Browsing by Author "Morroni, Chelsea"

Now showing 1 - 20 of 22
  • Thumbnail Image
    Item
    Open Access
    A multidimensional approach to inform family planning needs, preferences and behaviours amongst women in South Africa through body mapping
    (2019-11-06) Harries, Jane; Constant, Deborah; Wright, Vanessa; Morroni, Chelsea; Müller, Alex; Colvin, Christopher J
    Abstract Background In recent decades there have been great improvements in the reproductive health of women in low- and middle-income countries and increases in the use of modern contraceptive methods. Nonetheless, many women are not able to access information, contraceptive technologies and services that could facilitate preventing unintended pregnancies and planning the number and timing of desired pregnancies. In South Africa, the contraceptive prevalence rate is 64.6%. However, this relatively high contraceptive prevalence rate masks problems with quality contraceptive service delivery, equitable access, and women’s ability to correctly and consistently, use contraceptive methods of their choice. This study set out to understand the specific family planning and contraceptive needs and behaviours of women of reproductive age in South Africa, through a lived experience, multisensory approach. Methods Participatory qualitative research methods were used including body mapping workshops amongst reproductive aged women recruited from urban and peri urban areas in the Western Cape South Africa. Data including body map images were analysed using a thematic analysis approach. Results Women had limited biomedical knowledge of the female reproductive anatomy, conception, fertility and how contraceptives worked, compounded by a lack of contraceptive counseling and support from health care providers. Women’s preferences for different contraceptive methods were not based on a single, sensory or experiential factor. Rather, they were made up of a composite of sensory, physical, social and emotional experiences underscored by potential for threats to bodily harm. Conclusions This study highlighted the need to address communication and knowledge gaps around the female reproductive anatomy, different contraceptive methods and how contraception works to prevent a pregnancy. Women, including younger women, identified sexual and reproductive health knowledge gaps themselves and identified these gaps as important factors that influenced uptake and effective contraceptive use. These knowledge gaps were overwhelmingly linked to poor or absent communication and counseling provided by health care providers. Body mapping techniques could be used in education and communication strategies around sexual and reproductive health programmes in diverse settings.
  • Thumbnail Image
    Item
    Open Access
    Attitudes and intentions of future health care providers regarding termination of pregnancy (TOP) services in South Africa
    (2007) Wheeler, Stephanie Brooke; Morroni, Chelsea
    Voluntary or induced termination of pregnancy (TOP) is a common reproductive health phenomenon worldwide, whether legal or illegal (WHO, 2004; Schenker and Cain, 1999). Although some countries, including South Africa, have liberalized TOP laws to allow legal and safe provision of abortion, many barriers continue to impede successful rollout of services. Key among these are the following: * recruiting and retaining staff to provide such services, * incorporating TOP observation and training into medical training curricula, preventing burnout, * addressing negative attitudes and stigma of health providers, * diminishing professional discrimination and harassment, and * offering more TOP training modules, counselling workshops, and values clarification workshops over a spread of geographic areas (Adamo, 2003). Identifying future health professionals who may be interested in training and eventually providing TOP care has thus been prioritized by the South African Department of Health. Examining the knowledge, attitudes, beliefs, and intentions of medical students in training could make an important contribution to policy initiatives with respect to abortion provision. The current study measured these parameters among medical students in one of the eight medical training institutions in South Africa. With the liberalization of TOP legislation in South Africa, future health professionals' attitudes and intentions towards abortion services is a critical determinant to equity, access, and availability of women's reproductive care and to the successful implementation of TOP law.
