OpenUCT :: Browsing by Author "Coetzee, David"

Browsing by Author "Coetzee, David"

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Open Access
Access to care in people living with HIV
(2012) Du Toit, Elizabeth; Coetzee, David; Beyers, Nulda
South Africa has the most people living with HIV (PLWH) in the world. With increased access to HIV Counselling and Testing (HCT) as well as expanded Antiretroviral Therapy (ART) treatment guidelines; there is a large and increasing number of people who need access to HIV care. Limited data and few studies have evaluated access to HIV care. A cross sectional survey with stratified random sampling was conductedfrom January â€“ April 2011 to determine the proportion of PLWH in urban areas in thegreater Cape Town area who are accessing appropriate HIV care and factors associatedwith accessing care. The sampling frame for this study was the Zambia South Africa TBand AIDS Reduction (ZAMSTAR) Study. Self reported HIV positive adults were randomly selected. Self reported HIV negative adults or adults of unknown HIV status were also randomly selected in order to decrease possible stigmatisation. Consenting participants were interviewed and completed a questionnaire detailing their access to HIV testing and care. Participants who disclosed that they were HIV positive were included in the analysis. Access to appropriate HIV care was defined as one of three scenarios: 1. Receiving ART and having attended an ART clinic or collected ART medication within the last three months. 2. Undergoing ART work up and having attended an ART clinic within the last three months. 3. In PreART care having had a CD4 count in the last 6 months. 1257 participants were interviewed. 627(50%) reported being HIV positive, 487(39%) HIV negative and 143(11%) did not know or wish to disclose their status. Of the 627 HIV positive participants: 392 (63%) reported taking ART of whom 369 (94%) accessed appropriate HIV care. 25 (4 %) were being worked up for ART of whom 16 (64%) accessed appropriate HIV care. 210 (33%) were in PreART care, 81 (39%) having accessed appropriate HIV care. Females were 3.78 times more likely to be in appropriate care than males (p <0.001), and a person in the age category greater than 45 years was 4.63 times more likely to be in appropriate care than someone in the age category 15-24 (p= 0.002).
Open Access
Completion of isoniazid preventive therapy and factors associated with non-completion in an antiretroviral therapy-naive HIV-infected cohort in Cape Town by Tolu Oni.
(2012) Oni, Tolu; Coetzee, David
TB incidence in South Africa remains high, despite high rates of successful treatment suggesting ongoing transmission and a large reservoir of latently infected persons. Isoniazid preventive therapy (IPT) is recommended as preventive therapy in HIV-infected persons. However, implementation has been slow, impeded by barriers and challenges including the fear of non-adherence. A protocol was therefore written to conduct a study to measure IPT completion rates and evaluate predictors of non-completion of a six-month IPT course in Khayelitsha, an informal township in Cape Town. Prior to data analysis, a structured literature review was conducted to assess available evidence particularly from high-burden settings on IPT completion rates and factors associated with loss to follow up.
Open Access
Correcting for mortality among patients lost to follow up on antiretroviral therapy in South Africa: a cohort analysis
(Public Library of Science, 2011) Van Cutsem, Gilles; Ford, Nathan; Hildebrand, Katherine; Goemaere, Eric; Mathee, Shaheed; Abrahams, Musaed; Coetzee, David; Boulle, Andrew
BACKGROUND: Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system. Methods and FINDINGS: We included 6411 patients enrolled on ART between March 2001 and June 2007. Patients LTF with available civil identification numbers were matched with the national vital registration system to ascertain vital status. Corrected mortality and true LTF were determined by weighting these patients to represent all patients LTF. We used Kaplan-Meier estimates and Cox regression to describe LTF, mortality among those LTF, and true LTF. Of 627 patients LTF, 85 (28.8%) had died within 3 months after their last clinic visits. Respective estimates of LTF before and after correction for mortality were 6.9% (95% confidence interval [CI] 6.2-7.6) and 4.3% (95% CI 3.5-5.3) at one year on ART, and 23.9% (95% CI 21.0-27.2) and 19.7% (95% CI 16.1-23.7) at 5 years. After correction for mortality, the hazard of LTF was reversed from decreasing to increasing with time on ART. Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF. Mortality of patients LTF at 1, 12 and 24 months after their last visits was respectively 23.1%, 30.9% and 43.8%; 78.0% of deaths occurred during the first 3 months after last visit and 45.0% in patients on ART for 0 to 3 months. CONCLUSIONS: Mortality of patients LTF was high and occurred early after last clinic visit, especially in patients recently started on ART. Correction for these misclassified deaths revealed that the risk of true LTF increased over time. Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.
