Provision of HIV testing services and its impact on the HIV positivity rate in the public health sector in KwaZulu-Natal: a ten-year review

South Africa has been rated as having the most severe HIV epidemic in the world since it has one of the largest populations of people living with HIV (PLHIV). KwaZulu-Natal (KZN) is the epicentre of the HIV epidemic. The HIV test and treat services in the public health sector are critical to managing the epidemic and responding to the increase in HIV infections. The KwaZulu-Natal Department of Health (DOH) commissioned a review of the provision of HIV testing services in the province and aimed to investigate its impact on the HIV positivity rate over a ten-year period. The study was an ecological study design using data extracted from the Department's District Health Information System (DHIS). Descriptive analysis was conducted in addition to ANOVA and multiple regression analysis. The results of this study have shown that the total number of HIV tests conducted over the ten-year period in the province has increased with the highest number of HIV tests being conducted in the 2018/2019 MTEF year. ANOVA analysis indicates that there was a statistically significant difference in the total number of HIV tests conducted and the number of HIV tests per 100 000 population across the province's 11 districts (p < 0.001). Statistically significant differences were observed in the HIV testing rate and in the HIV positivity rate over the period (p < 0.001). Results from multiple regression analysis showed that the HIV testing rate per 100 000 population was the strongest predictor of the HIV positivity rate. HIV positivity among clients correlated negatively with the number of HIV tests conducted per 100 000 population (r = -0.823; p < 0.001) and the HIV testing rate (r = -0.324; p < 0.01). This study has found that HIV testing could have an impact on reducing the positivity rate of HIV in the province and is therefore an effective strategy in curbing the HIV epidemic. The KwaZulu-Natal Department of Health should ensure that strategies for implementing and maintaining HIV testing and treating services should continue at an accelerated rate in order to achieve the first 95 of the UNAIDS 2025 SDG target.

Tracking the Trauma Epidemic in KwaZulu-Natal, South Africa

BACKGROUND

Trauma remains an important cause of morbidity and mortality in South Africa, but attempts to track the epidemic are often based on mortality data, or derived from individual health facilities. This project is based on the routine collection of trauma data from all public health facilities in the province of KwaZulu-Natal (KZN), between 2012 and 2022.

METHODS

Hospital level data on trauma over the past ten years was drawn from the district health information system (DHIS). Data relating to assaults, gunshots and motor vehicle collisions (MVCs) were recorded in the emergency rooms, whilst data on admissions are recorded in the wards and intensive care units.

RESULTS

There were 1,263,847 emergency room visits for assaults, gunshots and MVCs over the ten-year period and trauma admissions ranged between four and five percent of the total number of hospital admissions annually. There was a dramatic decrease in trauma presentations and admissions over 2020/2021 as a result of the COVID lockdowns. Over the entire period, intentional injury was roughly twice as frequent as non-intentional injury. Intentional trauma had an almost equal ratio of blunt assault to penetrating assault. Gunshot-related assault increased dramatically over the 2021/2022 collecting period.

CONCLUSIONS

The burden of trauma in KZN remains high. The unique feature of this burden is the excessively high rate of intentional trauma in the form of both blunt and penetrating mechanisms. Developing injury-prevention strategies to reduce the burden of interpersonal violence is more difficult than for unintentional trauma.

Operational manager's knowledge and attitudes toward data and universal health coverage indicators in primary health clinics in Ugu, South Africa

Universal health coverage (UHC) aims to ensure people have access to the health services they need. Sixteen tracer indicators were developed for implementation by countries to measure UHC in the health system. South Africa uses 15 of the proposed 16 indicators. Operational managers in the public health care sector collect data and report on these indicators at a primary health clinic level. This qualitative study explored the knowledge and attitudes of managers toward data and UHC service indicators in a sub-district in Ugu, KwaZulu-Natal, South Africa. Operational managers saw data collection as information gathering, measuring performance and driving action. They understood UHC indicators as 'health for all' linking them to National Department of Health Strategic plans and saw the value of indicators for health promotion. They found the lack of training, inadequate numeracy skills, requests for data from multiple spheres of government and the indicator targets that they had to reach as challenging and untenable. While operational managers made the link between data, measuring performance and action, the limited training, skills gaps and pressures from higher levels of government may impede their ability to use data for local level planning and decision making.

Risk factors for COVID-19-related in-hospital mortality in a high HIV and tuberculosis prevalence setting in South Africa: a cohort study

Background

The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15–49 years and a tuberculosis prevalence of 0·7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19.

Methods

In this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality.