  • Thumbnail Image
    Item
    Open Access
    Clinical deterioration during antitubercular treatment at a district hospital in South Africa: the importance of drug resistance and AIDS defining illnesses
    (Public Library of Science, 2009) Pepper, Dominique J; Rebe, Kevin; Morroni, Chelsea; Wilkinson, Robert J; Meintjes, Graeme
    BACKGROUND: Clinical deterioration on drug therapy for tuberculosis is a common cause of hospital admission in Africa. Potential causes for clinical deterioration in settings of high HIV-1 prevalence include drug resistant Mycobacterium tuberculosis (M.tb) , co-morbid illnesses, poor adherence to therapy, tuberculosis associated-immune reconstitution inflammatory syndrome (TB-IRIS) and subtherapeutic antitubercular drug levels. It is important to derive a rapid diagnostic work-up to determine the cause of clinical deterioration as well as specific management to prevent further clinical deterioration and death. We undertook this study among tuberculosis (TB) patients referred to an adult district level hospital situated in a high HIV-1 prevalence setting to determine the frequency, reasons and outcome for such clinical deterioration. Method A prospective observational study conducted during the first quarter of 2007. We defined clinical deterioration as clinical worsening or failure to stabilise after 14 or more days of antitubercular treatment, resulting in hospital referral. We collected data on tuberculosis diagnosis and treatment, HIV-1 status and antiretroviral treatment, and investigated reasons for clinical deterioration as well as outcome. RESULTS: During this period, 352 TB patients met inclusion criteria; 296 were admitted to hospital accounting for 17% of total medical admissions (n = 1755). Eighty three percent of TB patients (291/352) were known to be HIV-1 co-infected with a median CD4 count of 89cells/mm 3 (IQR 38-157). Mortality among TB patients admitted to hospital was 16% (n = 48). The median duration of hospital admission was 9.5 days (IQR 4-18), longer than routine in this setting (4 days). Among patients in whom HIV-1 status was known (n = 324), 72% of TB patients (n = 232) had an additional illness to tuberculosis; new AIDS defining illnesses (n = 80) were the most frequent additional illnesses (n = 208) in HIV-1 co-infected patients (n = 291). Rifampin-resistant M.tb (n = 41), TB-IRIS (n = 51) and drug resistant bacterial infections (n = 12) were found in 12%, 14% and 3.4% of the 352 cases, respectively. Interpretation In our setting, new AIDS defining illnesses, drug resistant M.tb and other drug resistant bacteria are important reasons for clinical deterioration in HIV-1 co-infected patients receiving antitubercular treatment. HIV-1 co-infected patients may be at increased risk of acquiring nosocomial drug resistant pathogens because profound immune suppression results in co-morbid illnesses that require prolonged inpatient admissions. Routine infection control is essential and needs to be strengthened in our setting.
  • Thumbnail Image
    Item
    Open Access
    Emergency contraception - lack of awareness among women presenting for termination of pregnancy
    (2007) Moodley, Jennifer; Morroni, Chelsea
    Emergency contraception (EC) when used after unprotected intercourse, within defined time limits, can reduce the risk of an unwanted pregnancy. In South Africa EC is available free of charge in public sector clinics and over the counter, i.e. without prescription, in private sector pharmacies. Termination of pregnancy services have been legal in SA since 1996 and have resulted in a marked decrease in abortion-related morbidity and mortality. However, abortion services remain inaccessible for many women because of stigma, provider resistance and lack of trained providers and designated facilities. An increased use of EC could lead to a reduction in both legal and illegal abortion. In this article we report on the awareness and use of EC among women presenting for a termination of pregnancy.
  • Thumbnail Image
    Item
    Open Access
    Expanding contraceptive options in South Africa : knowledge, attitudes, and practices surrounding the intrauterine device (IUD)
    (2007) Gutin, Sarah Anne; Morroni, Chelsea
    The intrauterine device (IUD) is a safe, effective, convenient, reliable, inexpensive, and cost-effective form of reversible contraception. It rivals female sterilization, injectables, and implants with respect to effectiveness in pregnancy prevention. Once inserted, IUDs are nearly maintenance free; some IUDs can even be used for over a decade. In many settings however, the utilization of this form of contraception is poor and a number of barriers to usage exist. These barriers often relate to lack of knowledge and misperceptions among both potential users and healthcare providers. The IUD is a reliable option that may be an ideal form of contraception for many women in South Africa. In order to make this method available on a wider scale, it is necessary to provide correct information to women and health care professionals and to increase the availability and use of this highly effective method. We conducted a cross-sectional descriptive study designed to assess the current knowledge, attitudes, and practices of potential users and health care providers with respect to the IUD. We recruited 205 women between 15 to 49 years of age who were attending family planning and ST! care services at four primary level public clinics (two in the more urban Western Cape Province and two in the rural Eastern Cape Province in South Africa). In addition, we interviewed 32 providers from 12 clinics (six clinics per province). Ethical approval for this research was obtained from both the University of Cape Town and Walter Sisulu University (formerly the University of the Transkei). Permission was also given by the local and provincial health services. Among clients, knowledge of the IUD was poor. About 26% of women had heard of the IUD. After the method was explained to them, 89.7% of women believed that there were advantages to using the IUD and 72.7% of women said that they would consider using the JUD in the future. Also, women thought the IUD was an easier contraceptive method to use than oral contraceptive pills, injectables, male and female condoms, and female sterilization. Logistic regression modelling showed that, after adjusting for level of education, being from the Western Cape, older age, and having heard of emergency contraception all independently predicted awareness of the IUD method. For the most part, providers knew how the IUD worked to prevent pregnancy; however, providers were lacking in more detailed knowledge about the method and had misinformation about the IUD. Almost all (93 .6%) of providers recognized their need for more information and training about the IUD. Providers reported that barriers to IUD usage in South Africa were lack of knowledge of the method on the part of providers (84.4%), a lack of trained providers to insert or remove the IUD (62.5%), limited availability of the device at health facilities (56.3%), and a lack of knowledge on the part of potential users (46.9%). Despite these barriers, 81 % of providers believed women would be interested in the IUD if they knew about it and 73.3% believed the IUD should be promoted in South Africa. Our results suggest that the IUD would be a welcome addition to the contraceptive method mix in South Africa and that both clients and providers would be interested in this method. It is clear that awareness campaigns among women seeking contraception would be necessary for building support and publicizing the IUD. It will also be necessary to train and educate providers, focusing on up to date information, dispelling myths, and proper insertion and removal techniques. South Africa could re-introduce the IUD into the contraceptive method mix and increase women's choice by adding this valuable, viable, and sustainable option to the contraceptive method mix. The findings of this study, which was requested by the provincial health services, will be used to inform policy and as a starting point for assessing the feasibility and acceptability of a greater role for the IUD in the contraceptive method mix in South Africa.