Open Access
Differences in antiretroviral scale up in three South African provinces: the role of implementation management
(BioMed Central Ltd, 2010) Schneider, Helen; Coetzee, David; Van Rensburg, Dingie; Gilson, Lucy
BACKGROUND:South Africa's antiretroviral programme is governed by defined national plans, establishing treatment targets and providing funding through ring-fenced conditional grants. However, in terms of the country's quasi-federal constitution, provincial governments bear the main responsibility for provision of health care, and have a certain amount of autonomy and therefore choice in the way their HIV/AIDS programmes are implemented. METHODS: The paper is a comparative case study of the early management of ART scale up in three South African provincial governments - Western Cape, Gauteng and Free State - focusing on both operational and strategic dimensions. Drawing on surveys of models of ART care and analyses of the policy process conducted in the three provinces between 2005 and 2007, as well as a considerable body of grey and indexed literature on ART scale up in South Africa, it draws links between implementation processes and variations in provincial ART coverage (low, medium and high) achieved in the three provinces. RESULTS: While they adopted similar chronic disease care approaches, the provinces differed with respect to political and managerial leadership of the programme, programme design, the balance between central standardisation and local flexibility, the effectiveness of monitoring and evaluation systems, and the nature and extent of external support and programme partnerships. CONCLUSIONS: This case study points to the importance of sub-national programme processes and the influence of factors other than financing or human resource capacity, in understanding intervention scale up.
Open Access
Drug-drug interactions between antiretrovirals and bedaquiline
(2017) Pandie, Mishal; Coetzee, David
Tuberculosis (TB) is a leading cause of morbidity and mortality worldwide. People living with HIV are particularly susceptible to TB infection, and treatment of HIV-TB co-infection is challenging for multiple reasons, including potential drug-interactions. Drug-resistant TB is difficult to treat and is associated with high treatment failure rates, mainly because the antimycobacterial drugs currently available are ineffective against drug-resistant TB. Bedaquiline is a new antimycobacterial drug which has shown great promise through its excellent efficacy for treating drug-resistant TB. Being a new drug, however, potential drug interactions with antiretrovirals are a major concern. Bedaquiline is metabolized in the liver by an enzyme called cytochrome P450 3A (CYP3A). The antiretrovirals nevirapine, efavirenz, and lopinavir/ritonavir (LPV/r) can affect the activity of this enzyme, and consequently affect the concentration of bedaquiline in the patient's blood. Nevirapine and efavirenz increase the activity of CYP3A, which may result in increased metabolism of bedaquiline, thus decreasing the concentration of bedaquiline, with consequent risk of treatment failure or the further development of drug-resistance. LPV/r inhibits the CYP3A enzyme, which may result in decreased bedaquiline metabolism, thus causing high concentration of bedaquiline in the blood, with consequent risk of toxicity. We conducted a pharmacokinetic study in 43 adult patients with drug-resistant TB to evaluate the drug-interactions between bedaquiline and the antiretrovirals nevirapine and LPV/r. We did serial measurements of the bedaquiline concentration in their plasma over 48 hours, and compared these concentrations in patients who were on antiretroviral and those who were not on antiretrovirals. Our results showed that nevirapine had no significant effect on bedaquiline concentrations, while patients on LPV/r had bedaquiline concentrations 2 fold higher than patients not on antiretrovirals. We could not determine the clinical significance of this, but recommend that patients receiving LPV/r and bedaquiline in combination must be closely monitored for side-effects.
