 children (90 boys and 35 girls), aged 18 months to 15 years, were managed in our department for urolithiasis. Stone localization, stone composition, presence of anatomic abnormalities, and treatment modality were evaluated retrospectively.

RESULTS

In 102 children, the stone was located in renal pelvis (0.5-45-mm diameter), in eight in the renal pelvis and one in the calyx; three had staghorn calculi; and 12 had ureteral stone (4-12-mm diameter). Ninety-three of 125 children underwent a total of 108 SWL sessions. Stone size ranged from 0.5 to 35 mm. The stone-free rates were 86%, 92%, and 96% after first, second, and third SWL session, respectively. Ureteroscopy was performed in 12/125 children, and 10/12 (83.5%) were rendered stone free. Nine of 125 children underwent percutaneous nephrolithotomy, and four of nine were stone free (44.5%), although five of the nine children (55.5%) required SWL for residual stone fragments. Open surgery was performed as initial procedure in 11 (9%) children. In 9 of 11 children, ureteropelvic junction obstruction was corrected simultaneously. Open surgery was followed by SWL in 3 of 11 patients. Two of three patients with staghorn calculi underwent nephrolithotomy and SWL and one of three with cysteinuria was managed with SWL.

CONCLUSIONS

SWL and endourological techniques are safe and effective in managing urolithiasis in pediatric patients. These minimally invasive methods reduced dramatically the cases of open surgery, which should be undertaken mainly in coexisting anatomic abnormalities.

Contribution of reinfection to recurrent tuberculosis in South African gold miners

SETTING

A gold mine in South Africa.

OBJECTIVE

To investigate incidence and risk factors for tuberculosis (TB) recurrence and the relative contribution of reinfection and relapse to recurrence.

DESIGN

Prospective cohort study.

METHODS

Employees cured of a first episode of culture-positive TB were followed up for recurrence, which was classified as reinfection or relapse by restriction fragment length polymorphism using an insertion sequence (IS) 6110 probe.

RESULTS

Among 609 patients, 57 experienced recurrence during a median follow-up period of 1.02 years, corresponding to a recurrence rate of 7.89 per 100 person-years (py). The culture positive recurrence rate was 5.79/100 py, and was higher in human immunodeficiency virus (HIV) infected patients (8.86/100 py in HIV-infected vs. 3.35/100 py in non-HIV-infected). Among HIV-infected patients, the risk of culture-positive recurrence was higher with decreasing CD4 count (compared with CD4 < 200, hazard ratios for recurrence among individuals with CD4 200-500 and CD4 > 500 were 0.40 [95%CI 0.14-1.09] and 0.14 [95%CI 0.02-1.10], respectively, Ptrend = 0.01). IS6110 genotyping was available on both the initial and subsequent isolate for 16/42 (38%, 14 HIV-infected) patients with culture-positive recurrence, and showed reinfection in 11 (69%).

CONCLUSION

HIV-infected gold miners, particularly those who are more immunosuppressed, are at higher risk of TB recurrence. TB control strategies need to take into account reinfection as an important cause of recurrent TB.

Transvaginal vs transobturator approach for synthetic sling placement in patients with stress urinary incontinence

We present comparative short-term experience with the transvaginal (TVT) and the transobturator (TVT-O) approaches for the treatment of stress urinary incontinence (SUI). We studied 315 women with SUI, treated with a tension-free tape placement. The TVT approach was applied in 265 women, while 50 women were treated by the TVT-O approach. The mean operation time was 25 and 17 min in the TVT and TVT-O group, respectively (p<0.001). In the TVT group, continence rates were 87% after 1 year, while in the TVT-O group, the continence rate was 94%. Postoperative pain was reported in 14.4 and 28% of the TVT and TVT-O patients, respectively (p=0.02). Complications such as bladder perforation, retropubic hematoma, and urinary retention took place only in the TVT group. Urinary tract infections were recorded in 20 and 8% of the TVT and TVT-O patients, respectively (p=0.04), while vaginal erosion took place in 1.5 and 2% and de novo urgency in 14 and 8%. Both approaches show high rates of cure at the first postoperative year, while complications are less with the TVT-O procedure.