  • Thumbnail Image
    Item
    Open Access
    Experience of and factors associated with violence against sexual and gender minorities in nine African countries: a cross-sectional study
    (2021-02-15) Müller, Alex; Daskilewicz, Kristen; Kabwe, Mc L; Mmolai-Chalmers, Anna; Morroni, Chelsea; Muparamoto, Nelson; Muula, Adamson S; Odira, Vincent; Zimba, Martin
    Objective The objective of this research was to assess physical and sexual violence experienced by sexual and gender minorities in nine African countries, and to examine factors associated with violence. Methods We conducted an exploratory multi-country cross-sectional study among self-identifying sexual and gender minorities, using a survey tool available in paper and online. Participants were sampled through venue-based and web-based convenience sampling. We analysed data using descriptive statistics and logistic regression, with Stata15. Findings Of 3798 participants, 23% were gender minorities, 20% were living with HIV, and 18% had been coerced into marriage. Fifty-six per cent of all participants had experienced physical or sexual violence in their lifetime, and 29% in the past year. Gender minorities had experienced significantly higher levels of violence compared to cisgender (sexual minority) participants. The variable most strongly associated with having experienced violence was being coerced into marriage (AOR, 3.02), followed by people living nearby knowing about one’s sexual orientation and/or gender identity (AOR, 1.90) and living with HIV (AOR, 1.47). Conclusion Sexual and gender minorities in Eastern and Southern Africa experience high levels of violence. Sexual orientation and gender identity need to be recognised as risk factors for violence in national and regional law and policy frameworks. States should follow the African Commission Resolution 275 and provide protection against violence based on real or perceived sexual orientation or gender identity.
  • Thumbnail Image
    Item
    Open Access
    Factors affecting men’s support for the use of the contraceptive implant by their female intimate partners
    (2020-11-23) Jonas, Kim; Kalichman, Moira; Kalichman, Seth; Morroni, Chelsea; Mathews, Catherine
    Abstract Background Family planning services have been available at no cost in the public health settings of South Africa since 1994, and now include the long-acting reversible contraceptives (LARCs) namely, the contraceptive implant and intra-uterine device (IUD). However, the uptake of LARCs has been declining in the recent years and little is known about the cause of the decline. In many relationships, men may influence their female intimate partner’s contraceptive choices. Thus, men’s involvement in reproductive health decisions and family programming may improve their support for contraceptive use, including the LARC use by their female intimate partners. This study investigated factors affecting men’s support for the use of contraceptive implant by their female intimate partners. Methods A quantitative, cross-sectional survey was conducted among adult men attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, we measured men’s knowledge, awareness and support of, and attitudes towards use of the contraceptive implant by their female intimate partners. Data were analyzed using SPSS version 25. Results The sample included 65 men with a mean age of 31.2 years. Most (76.6%) believed that both men and women should be responsible for family planning. Support for general contraception use by their female intimate partners was prevalent at 80.0%, but only 33.9% reported that they would like their partners to use the implant in the future, while 35.6% were unsure and 30.5% did not support their partner’s use of the implant. Factors significantly associated with men’s support of their partner’s future use of the contraceptive implant included men’s reports that their partner wished to have another child in future, knowledge that the implant is safe for use by women who have not had children, knowledge that the implant can effectively prevent pregnancy for 3 years, and a positive attitude towards the implant’s long-lasting effectiveness. Conclusion Improving men’s knowledge of, and attitudes toward the contraceptive implant might increase their support for their partner’s use of the implant, which in turn might promote uptake of the implant among women. The findings of our study suggest the importance of actively engaging men in reproductive health and family planning programs.