Open Access
The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study
(Public Library of Science, 2012) Kerschberger, Bernhard; Hilderbrand, Katherine; Boulle, Andrew M; Coetzee, David; Goemaere, Eric; Azevedo, Virginia De; Cutsem, Gilles Van
BACKGROUND: Studies have shown that early ART initiation in TB/HIV co-infected patients lowers mortality. One way to implement earlier ART commencement could be through integration of TB and HIV services, a more efficient model of care than separate, vertical programs. We present a model of full TB/HIV integration and estimate its effect on time to initiation of ART. METHODOLOGY/PRINCIPAL FINDINGS: We retrospectively reviewed TB registers and clinical notes of 209 TB/HIV co-infected adults with a CD4 count <250 cells/µl and registered for TB treatment at one primary care clinic in a South African township between June 2008 and May 2009. Using Kaplan-Meier and Cox proportional hazard analysis, we compared time between initiation of TB treatment and ART for the periods before and after full, "one-stop shop" integration of TB and HIV services (in December 2009). Potential confounders were determined a priori through directed acyclic graphs. Robustness of assumptions was investigated by sensitivity analyses. The analysis included 188 patients (100 pre- and 88 post-integration), yielding 56 person-years of observation. Baseline characteristics of the two groups were similar. Median time to ART initiation decreased from 147 days (95% confidence interval [CI] 85-188) before integration of services to 75 days (95% CI 52-119) post-integration. In adjusted analyses, patients attending the clinic post-integration were 1.60 times (95% CI 1.11-2.29) more likely to have started ART relative to the pre-integration period. Sensitivity analyses supported these findings. Conclusions/Significance Full TB/HIV care integration is feasible and led to a 60% increased chance of co-infected patients starting ART, while reducing time to ART initiation by an average of 72 days. Although these estimates should be confirmed through larger studies, they suggest that scale-up of full TB/HIV service integration in high TB/HIV prevalence settings may shorten time to ART initiation, which might reduce excess mortality and morbidity.
Open Access
Effect of counselling and condom provision on sexual behaviour of heterosexual HIV discordant couples as part of an HIV prevention trial South Africa
(2011) Namale, Phiona Enid; Coetzee, David
South Africa as a country has a high HIV prevalence. Due to the fact that HIV transmission is predominantly heterosexual, HIV discordant couples are a high risk group for HIV. A number of HIV prevention interventions have been targeted at HIV discordant couples including HIV testing and counselling. An HIV prevention trial assessing the efficacy of daily acyclovir on HIV transmission among heterosexual HIV discordant couples was undertaken in South Africa. We conducted a before and after study with the aim of evaluating the effect of HIV counselling and condom provision on sexual behaviour of the heterosexual HIV discordant couples enrolled in this prevention trial.
Open Access
The effectiveness of PMTCT in the Free State - An anonymously linked cord blood survey
(2010) Amoo, Marian Ama; Coetzee, David
[ Background ] PMTCT has become freely available in many African countries however the impact of these interventions at the population level has not been widely estimated. [ Aim ] The aim of this study was to estimate the proportion of HIV infected/exposed mother and infant pairs who received the appropriate prophylaxis. [ Methods ] Cord blood specimens were collected anonymously from women delivering in 10 facilities in the Free State from November 2007 to April 2008. Collected specimens were tested for antibodies to HIV. Specimens found to be seropositive were tested for the presence of nevirapine using chromatography. All PMTCT sites used single dose nevirapine as the minimum prophylaxis, a few used dual therapy including zidovudine and nevirapine and some included nevirapine-based HAART for eligible women. Information was also collected from the clinical records. Maternal PMTCT coverage was determined through cord blood chromatography and infant coverage was determined from documentation of receipt on the clinical records. [ Results ] 1619 specimens were collected from women who gave birth to live infants were collected and tested (3.6% collection rate). 472 specimens tested positive for HIV antibodies on cord blood testing giving an HIV prevalence of 29.2% (95% CI 26.9-31.4%). Only 45.8% (95% CI 41.2-50.4%) of the 472 live infants born to HIV-infected mothers received both the maternal and infant doses of ARV prophylaxis. Reasons for failed dosing included, pre-test counseling not offered, refused testing, positive test resultnot received, prophylaxis was not dispensed, mother did not adhere and infant did not receive the prophylaxis dose. [ Conclusion ] This study showed that coverage in the Free State Province is poor despite the national expansion of PMTCT services to all antenatal sites. Failures occurred at each step of the PMTCT cascade and resulted in low coverage. Interventions should be introduced at each step of the PMTCT cascade to increase coverage.