Establishing a workplace antiretroviral therapy programme in South Africa

Ways to expand access to antiretroviral treatment (ART) in low income settings are being sought. We describe an HIV care programme including ART in an industrial setting in South Africa. The programme uses guidelines derived from local and international best practice. The training component aims to build capacity among health care staff. Nurses and doctors are supported by experienced HIV clinicians through telephone consultation and site visits. Patients undergo a three-stage counselling procedure prior to starting ART. Drug regimens and monitoring are standardised and prophylaxis against opportunistic infections (isoniazid and cotrimoxazole) is offered routinely. Laboratory and pharmacy services, using named-patient dispensing, are centralized. The programme is designed to ensure that data on clinical and economic outcomes will be available for programme evaluation. Between November 2002-December 2004, ART delivery has been established at 70 ART workplace ART sites. The sites range from 200 to 12000 employees, and from small occupational health clinics and general practitioner rooms to larger hospital clinics. During this period, 2456 patients began ART. Of those on treatment for at least three months, 1728 (78%) have been retained on the programme and only 38 (1.7%) patients have failed the first-line ART regimen. This model for delivery of ART is feasible and successful in an industrial setting. The model may be generalizable to other employment health services in settings of high HIV prevalence, and as a model for implementing ART in other types of health-care settings.

Evaluation of antiretroviral therapy (ART)-related counselling in a workplace-based ART implementation programme, South Africa

Counselling about antiretroviral therapy (ART) is thought important to prepare patients for treatment and enhance adherence. A workplace-based HIV care programme in South Africa instituted a three-step ART counselling protocol with guidelines prompting issues to be covered at each step. We carried out an early evaluation of ART counselling to determine whether patients understood key information about ART, and the perceptions that patients and health care professionals (HCP) had of the process. Among 40 patients (median time on ART 83 days), over 90% answered 6/7 HIV/ART knowledge-related questions correctly. 95% thought counselling sessions were good. 93% thought ongoing counselling was important. Recommendations included the need for continuing education about HIV/ART, being respectful, promoting HIV testing and addressing the issues of infected partners and stigma. 24 participating HCP identified additional training needs including counselling of family and friends, family planning, sexually transmitted infections and running support groups. 90% of HCP thought that counselling guidelines were helpful. The programme appears to be preparing patients well for ART. Counselling should be offered at every clinic visit. Counselling guidelines were a valuable tool and may be useful elsewhere. The evaluation helped to assess the quality of the programme and to suggest areas for improvement.

Tension-free vaginal tape for the treatment of stress urinary incontinence in geriatric patients

OBJECTIVE

To evaluate the safety and efficacy of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence (SUI) in geriatric patients.

PATIENTS AND METHODS

Fifty-one women, aged 65-80 (mean 72.3) years, underwent a TVT procedure for genuine SUI from 2001 to 2004. A urodynamic test together with uroflowmetry were performed. The patients' SUI bother score was assessed using a visual analog scale (VAS).

RESULTS

The mean operative time was 25 (range 14-29) min and mean hospitalization time was 1.2 (range 1-2) days. Bladder perforation occurred in 3 cases (5.8%) and was managed conservatively. Pre- and postoperative maximum flow rate were not significantly different (p > 0.05). The patients' SUI bother score estimated by the VAS was statistically significantly improved (p < 0.0001). After a mean follow-up of 35.6 (range 14-60) months, 49 patients (96%) had no SUI, while 2 patients (3.9%) had persistent SUI. Also, during the follow-up 5 patients (9.8%) were diagnosed with de novo urgency due to detrusor overactivity and 1 patient (1.9%) had persistent dysuria that was resolved with urethrolysis.

CONCLUSIONS

SUI in elderly women can be safely treated with the TVT procedure in the vast majority of the patients. However, bladder perforation during surgery and de novo urgency postoperatively should be taken into account.