  • Thumbnail Image
    Item
    Open Access
    Failed contraception?
    (2004) Morroni, Chelsea; Myer, Landon; Cooper, Di
    The frequency, cost and harms of the procedure must have been weighed up by the British National Health Service (NHS) — usually pretty sensible about their medical recommendations — which proposed 3-yearly screening for women aged between 50 and 64 years. Obviously more cancers would be discovered by 2-yearly rather than 3-yearly screening, and yet more by annual screening. Six-monthly screening, in turn, would clearly yield more cancers than annual screening. This would fit well with Dr Whitehorn’s ‘simple arithmetic’. However a balance has to be found between benefits and harms, and we chose the NHS one. The following organised screening programmes recommend 2- yearly mammography, most of them for women between 50 and 69 years: Australia, Finland, Iceland, Israel, Netherlands, France, Belgium, Canada, Denmark, Ireland, Italy, Norway, Portugal and Greece. Annual mammography, and mammography at an early age are the usual recommendations of interest groups. They are also the recommendation of the correspondence printed above. Like Dr Paul Sneider, we conclude with a quote from Boyle: ‘Every woman has a right to participate in an organised screening program . . .’. This right, alas, does not apply to this country, where other health care priorities make an organised programme an impossibility. However, should a woman have the privilege of medical aid, or be able to afford mammography, it is her choice to undergo it, a choice open to only a minority of South Africans. The majority of South African women would, in our opinion, be well served by an organised programme of ‘breast awareness’, a proposal that Dr Russell Whitehorn finds difficult to fathom.
  • Thumbnail Image
    Item
    Open Access
    Independent Midwifery practices in Cape Town: birth outcomes and predictors for medical interventions from 2003-2009
    (2010) Evans, Kristy; Morroni, Chelsea
    The midwifery model of care is a safe, effective, inexpensive, holistic, woman and baby centered-approach to maternal and infant health. It is widely used in developing and developed world contexts and has proven to have birth outcomes that are comparable to hospital-based, obstetric models. In many settings however, application of the independent midwifery model of care has become increasingly difficult to maintain. Tensions surrounding perceived skills and competencies of midwives, the increasing acceptance of hospital-based, obstetric models of childbirth, controversy over necessity and use of medical interventions, rising insurance premiums, and competition over clients in private sector scenarios are all factors contributing to both low availability and utilization in many countries, including South Africa. In order to consider the role of this model in maternity services in South Africa and to potentially make this model available on a wider scale, it is necessary to understand the demographics of current utilization of existing independent midwifery services, as well their as birth outcomes. This retrospective cohort study documents the total number of deliveries attended by independent midwives, the socio-demographic and reproductive characteristics of women using independent midwives and the birth outcomes and delivery types in the greater Cape Town region among the 16 independent midwives who have practiced during the six and a half year period of January 2003 - end of June 2009. It identifies factors associated with normal vaginal deliveries, instrumental deliveries and caesarean sections, as well as documents the socio-demographic and professional characteristics of the 16 independent midwives. Ethical approval for this research was granted by the University of Cape Town. Anonymous client data was collected from midwifery practices' Maternity Registers and transferred onto a data abstraction sheet. Midwife data was collected via an interviewer-administered questionnaire. All data was entered into Microsoft Excel and analyzed using Stata. The findings of this study will be used to inform maternal and infant health care policy, as well as provide statistics for independent midwives' quality assurance and auditing of services.
  • No Thumbnail Available
    Item
    Open Access
    Independent midwifery practices in Cape Town: birth outcomes and predictors for medical interventions from 2003-2009
    (2010) Evans, Kristy; Morroni, Chelsea
    The midwifery model of care is a safe, effective, inexpensive, holistic, woman and baby cantered approach to maternal and infant health. It is widely used in developing and developed world contexts and has proven to have birth outcomes that are comparable to hospital-based, obstetric models. In many settings however, application of the independent midwifery model of care has become increasingly difficult to maintain. Tensions surrounding perceived skills and competencies of midwives, the increasing acceptance of hospital-based, obstetric models of childbirth, controversy over necessity and use of medical interventions, rising insurance premiums, and competition over clients in private sector scenarios are all factors contributing to both low availability and utilization in many countries, including South Africa. In order to consider the role of this model in maternity services in South Africa and to potentially make this model available on a wider scale, it is necessary to understand the demographics of current utilization of existing independent midwifery services, as well their as birth outcomes. This retrospective cohort study documents the total number of deliveries attended by independent midwives, the socio-demographic and reproductive characteristics of women using independent midwives and the birth outcomes and delivery types in the greater Cape Town region among the 16 independent midwives who have practiced during the six-and-a-half-year period of January 2003 - end of June 2009. It identifies factors associated with normal vaginal deliveries, instrumental deliveries and caesarean sections, as well as documents the socio-demographic and professional characteristics of the 16 independent midwives. Ethical approval for this research was granted by the University of Cape Town. Anonymous client data was collected from midwifery practices‟ Maternity Registers and transferred onto a data abstraction sheet. Midwife data was collected via an interviewer-administered questionnaire. All data was entered into Microsoft Excel and analyzed using Stata. The findings of this study will be used to inform maternal and infant health care policy, as well as provide statistics for independent midwives‟ quality assurance and auditing of services.