Open Access
The effectiveness of PMTCT programmes through the measurement of NVP coverage in populations of women delivering in designated areas in the Western Cape Region of South Africa
(2010) Tabana, Hanani; Coetzee, David
[Objective] The objective was to assess the uptake and coverage of SD-NVP to prevent mother-to-child transmission of HIV in women of unknown HIV status presenting in labour a sample of delivery sites in the Western Cape. This monitoring activity also accurately measures the prevalence of HIV among pregnant women and ascertains the proportion of HIV exposed infants delivered to these mothers, who received NVP prophylaxis to prevent MTCT. [ Design ] Anonymous, unlinked specimens of cord blood from discarded placentas were tested for HIV antibodies to determine population-level information on HIV infection and NVP coverage among all women delivering in the facilities. Uptake was measured by counting the number of women who were recorded to have accepted NVP when offered while coverage was measured by using the cord blood NVP assay. [ Results ] A total of 2198 (96.5%) cord blood specimens were collected from women at delivery. From these, 1876 (85.4%) women received pre-test counselling. Of those who were counselled, 1851 (84.2%) were tested for HIV and 365 (19.3%) tested positive. Amongst those who were infected, 229 (62.7%) received SD-NVP and but only 57.8% adhered to SD-NVP according to the cord blood. Of the infants born to HIV-infected mothers, 311 (85.2%) were recorded as 9 having received SD-NVP. There was no significant difference in SD-NVP uptake between the two facilities. The overall NVP coverage (mother and infant doses) was 55.3%. [ Conclusions ] The NVP coverage of 55.3% is poor. In order for PMTCT services to be successful, each mother-infant pair should go through a rigorous cascade of events that include HIV testing, receipt of results, diagnosis and drug adherence. The attrition cascade in this study was described using a new cord blood surveillance methodology. Coverage fails for a number of reasons and interventions are likely to differ from one facility to another. Appropriate interventions should be introduced to reduce the transmission to infants.
Open Access
Effectiveness of the first district-wide programme for the prevention of mother-to-child transmission of HIV in South Africa
(2005) Coetzee, David; Hilderbrand, Katherine; Boulle, Andrew; Draper, Beverley; Abdullah, Fareed; Goemaere, Eric
Objective: The aim of this study was to estimate the field efficacy of the first routine programme for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) initiated in South Africa, in the subdistrict of Khayelitsha. Methods: A consecutive sample of 658 mother–infant pairs, identified from the PMTCT register from 1 March to 30 November 2003, were identified for enrolment in this study. Details of the regimen received were established and HIV status of the infants at between 6 and 10 weeks of age was determined by qualitative DNA polymerase chain reaction. Zidovudine (AZT) was provided antenatally from week 34 of gestation and during labour. Infant formula milk was offered to mothers who chose not to breastfeed. The protocol was amended in July 2003 such that women who had received < 2 weeks of treatment with AZT were given a single dose of nevirapine (NVP) at the onset of labour, and the infant received a weight-adjusted dose of NVP within 72 h of delivery. Results: Of the 535 mother–infant pairs (81%) eventually included in the study, 410 (77%) received an effective PMTCT intervention according to the protocol. The rate of transmission of HIV from mother to child was 8.8% (95% confidence interval (CI), 6.2–10.9). A maternal age of > 25 years was the only significant independent risk factor for transmission (odds ratio, 2.12; 95% CI, 1.14–4.07). Conclusion: The results of this study demonstrate the feasibility and effectiveness of a large-scale PMTCT programme in an urban public-sector setting.
Open Access
Epidemic levels of drug resistant tuberculosis (MDR and XDR-TB) in a high HIV prevalence setting in Khayelitsha, South Africa
(Public Library of Science, 2010) Cox, Helen S; McDermid, Cheryl; Azevedo, Virginia; Muller, Odelia; Coetzee, David; Simpson, John; Barnard, Marinus; Coetzee, Gerrit; van Cutsem, Gilles; Goemaere, Eric
BACKGROUND: Although multidrug-resistant tuberculosis (MDR-TB) is emerging as a significant threat to tuberculosis control in high HIV prevalence countries such as South Africa, limited data is available on the burden of drug resistant tuberculosis and any association with HIV in such settings. We conducted a community-based representative survey to assess the MDR-TB burden in Khayelitsha, an urban township in South Africa with high HIV and TB prevalence. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional survey was conducted among adult clinic attendees suspected for pulmonary tuberculosis in two large primary care clinics, together constituting 50% of the tuberculosis burden in Khayelitsha. Drug susceptibility testing (DST) for isoniazid and rifampicin was conducted using a line probe assay on positive sputum cultures, and with culture-based DST for first and second-line drugs. Between May and November 2008, culture positive pulmonary tuberculosis was diagnosed in 271 new and 264 previously treated tuberculosis suspects (sample enriched with previously treated cases). Among those with known HIV status, 55% and 71% were HIV infected respectively. MDR-TB was diagnosed in 3.3% and 7.7% of new and previously treated cases. These figures equate to an estimated case notification rate for MDR-TB of 51/100,000/year, with new cases constituting 55% of the estimated MDR-TB burden. HIV infection was not significantly associated with rifampicin resistance in multivariate analyses. Conclusions/Significance There is an extremely high burden of MDR-TB in this setting, most likely representing ongoing transmission. These data highlight the need to diagnose drug resistance among all TB cases, and for innovative models of case detection and treatment for MDR-TB, in order to interrupt transmission and control this emerging epidemic.