Screening for tuberculosis prior to isoniazid preventive therapy among HIV-infected gold miners in South Africa

SETTING

Human immunodeficiency virus (HIV) clinic for employees of a gold mine, Free State, South Africa.

OBJECTIVE

To evaluate the process of screening for active tuberculosis (TB) prior to commencing TB preventive therapy in HIV-infected individuals.

DESIGN

Cross-sectional study comparing performance of various combinations of screening tests for TB against a gold standard diagnosis of TB based on symptoms, chest radiograph (CXR), sputum microscopy and culture.

RESULTS

Of 899 individuals, 44 (4.9%) had TB. The most sensitive symptom combination (59.1%) was any of night sweats, new or worsening cough or reported weight loss; measured weight loss > 5% or abnormal CXR increased sensitivity to 90.9%. Sputum microscopy did not increase sensitivity further, but including World Health Organization HIV clinical staging or CD4 count did. As the specificity of all these combinations was low, many individuals required further investigation to rule out TB. TB prevalence was high (11.7%) among individuals with a CD4 count < 200/mm3.

CONCLUSION

CXR greatly increased the sensitivity of screening for TB in this population. Sputum microscopy conferred no additional benefit among asymptomatic patients with a normal CXR. The high prevalence of TB amongst those with a low CD4 count underlines the importance of screening for active TB prior to commencing TB preventive therapy, and before antiretroviral therapy.

Management of nocturnal enuresis in Greek children

Our experiences of managing nocturnal enuresis in Greek children at our Outpatient Clinics of Pediatric Urology are described. Between March 2001 and October 2003, 142 children with primary nocturnal enuresis (93 boys and 49 girls), aged 7-18 years old (mean: 9.0+/-0.5) were included in this prospective study. Initially, behavioral conditioning therapy, using a body-worn urinary alarm, was instructed in all cases. If no improvement was recorded, 40 microg of intranasal desmopressin was administered, initially for three months. If urodynamic studies demonstrated pure detrusor instability, anticholinergics (5 mg oxybutinine or 2 mg tolterodine) were given instead. Combination medication (desmopressin and anticholinergics) was administered for coexisting diurnal enuresis, which was present in 8 children. Among the 142 children the overall response rate was 51.41%. Successful response was recorded in 16 children practicing conditioning behavioral therapy, in 47 receiving desmopressin (with or without anticholinergics), and in 10 children receiving only anticholinergics. During the follow-up period (mean: 6.2 months), no serious side effect was recorded. The use of desmopressin, and anticholinergics in specific subgroups, was found to be effective and safe for the management of nocturnal enuresis in children.

Feasibility and acceptability of a specialist clinical service for HIV-infected mineworkers in South Africa

Occupational settings offer an ideal opportunity to provide preventive health services for HIV-infected workers. A specialized clinic was established in a mining hospital in the Free State, South Africa, with the primary aim of delivering preventive therapy such as isoniazid to those at high risk of tuberculosis (individuals with HIV infection or silicosis), and cotrimoxazole to those at highest risk for opportunistic infections. The clinic design has taken regard of the importance of minimizing stigma, protecting confidentiality, monitoring potential side effects, supporting adherence and identification of prophylaxis failure. The clinic opened in April 1999 and, by August 2001, 1773 patients had attended at least once; 1762 are HIV-infected and 11 have silicosis. Of those with HIV infection, most were asymptomatic at their first visit. The clinic has achieved high acceptability: 99% of persons who were actively recruited to the service agreed to attend. The number still attending after a median of 13 months from recruitment was 1,270 (72%) and only 48 (2.7%) have declined continued attendance. Most losses were due to termination of employment unrelated to a medical condition. The clinic has already been successfully replicated in two other regions of the mining health service in South Africa and provides a model for workplace HIV clinical services that could be used for implementation of further interventions such as antiretroviral therapy.