  • Thumbnail Image
    Item
    Open Access
    Knowledge of the abortion legislation among South African women: a cross-sectional study
    (BioMed Central Ltd, 2006) Morroni, Chelsea; Myer, Landon; Tibazarwa, Kemilembe
    BACKGROUND:In order to ensure that legalized abortion in South Africa improves reproductive health, women must know that abortion is a legal option in the case of unwanted pregnancy. This study investigated knowledge of abortion legislation eight years after the introduction of legal abortion services in one province of South Africa. METHODS: In 2004/2005, we conducted a cross-sectional study among 831 sexually-active women attending 26 public health clinics in one urban and one rural health region of the Western Cape Province. RESULTS: Thirty-two percent of women did not know that abortion is currently legal. Among those who knew of legal abortion, few had knowledge of the time restrictions involved. CONCLUSION: In South Africa there is an unmet need among women for information on abortion. Strategies should be developed to address this gap so that women are fully informed of their rights to a safe and legal termination of pregnancy.
  • Thumbnail Image
    Item
    Open Access
    Papanicolaou smears and cervical inflammatory cytokine responses
    (BioMed Central Ltd, 2007) Passmore, Jo-Ann; Morroni, Chelsea; Shapiro, Samual; Williamson, Anna-Lise; Hoffman, Margaret
    In a case-control study among 2064 South African women to investigate the risk of clinically invasive cancer of the cervix, we found a marked reduction in the risk of cervical cancer among women who gave a history of ever having undergone even a single Pap smear, and a statistically significant decline in the HPV positivity rate correlated with the lifetime number of Pap smears received. HPV infections and their associated low-grade lesions commonly regress, indicating that most often there is an effective host immune response against HPV infection. We hypothesized that act of performing a Pap smear is associated with inflammatory responses at the site of trauma, the cervix, and that this inflammatory signalling may be an immunological factor initiating these productive anti-HPV responses. In the present study, a randomized controlled trial, we enrolled 80 healthy young women to investigate the impact of performing a Pap smear on cervical inflammation. Forty one women, in the intervention group, received a Pap smear at enrollment and cervicovaginal lavages (CVLs) were collected at baseline and 2 weeks later. Thirty nine women received no intervention at enrollment (control group) but CVLs were collected at enrolment and 2 weeks later. We assessed various markers of inflammation including IL-12 p70, TNF-alpha, IL-8, IL-6, IL-10, and IL-1beta in CVL specimens. While CVL levels of IL-8, IL-1beta and IL-6 remained unchanged following a Pap smear, markers of cell mediated immunity (IL-12 p70 and TNF-alpha) and T cell regulation (IL-10) were significantly elevated.
  • Thumbnail Image
    Item
    Open Access
    Patient and provider delay in tuberculosis suspects from communities with a high HIV prevalence in South Africa: A cross-sectional study
    (BioMed Central Ltd, 2008) Meintjes, Graeme; Schoeman, Hennie; Morroni, Chelsea; Wilson, Douglas; Maartens, Gary
    BACKGROUND: Delay in the diagnosis of tuberculosis (TB) results in excess morbidity and mortality, particularly among HIV-infected individuals. This study was conducted at a secondary level hospital serving communities with a high HIV prevalence in Cape Town, South Africa. The aim was to describe patient and provider delay in the diagnosis of TB in patients with suspected TB requiring admission, and to determine the risk factors for this delay and the consequences. METHODS: A cross-sectional study was conducted. Patients admitted who were TB suspects were interviewed using a structured questionnaire to assess history of their symptoms and health seeking behaviour. Data regarding TB diagnosis and outcome were obtained from the medical records. Bivariate associations were described using student's T-tests (for means), chi-square tests (for proportions), and Wilcoxon rank-sum tests (for medians). Linear regression models were used for multivariate analysis. RESULTS: One hundred twenty-five (125) patients were interviewed. In 104 TB was diagnosed and these were included in the analysis. Seventy of 83 (84%) tested were HIV-infected. Provider delay (median = 30 days, interquartile range (IQR) = 10.3-60) was double that of patient delay (median = 14 days, IQR = 7-30). Patients had a median of 3 contacts with formal health care services before referral. Factors independently associated with longer patient delay were male gender, cough and first health care visit being to public sector clinic (compared with private general practitioner). Patient delay [greater than or equal to] 14 days was associated with increased need for transfer to a TB hospital. Provider delay [greater than or equal to] 30 days was associated with increased mortality. CONCLUSION: Delay in TB diagnosis was more attributable to provider than patient delay, and provider delay was associated with increased mortality. Interventions to expedite TB diagnosis in primary care need to be developed and evaluated in this setting.