Open Access
Evaluating measles vaccination coverage in high incidence areas of the Western Cape Province, following the mass vaccination campaign
(2012) Bernhardt, Gina Leanne; Coetzee, David; Cameron, Neil
Measles virus is known to be one of the most contagious of infectious agents and despite considerable progress towards elimination, a number of Sub-Saharan African countries experienced epidemics in 2009-2011, including South Africa, in which there were over 18 000 confirmed cases. The South African measles vaccination programme started in 1975 with 1 dose schedule, and from 1996-8 has followed the World Health Organization-United Nations Children’s Fund strategy. This includes a 2 dose routine vaccination schedule for children at 9 and 18 months of age, supplementary mass vaccination campaigns (MVCs) for children conducted 4 yearly, improved case management and casebased laboratory surveillance. Administrative monitoring of routine vaccination coverage is problematic, and often overestimated, because of denominator and numerator inaccuracies. The potential for a significant outbreak in the Western Cape Province was therefore not recognized. Over 2000 cases were confirmed in the Western Cape epidemic which began in September 2009 and peaked in March 2010. The Metropole district was mainly affected and over 60% of the cases were under 5 years of age, with 29% aged 6 to 11 months. A MVC, against measles had already been planned; however as a result of the epidemic the targeted age group for measles vaccination was extended from 9 to 59 months, to include children from 6 months to 15 years. This was conducted nationally from 12 to 23 April 2010.
Open Access
An evaluation of the quality of antenatal care and patient satisfaction in two provinces of South Africa
(2011) Besada, Donnela; Stinson, Kathryn; Coetzee, David; Little, Francesca
The aim of this study was to investigate the quality of service delivery for HIV-infected women at antenatal clinics in the Western Cape and Free State provinces, South Africa and to highlight areas for improvement. It was part of a larger one to determine the effectiveness of PMTCT programmes in 4 countries. These two provinces were selected because the researchers had access to facilities there. The population included all clinics with antenatal services in these provinces. Pregnant women attending the clinics were selected to assess care at these services. The sampling frame for the facility survey consisted of the antenatal clinics that referred patients to the delivery sites where the first component of the PEARL study, a cord blood surveillance exercise had taken place.
Open Access
Factors associated with outcomes of patients placed on tuberculosis treatment in the western geographic service area of Cape Town
(2018) Nyoni, Irene; Coetzee, David
Background In the Western Cape Province of South Africa, tuberculosis (TB) is a major health problem and in 2012 accounted for 7.40% of premature deaths. The Province has also experienced an increase in TB incidence in the past 20 years. Objectives The aims of the study were to describe the distribution of tuberculosis and identify risk factors associated with TB treatment outcomes in public sector tuberculosis facilities in the Western Geographic Service Area of the Cape Town Metropole District. Methods A cross sectional study was conducted using data collected in electronic TB registers from June 2011 to July 2012. Patients initiated on TB treatment aged 15 years and above with a known treatment outcome were included in the study. Results The study included 10 251TB patients registered during the study period who had a final treatment outcome and 55.35% (5 674) were males. The mean age was 36.0 years and 72.20% (7398) were new cases. Most patients had pulmonary TB (83.21%). Almost half of the patients (49.62%) were co-infected with HIV. Of the 10 251 cases, 47.02% (4 820) completed treatment, 37.43% (3 837) were cured, 8.67% (889) defaulted, 5.18% (531) died and 1.70% (147) failed treatment. There was a significant association between treatment outcome and sex, disease classification, treatment regimen, HIV status and patient category. Conclusion A high proportion of incident TB cases had previously been treated for TB. Overall treatment outcomes were poor. Unfavourable treatment outcomes were more common in men, those with extra pulmonary TB, retreatment patients and those co-infected with HIV.