Findings

Among the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23·3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37·4%) of 163 350, diabetes in 43 885 (27·4%) of 159 932, and HIV in 13 793 (9·1%) of 151 779. Tuberculosis was reported in 5282 (3·6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1·34, 95% CI 1·27–1·43), past tuberculosis (1·26, 1·15–1·38), current tuberculosis (1·42, 1·22–1·64), and both past and current tuberculosis (1·48, 1·32–1·67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1·45, 95% CI 1·22–1·72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29·2% compared with 30·8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased COVID-19 in-hospital mortality risk in both people with HIV and HIV-uninfected individuals.

Interpretation

Individuals identified as being at high risk of COVID-19 in-hospital mortality (older individuals and those with chronic comorbidities and people with HIV, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation as well as early referral and treatment.

Funding

South African National Government.

'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.

A hospital based surveillance system to assess the burden of trauma in KwaZulu-Natal Province South Africa

INTRODUCTION

In response to the ongoing excessive burden of trauma in South Africa the Data Management and Epidemiology Units of the Department of Health in conjunction with a group of trauma specialists developed a number of trauma data variables for inclusion on the routine District Health Information System (DHIS). The aim of this study is to describe the process followed and review the 2012-2014 data.

METHODOLOGY

The variables collected included: total patient numbers assessed in the emergency room with a diagnosis of trauma; the mechanisms of trauma (blunt assault, motor vehicle accident, pedestrian vehicle accident, stab, gunshot wound, other); any trauma patient admitted to a health facility ward/ICU for longer than 12h; and whether the patient required transfer to a higher centre of care. All trauma deaths in hospital were recorded. The severity of trauma was measured using the Emergency Medical Services (EMS) classification of blue code (dead), red code (stretcher case with deranged physiology), yellow code (stretcher case with normal physiology) and green code (able to walk with normal physiology. The DHIS trauma data from April 2012 to March 2014 was reviewed.

RESULTS

There were 197,219 emergency room visits for trauma in KZN in the 2013/2014 financial year. This constitutes 27.0% of all emergency room visits. The ratio of intentional to non-intentional injury is 45:55. There were 18,716 admissions to public sector hospitals for trauma in KZN in the 2013/2014 financial year. This constitutes 2.4% of all admissions in the province. There were 1045 inpatient deaths due to trauma in the same period, constituting 2.5% of all inpatient deaths. The overall rate of trauma in KZN was 17 per 1000 population.

CONCLUSION

The adapted DHIS has successfully collected essential data that quantify the hospital burden of trauma in KZN province. This has provided the most complete overview of the burden of trauma in the Province. These trauma indicators should remain a permanent part of the DHIS to allow planners to track the trauma epidemic and to institute informed management strategies.

Heavy metal contamination in a school vegetable garden in Johannesburg

BACKGROUND

Feeding schemes based on school garden produce have been proposed as an effective solution to food insecurity and hunger among learners in South Africa. However, few studies have looked at the potential contamination of school food gardens when situated near mine tailing dams.

OBJECTIVES

The aim of the study was to evaluate the potential heavy metal contamination in a school vegetable garden in Johannesburg.

METHODS

Twenty soil samples were collected from the study school and a comparison school. Surface and deep (±10 cm beneath the surface) soil samples were analysed using X-ray fluorescence for levels of arsenic, chromium, copper, lead and zinc. Thirteen vegetables samples were collected from the school garden, and compared with six samples from a national retailer and four obtained from a private organic garden. The heavy metal concentrations of the vegetable samples were analysed in the laboratories of the South African Agricultural Research Council.

RESULTS

High levels of arsenic were found in the school soil samples, and elevated concentrations of lead and mercury in the school vegetables. Calculation of the estimated daily intake for a child of 30 kg however, indicated that levels of lead, mercury and arsenic in vegetables were within acceptable limits. However, the levels of lead in the vegetable samples were high across all three sites.

CONCLUSION

Further investigation and research should be undertaken to assess the source/s and extent of public exposure to heavy metals in vegetables in South Africa.

NK2 receptors mediate tachykinin-induced contractions of rat uterus during the oestrous cycle