  • Thumbnail Image
    Item
    Open Access
    Perspectives on contraceptive implant use in women living with HIV in Cape Town, South Africa: a qualitative study among primary healthcare providers and stakeholders
    (2019-07-26) Brown, Anna; Harries, Jane; Cooper, Diane; Morroni, Chelsea
    Abstract Background This study explored primary healthcare provider and HIV/contraception expert stakeholder perspectives on South Africa’s public sector provision of contraceptive implants to women living with HIV. We investigated the contraceptive service-impact of official advice against provision of implants to women using the HIV antiretroviral drug, efavirenz, issued by the South African National Department of Health (NDoH) in 2014. Methods Qualitative data was collected in Cape Town in 2017 from primary healthcare contraceptive providers in four clinics that provide implants, as well as from other expert stakeholders selected for expertise in HIV and/or contraception. In-depth interviews and a group discussion explored South Africa’s implant introduction and implant provision to women living with HIV. Data was analysed using an inductive thematic analysis approach. Results Interviews were conducted with 10 providers and 10 stakeholders. None of the four clinics where the providers worked currently offered the implant to women living with HIV. Stakeholders confirmed that this was consistent with patterns of implant provision at primary healthcare facilities across Cape Town. Factors contributing to providers’ decisions to suspend provision of the implant to women living with HIV included: inadequate initial and ongoing provider training; interpretation of NDoH communications about implant use with efavirenz; provider unwillingness to risk harming clients and concerns about professional liability; and other pressures related to provider capacity. Conclusions All South African women, including those living with HIV, should have access to the full range of contraceptive options for which they are medically eligible. Changing guidance should be initiated and communicated in consultation with primary-level providers and service beneficiaries. Guidance issued to providers needs to be clear and fully evidence-informed, and its correct interpretation and implementation facilitated and monitored. Guidance should be accompanied by provider training, as well as counselling messages and tools to support providers. Generalized retraining of providers in rights-based, client-centred family planning, and in particular implant provision for women with HIV, is needed. These recommendations accord with the right of women living with HIV to access the highest possible standard of sexual and reproductive healthcare, including informed contraceptive choice and access to the contraceptive implant.
  • Thumbnail Image
    Item
    Open Access
    Perspectives on etonogestrel implant use in HIV-infected women in Cape Town, South Africa: a qualitative study among providers and stakeholders
    (2018) Brown, Anna; Morroni, Chelsea; Harries, Jane
    Access to a range of safe and effective modern contraceptive methods enables women to make free and informed choices about their reproductive lives and broadly improves maternal and child health outcomes. Successful avoidance of unintended pregnancy and the corresponding ability to plan for pregnancy are especially valuable in the context of Human Immunodeficiency Virus (HIV) infection. Revised South African national guidelines seeking to expand overall contraceptive access were released in 2012 and, in response to the severity of the domestic HIV epidemic, specifically detailed the sexual and reproductive health rights and needs of HIV-positive women. Six years later, evaluation of the implementation and impact of these guidelines, as well as of more recent policy responses in this area, is necessary. This need for evaluation is outlined in Part A of this mini-dissertation in the form of a research proposal. A literature review (Part B) assesses what is currently known about considerations surrounding contraceptive decision-making in the context of HIV and antiretroviral therapy (ART). The use of the subdermal Long Acting Reversible Contraceptive (LARC) implant in HIV-positive women is explored in depth, given that the 2012 guidelines introduced the method as an entirely new option for South African women, as well as in light of recent controversy surrounding the implant’s provision to women taking the first-line ART drug, efavirenz (EFV). A journal-style article structured for submission to BMC Public Health (Part C) then uses thematic qualitative methodology to explore primary family planning provider and other relevant stakeholder perspectives on the provision of implants to HIV-positive women clients attending Cape Town primary care facilities. The study adds to existing literature regarding implant provision in the context of HIV and ART, and offers new insight into the impact of a 2014 South African Department of Health decision to recommend against the then-newly introduced implant as an option for women taking EFV-based ART. This research finds that several converging factors may have lead primary providers to view the implant as broadly contraindicated in all HIV-positive clients regardless of their iii exposure to EFV, namely: insufficient provider training; provider and community unfamiliarity with and scepticism about the new method; structural pressures on providers to keep up to date with and provide wide-ranging integrated services in busy clinical environments; and inadequate stakeholder consultation surrounding the wording and overall appropriateness of the implant/EFV guidance itself. Recommendations are provided in the article, including the need for: the retraining of primary healthcare providers in rights and choice-based family planning (particularly in implant provision and counselling); simplified counselling messages and user-friendly decision-making tools to help providers facilitate informed contraceptive choice for HIV-positive women; generalized beneficiary and community sensitization/education about implants including in the context of HIV and ART; and more comprehensive stakeholder/beneficiary consultation in future contraceptive policy-related endeavors.