Use of spoligotyping for accurate classification of recurrent tuberculosis

The spoligotyping method has become an important tool for the tracking of Mycobacterium tuberculosis strains in different epidemiological settings. In this study, we demonstrate the ability of the spoligotyping technique to accurately determine the pathogenetic mechanism of recurrent disease. This methodology has advantages over conventional restriction fragment length polymorphism methods which may be useful in large-scale intervention studies.

Persistent radiological changes following miliary tuberculosis in miners exposed to silica dust

SETTING

Silicosis leads to increased susceptibility to tuberculosis, but it has also been suggested that tuberculosis may interact with intra-pulmonary silica to exacerbate fibrotic lung disease.

OBJECTIVES

To investigate the possibility that silicosis developed due to or was exacerbated by tuberculosis.

METHODS

In a case series of 15 miners presenting with culture-positive miliary tuberculosis, serial radiographs taken premorbidly, at presentation, and after 2 and 6 months of standard anti-tuberculosis treatment were graded for nodularity using the International Labour Organization system.

RESULTS

Increased nodule profusion (compared to premorbid film) remained in 13 (87%) and eight (53%) patients after 2 and 6 months of treatment, respectively, despite clinical improvement in all and documented bacteriological cure in eight (53%). These phenomena, observed irrespective of human immunodeficiency virus (HIV) status, were most pronounced in men with minor premorbid changes. Abnormal pulmonary collagenisation related to silica particles was apparent at post-mortem in two men who died of HIV-associated cryptococcosis after completing TB treatment.

CONCLUSIONS

Previous silica exposure appears to result in delayed and potentially incomplete radiological resolution of miliary TB. We postulate that the immune response in tubercles may evoke a 'bystander' fibrotic response, as cytokines play a central role in the pathogenesis of both TB and silicosis.

Indoor radon concentrations in Greek apartment dwellings

Radon concentrations indoors were determined in 24 typical occupied apartments in the city of Thessaloniki, North Greece (40 degrees 38'N, 22 degrees 58'E), by means of 12 surveys, each 2 mo long, over a 2-y period starting October 1989. The ratio of the winter and summer averages for the first year of measurements was 1.8 +/- 0.78, and for the second year of measurements was 1.6 +/- 0.61. The indoor radon concentration in the summer (1990) period ranged between 8 and 81 Bq m-3, while in the winter (1989-1990) it ranged between 20 and 143 Bq m-3 for the first year of measurements or between 8 and 92 Bq m-3 in the summer (1991) period and between 12 and 119 Bq m-3 in the winter (1990-1991) for the second year of measurements. These results were obtained by type CN-85 alpha track detectors. Some parameters that influenced the concentrations, such as precipitation rates and use of fly ash in building materials, are discussed.

Dose rate dependence on the response of CR-39 SSNT-detector

The dose rate dependence on the response of CR-39 SSNT-Detector was examined. The dose rate region studied was 10(2)-10(6) rad/min for doses 0 up to 1 Mrad. For relatively low and high dose rates a drop in the response of the detector was observed. The behavior changes for low doses and above 1 Mrad. The contribution of recombination and degradation mechanisms on the observed behavior was discussed.

A simplified procedure for the observation in situ of chromosome aberrations or sister chromatid exchanges and the estimation of the mitotic index in mammalian monolayer cell cultures

Chinese hamster V-79 cells are widely used in short term screening for potential physical or chemical mutagens of the environment. A simplified version of the standard Giemsa protocol of Moorhead and the Feulgen plus Giemsa protocol of Wolff and Perry is given which permits the observations in situ of chromosome aberrations or sister chromatid exchanges and the estimation of the mitotic index in the Petri dishes for the culture of the V-79 cells.

On the escaping radioactivity from coal power plants (CPP)

The escaping radioactivity from Greek coal power plants (CPP) was studied. For the case studied the radioactivity is due to the uranium series. The major part (99%) escapes as very fine particles, while the rest is fly ash. The total escaping 226Ra activity is of the order of 40 Ci/yr. The particulate dispersion of fly ash in sites around the stacks of CPP is described. The hazards from the escaping radioactivity are evaluated.