We examined tachykinin-induced contractions of uteri from rats during the oestrous cycle. The potencies of substance P, neurokinin A, neurokinin B and the tachykinin NK2 receptor-selective agonist, [Lys5, MeLeu9, Nle10] neurokinin A-(4-10), and of the non-peptide tachykinin NK1, NK2 and NK3 receptor antagonists (S)1-[2-[3-(3,4-dichlorophenyl)-1-(3-isopropoxyphenylacetyl)pip eridin-3-yl]ethyl]-4phenyl-1-azonia-bicyclo[2.2.2]octane (SR 140333), (S)-N-methyl-N [4-(4-acetylamino-4-phenylpiperidino)-2-(3,4-dichlorophenyl)butyl]benzam ide (SR 48968) and (S)-(N)-(1-(3-(1-benzoyl-3-(3,4-dichlorophenyl)piperidin-3-yl)prop yl)-4-phenylpiperidin-4-yl)-N-methylacetamide (SR 142801), were examined. The relative agonist potencies, i.e., [Lys5, MeLeu9, Nle10] neurokinin A-(4-10) > or = neurokinin A > neurokinin B > or = substance P were similar in preparations from rats in dioestrus/metoestrus and those in proestrus/oestrus. Apparent pK(B) values for SR 48968 versus neurokinin A and [Lys5, MeLeu9, Nle10] neurokinin A-(4-10), were 9.9 and 9.2, respectively, indicating activation of an NK2 receptor. SR 140333 (10 nM) produced only a small rightward shift of the log concentration-response curve to substance P. SR 48968 (3 nM), but not SR 142801 (100-300 nM) reduced the effect of neurokinin B. These data indicate that in the rat tachykinin-induced contractions of the uteri during the oestrous cycle are mediated primarily by tachykinin NK2 receptors, and that fluctuations in ovarian hormonal levels during the oestrous cycle have little influence on the uterine response to tachykinins.

Comparison of passive haemagglutination test with Widal agglutination test for serological diagnosis of typhoid fever in an endemic area

A passive haemagglutination test, using sheep red blood cells sensitised with Salmonella typhi lipopolysaccharide, was compared with the Widal test for the serological diagnosis of typhoid fever in an endemic area. The results obtained on sera from 152 patients with bacteriologically confirmed typhoid and 183 patients who did not have typhoid were analysed in terms of sensitivity, specificity, simplicity, and rapidity of the respective tests. The passive haemagglutination test was found to be more sensitive (80%) than the S typhi O antigen (71%) but marginally less sensitive than the H antigen (82%) of the Widal test. The false positive rate on control sera was 1.2% and 6.6%, respectively, for the Widal O and H antigens, and 1.6% for the passive haemagglutination test. Our findings indicate that the passive haemagglutination test is comparable with the Widal test for the serological diagnosis of typhoid fever in endemic areas, but is more simple, rapid, and economic. The passive haemagglutination test may be a useful alternative to the Widal test for the serological diagnosis of typhoid fever in busy microbiology laboratories in areas in which the disease is endemic.

Binding of DNA to albumin and transferrin modified by treatment with water-soluble carbodiimides

N-Acylurea derivatives of albumin and transferrin prepared with the water-soluble carbodiimides N-ethyl-N'-(3-dimethylaminopropyl)carbodiimide and N-ethyl-N'-(3-trimethylpropylammonium)carbodiimide iodide have been found to bind different types of DNA. The two proteins were reacted with varying amounts of carbodiimide in water at pH 5.5 for 36-60 hr at 20 degrees, and then purified. In the case of iron-loaded transferrin, reactions with carbodiimides were in phosphate-buffered saline (pH 7.5) to prevent loss of iron from the protein. [3H]N-Ethyl-N'-(3-trimethylpropylammonium)carbodiimide iodide was used for the determination of covalently attached N-acylurea groups in the modified proteins, and gel electrophoresis for changes in charge and possible aggregation through cross-linking. Binding of DNA to N-acylurea proteins was studied by means of gel electrophoresis and nitrocellulose filter binding. N-Acylurea albumin and N-acylurea transferrin at low concentrations retarded the migration of lambda-Pstl restriction fragments, pBR322 plasmid and M13 mp8 single-stranded DNA on agarose gels, while at higher concentrations of modified protein the N-acylurea protein-DNA complexes were unable to enter the gel. Nitrocellulose filter assays showed that binding pBR322 DNA and calf thymus DNA to N-acylurea proteins is rapid and dependent on protein concentration and the ionic strength of the medium. N-Acylurea albumins prepared with each each of the two carbodiimides gave comparable plots for DNA bound versus protein concentration. On the other hand, binding of DNA by N-acylurea transferrins differed according to the carbodiimide used in the synthesis. N-Acylurea CDI-tkransferrin (prepared with tertiary carbodiimide) was less effective than either of the two N-acylurea albumins in binding DNA. In contrast with these results, N-acylurea Me+-CDI-transferrin (prepared with quaternary carbodiimide) was far more effective in binding DNA and in this respect was similar to the N-acylurea albumins. On the basis of experiments in which N-acylurea protein-DNA complexes were treated with heparin, two types of binding could be distinguished. These were a weak binding occurring in the initial stages of interaction and a tight binding which developed on further incubation of the complexes. These studies show that binding of DNA by N-acylurea proteins is a reversible process dependent on ionic strength; interaction appears to be electrostatic in nature, although other forms of binding might be involved.(ABSTRACT TRUNCATED AT 400 WORDS)