  • Thumbnail Image
    Item
    Open Access
    Prolonged tuberculosis-associated immune reconstitution inflammatory syndrome: characteristics and risk factors
    (BioMed Central, 2016-09-27) Bana, Tasnim M; Lesosky, Maia; Pepper, Dominique J; van der Plas, Helen; Schutz, Charlotte; Goliath, Rene; Morroni, Chelsea; Mendelson, Marc; Maartens, Gary; Wilkinson, Robert J; Meintjes, Graeme
    Background: In a proportion of patients with HIV-associated tuberculosis who develop paradoxical immune reconstitution inflammatory syndrome (IRIS), the clinical course of IRIS is prolonged necessitating substantial health care utilization for diagnostic and therapeutic interventions. Prolonged TB-IRIS has not been prospectively studied to date. We aimed to determine the proportion of patients with prolonged TB-IRIS, as well as the clinical characteristics and risk factors for prolonged TB-IRIS. Methods: We pooled data from two prospective observational studies and a randomized controlled trial conducted in Cape Town, South Africa, that enrolled patients with paradoxical TB-IRIS. We used the same diagnostic approach and clinical case definitions for TB-IRIS in the 3 studies. Prolonged TB-IRIS was defined as TB-IRIS symptoms lasting > 90 days. Risk factors for prolonged TB-IRIS were analysed using Wilcoxon rank sum test, Fisher’s exact test, multivariate logistic regression and Cox proportional hazards models. Results: Two-hundred and sixteen patients with TB-IRIS were included. The median duration of TB-IRIS symptoms was 71.0 days (IQR 41.0–113.2). In 73/181 patients (40.3 %) with adequate follow-up data, IRIS duration was > 90 days. Six patients (3.3 %), mainly with lymph node involvement, had IRIS duration > 1 year. In univariate logistic regression analysis the following were significantly associated with IRIS duration > 90 days: lymph node involvement at initial TB diagnosis, drug-resistant TB, lymph node TB-IRIS, and not being hospitalised at time of TB-IRIS diagnosis. In our multivariate logistic regression model lymph node TB-IRIS (aOR 2.27, 95 % CI 1.13–4.59) and not being hospitalised at time of TB-IRIS diagnosis (aOR for being hospitalised 0.5, 95 % CI 0.25-0.99) remained significantly associated with prolonged TB-IRIS, and drug-resistant TB was of borderline significance (aOR 3.26, 95 % CI 0.97–12.99). The association of not being hospitalised with longer duration of IRIS might be related to 1 of the 3 cohorts in which all patients were hospitalised at ART initiation with close inpatient follow-up. This could have resulted in diagnosis of milder cases and earlier IRIS treatment potentially resulting in shorter TB-IRIS duration in these hospitalised patients. Conclusions: Around 40 % of patients with TB-IRIS have symptoms for more than 90 days. Involvement of lymph nodes at time of TB-IRIS is an independent risk factor for prolonged TB-IRIS. Future studies should address whether more prompt anti-inflammatory treatment of lymph node TB-IRIS reduces the risk of prolonged TB-IRIS. Trial registration: The randomized controlled trial was registered with Current Controlled Trials ISRCTN21322548 on 17 August 2005.