Open Access
Factors that influence the use of insecticide treated bed nets in a rural community in Mangochi District, Malawi
(2005) Chithope-Mwale, George; Coetzee, David
The aim of the current study was to investigate factors that influence the use of insecticide treated bed nets in a rural community in Mangochi district in Malawi.
Open Access
Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: the PEARL study
(Public Library of Science, 2012) Ekouevi, Didier K; Stringer, Elizabeth; Coetzee, David; Tih, Pius; Creek, Tracy; Stinson, Kathryn; Westfall, Andrew O; Welty, Thomas; Chintu, Namwinga; Chi, Benjamin H
BACKGROUND: Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. METHODOLOGY/PRINCIPAL FINDINGS: We conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. We constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, we collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. Conclusions/RESULTS: We observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.
Open Access
High yield of culture-based diagnosis in a TB-endemic setting
(BioMed Central Ltd, 2012) Demers, Anne-Marie; Verver, Suzanne; Boulle, Andrew; Warren, Robin; van Helden, Paul; Behr, Marcel; Coetzee, David
BACKGROUND: In most of the world, microbiologic diagnosis of tuberculosis (TB) is limited to microscopy. Recent guidelines recommend culture-based diagnosis where feasible. METHODS: In order to evaluate the relative and absolute incremental diagnostic yield of culture-based diagnosis in a high-incidence community in Cape Town, South Africa, subjects evaluated for suspected TB had their samples processed for microscopy and culture over a 21 month period. RESULTS: For 2537 suspect episodes with 2 smears and 2 cultures done, 20.0% (508) had at least one positive smear and 29.9% (760) had at least one positive culture. One culture yielded 1.8 times more cases as 1 smear (relative yield), or an increase of 12.0% (absolute yield). Based on the latter value, the number of cultures needed to diagnose (NND) one extra case of TB was 8, compared to 19 if second specimens were submitted for microscopy. CONCLUSION: In a high-burden setting, the introduction of culture can markedly increase TB diagnosis over microscopy. The concept of number needed to diagnose can help in comparing incremental yield of diagnosis methods. Although new promising diagnostic molecular methods are being implemented, TB culture is still the gold standard.
Open Access
Human papillomavirus prevalence in South African women and men according to age and human immunodeficiency virus status
(2015-10-26) Mbulawa, Zizipho Z A; Coetzee, David; Williamson, Anna-Lise
Background: Both cervical cancer and human immunodeficiency virus (HIV) are major public health problems in Sub-Saharan Africa. The objectives of the study were to investigate human papillomavirus (HPV) prevalence according to age, HIV status and gender. Methods: Participants were 208 HIV-negative women, 278 HIV-positive women, 325 HIV-negative men and 161 HIV-positive men between the ages of 18–66 years. HPV types were determined in cervical and penile cells by Roche Linear Array HPV genotyping assay. Results: HPV prevalence was 36.7 % (76/207; 95 % confidence intervals (CI): 30.4–43.4 %) in HIV-negative women, with the highest prevalence of 61.0 % (25/41; 95 % CI: 45.7–74.4 %) in women aged 18–25 years. HPV prevalence was 74.0 % (205/277; 95 % CI: 68.5–78.8 %) in HIV-positive women, with the highest prevalence of 86.4 % (38/44; 95 % CI: 72.9–94.0 %) in women aged 18–25 years. HPV prevalence was found to decrease with increasing age in HIV-negative women (P = 0.0007), but not in HIV-positive women (P = 0.898). HPV prevalence was 50.8 % (159/313; 95 % CI: 45.3–56.3 %) in HIV-negative men, with the highest prevalence of 77.0 % (27/35; 95 % CI: 60.7–88.2 %) in men aged 18–25 years. HPV prevalence was 76.6 % (121/158; 95 % CI: 69.2–82.9 %) in HIV-positive men, with the highest prevalence of 87.5 % (7/8; 95 % CI: 50.8–99.9 %) in men 18–25 years of age. HPV prevalence was found to decrease with increasing age in HIV-negative men (P = 0.004), but not in HIV-positive men (P = 0.385). HIV-positive women had a significantly higher prevalence of one or more HPV type(s) in the bivalent (HPV-16/18: 20 % 55/277, 9 % 12/207; P <0.001), quadrivalent (HPV-6/11/16/18: 26 % 71/277, 12 % 24/207; P = 0.001) and nonavalent vaccine (HPV-6/11/16/18/31/33/52/56/58: 65 % 181/277, 24 % 50/207; P <0.001) compared to HIV-negative women. Similar observation were observed in men for bivalent (20 % 32/158, 10 % 30/313; P = 0.001), quadrivalent (35 % 56/158, 13 % 41/313; P <0.001) and nonavalent vaccine (75 % 119/158, 28 % 87/313; P <0.001). Conclusions: This study demonstrated high HPV prevalence among HIV-positive women and men in all age groups. The high prevalence of HPV types found in bivalent, quadrivalent and nonavalent vaccines in South African HIV-positive and HIV-negative women and men demonstrate that this population will greatly benefit from current HPV vaccines.