  • Thumbnail Image
    Item
    Restricted
    Randomized placebo-controlled trial of prednisone for paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome
    (Lippincott, Williams & Wilkins, 2010) Meintjes, Graeme; Wilkinson, Robert J; Morroni, Chelsea; Pepper, Dominique J; Rebe, Kevin; Rangaka, Molebogeng X; Oni, Tolu; Maartens, Gary
    Objective: Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of antiretroviral therapy in resource-limited countries. We aimed to assess whether a 4 week course of prednisone would reduce morbidity in patients with paradoxical TB-IRIS without excess adverse events. Design: A randomised double blind placebo-controlled trial of prednisone (1.5mg/kg/day for 2 weeks then 0.75mg/kg/day for 2 weeks). Patients with immediately life-threatening TB-IRIS manifestations were excluded. Methods: The primary combined endpoint was days of hospitalization and outpatient therapeutic procedures, which were counted as one hospital day. Results: 110 participants were enrolled (55 to each arm). The primary combined endpoint was more frequent in the placebo than the prednisone arm (median hospital days 3 (IQR 0-9) and 0 (IQR 0-3) respectively; p=0.04). There were significantly greater improvements in symptoms, Karnofsky score, and quality of life (MOS-HIV) in the prednisone versus the placebo arm at 2 and 4 weeks, but not at later timepoints. Chest radiographs improved significantly more in the prednisone arm at weeks 2 (p=0.002) and 4 (p=0.02). Infections on study medication occurred in more participants in prednisone than placebo arm (27 vs 17 respectively; p=0.05), but there was no difference in severe infections (2 vs 4 respectively; p=0.40). Isolates from 10 participants were found to be resistant to rifampicin after enrollment. Conclusions: Prednisone reduced the need for hospitalisation and therapeutic procedures, and hastened improvements in symptoms, performance and quality of life. It is important to investigate for drug-resistant tuberculosis and other causes for deterioration before administering glucocorticoids.
  • Thumbnail Image
    Item
    Open Access
    Randomized trial comparing bleeding patterns after immediate and conventional oral contraceptive initiation
    (2001) Morroni, Chelsea; Westhoff, Carolyn
    Starting oral contraceptives immediately, under direct observation, increase OC initiation rates and may increase effective use and continuation However, if adverse bleeding pattern occur, then such an approach may paradoxically decrease continuation rates. The purpose of this study is comapare 90-day bleeding patterns following immediate ("Quickstart) versus conventional OC initiation.
  • Thumbnail Image
    Item
    Open Access
    The role of urine pregnancy testing in facilitating access to antenatal care and abortion services in South Africa: a cross-sectional study
    (BioMed Central Ltd, 2006) Morroni, Chelsea; Moodley, Jennifer
    BACKGROUND:Effective confirmation of pregnancy is a basic component of reproductive health services. It is a prerequisite for accessing antenatal care (AnC) if the pregnancy is wanted and abortion services if the pregnancy is unwanted. This study examined the role of urine pregnancy testing in the timing of presentation for pregnancy-care.METHOD:A cross-sectional study was conducted among 158 women presenting for antenatal care and 164 women presenting for abortion at public sector clinics in Cape Town, South Africa. RESULTS: The median gestational age at first presentation was 23 weeks for AnC clients and 13 weeks for abortion clients. Obtaining a urine pregnancy test of one's own accord was associated with a decrease in the gestational age at presentation of 3.6 and 1.4 weeks for antenatal and abortion clients, respectively, independently of all other factors. CONCLUSION: Given the proven clinical benefit and public health impact of early presentation for antenatal and abortion services, strategies to decrease gestational age at presentation for pregnancy care should be given priority. 'Fast-track' urine pregnancy testing services should be established in public sector clinics in South Africa.
  • Thumbnail Image
    Item
    Open Access
    Sexual risk behaviours are influenced by knowing someone with HIV/AIDS
    (Health and Medical Publishing Group, 2004) Ijumba, Ken; Gamieldien, Ragmat; Myer, Landon; Morroni, Chelsea
    Behavioural risk reduction interventions are a central part of continuing efforts to stem the spread of the HIV epidemic. A range of interventions have been developed and tested in different populations within South Africa. These seek to lower individual risk of HIV infection by discouraging sexual relations with multiple partners and increasing levels of condom use. Many interventions to date have met with mixed success, and understanding the determinants of high-risk sexual behaviour remains a major concern in addressing HIV/AIDS.1 Several studies from other parts of sub-Saharan Africa have suggested that knowing someone with HIV/AIDS may be an important predictor of decreased risk behaviour. One pooled analysis2 found that adult men in Kenya, Zambia and Uganda were more likely to reduce their risk behaviours if they knew someone who had HIV/AIDS. Similar results have been reported in a population-based study3 of women in rural Zimbabwe. However, one previous study from South Africa4 using data from the 1998 Demographic and Health Survey (DHS) found that there was no association between knowing someone with HIV and levels of condom use. Given that the links between knowing someone with HIV and risk behaviours have important implications for HIV prevention efforts, we investigated this association in a survey of individuals attending a public sector health facility in Khayelitsha, near Cape Town.