Open Access
Immunisation coverage of the Western Cape Province : household survey 2005
(2009) Corrigall, Joanne; Coetzee, David
[Objective] To determine the routine immunisation coverage rates in children aged 12-23 months in the Western Cape and factors affecting immunisation coverage. [Design] Cross-sectional Household Survey using an adaptation of the '30x7' cluster survey technique (multi-stage sampling). [Setting] Households across the Western Cape. [Subjects] 3705 caregivers of children aged 12-23 months who had been living in the Western Cape for at least 6 months. [Outcome Measures] Vaccination Status (1=fully vaccinated, 0=partially vaccinated) as recorded on a Road to Health card or given by history. Factors affecting caregivers' vaccination behaviour established from a questionnaire. [Results] The immunisation coverage was 76.8% for vaccines due by 9 months and 53.2% for vaccines due by 18 months. The reasons given for not being imunised were clinic-related factors (47%), lack of information (27%), lack of information (27%), caregiver being unable to attend the clinic (23%) and lack of motivation (14%). Of clinic factors cited, the two commonest factors were missed opportunities (34%) and being told by clinic staff to come back another time (20%). Factors enhancing coverage included possession of a Road-to-Health card, caregiver knowledge about vaccines and perceived attitude of clinic staff. Certain racial inequities in coverage were also apparent, particularly in the Boland-Overberg Region. [Conclusion] While the coverage indicated that a lot of good work has been done, the coverage was insufficient to prevent outbreaks of measles and other common childhood conditions including polio. The coverage was too low to consider not running periodic mass campaigns for measles and polio. The reasons given by caregivers for their children not being immunized and factors associated with increased coverage are valuable pointers as to where interventions should be focused.
Open Access
Increased alpha-9 human papillomavirus species viral load in human immunodeficiency virus positive women
(2014-01-31) Mbulawa, Zizipho Z; Johnson, Leigh F; Marais, Dianne J; Gustavsson, Inger; Moodley, Jennifer R; Coetzee, David; Gyllensten, Ulf; Williamson, Anna-Lise
Abstract Background Persistent high-risk (HR) human papillomavirus (HPV) infection and increased HR-HPV viral load are associated with the development of cancer. This study investigated the effect of human immunodeficiency virus (HIV) co-infection, HIV viral load and CD4 count on the HR-HPV viral load; and also investigated the predictors of cervical abnormalities. Methods Participants were 292 HIV-negative and 258 HIV-positive women. HR-HPV viral loads in cervical cells were determined by the real-time polymerase chain reaction. Results HIV-positive women had a significantly higher viral load for combined alpha-9 HPV species compared to HIV-negative women (median 3.9 copies per cell compared to 0.63 copies per cell, P = 0.022). This was not observed for individual HPV types. HIV-positive women with CD4 counts >350/μl had significantly lower viral loads for alpha-7 HPV species (median 0.12 copies per cell) than HIV-positive women with CD4 ≤350/μl (median 1.52 copies per cell, P = 0.008), but low CD4 count was not significantly associated with increased viral load for other HPV species. High viral loads for alpha-6, alpha-7 and alpha-9 HPV species were significant predictors of abnormal cytology in women. Conclusion HIV co-infection significantly increased the combined alpha-9 HPV viral load in women but not viral loads for individual HPV types. High HR-HPV viral load was associated with cervical abnormal cytology.