OpenUCT :: Browsing by Author "Myer, Landon"

Browsing by Author "Myer, Landon"

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Open Access
A Retrospective Cohort Study comparing Retention and Viral suppression between Co-morbidity Adherence Clubs and HIV-Only Adherence Clubs in Cape Town, South Africa
(2018) Allerton, Joanna; Phillips,Tammy; Myer, Landon
In South Africa, there is an increasing population of those with both Human Immunodeficiency Virus (HIV) and one or more non-communicable diseases (NCDs). This is thought to be due to a number of factors, including both the successful Antiretroviral Therapy (ART) programme (which has increased the life-expectancy of those with HIV) and the increasing prevalence of NCDs (due to an aging population, lifestyle changes and urbanisation). This co-morbid population has been shown have poor health outcomes especially in terms of adherence (due to pill burden, multiple appointments etc). There are currently very few models of integrated care for those with both HIV and NCDs, despite well-documented potential benefits of this approach for both the patient and the health system (in terms of efficiency). One such model of care, the co-morbidity adherence clubs (for those with both HIV and hypertension and/or diabetes), was implemented in 2016 in South Africa and this study aims to compare the key outcomes of retention and viral suppression between these clubs and the established HIV-only adherence clubs. Part A is the study protocol which lays the foundation for the need for this research, and explains how the research will be conducted. Part B forms the literature review which gives a summary of the existing literature and provides context for the dissertation. Part C is the manuscript, presenting the analysis of the retrospective cohort study, and includes a discussion on the implications of key findings. The study sample comprised 602 HIV-positive adults (501 from the HIV-only club model and 101 from the co-morbidity club model). The overall female proportion was 70.3% and the median age was 38 years. The results showed that there was no difference in the proportion of those retained (84.2% vs 85.6%, p=0.703) or the proportion who were virally suppressed (97% vs 97%, p=0.999) in the co-morbidity club compared to the HIV-only club. In multivariable logistic regression models, adjusted for age, sex and duration on ART, there was no significant difference in retention (adjusted odds ratio [aOR] 0.75 95% confidence interval [CI] 0.38, 1.47) or viral suppression (aOR 0.98 95% CI 0.23, 4.14) by club model. The most common reason for loss of retention from the HIV-only club was non-attendance whereas for the co-morbidity club it was being sent back to clinic for high blood pressure. This study provides early evidence of comparable short-term patient outcomes between HIV-only and co-morbidity club models and provides reassurance that co-morbidity clubs can be implemented without affecting the outcomes of HIV care. It also provides early promise that, whilst the differential reasons for loss of retention by club model merit further investigation, patients with HIV and hypertension and/or diabetes can safely be managed in co-morbidity clubs.
Open Access
A systematic review of interventions to improve adherence to anti-diabetic medications in patients with type 2 diabetes in sub-Saharan Africa
(2022) Iyun, Oluwatosin Busola; Myer, Landon
Background: Diabetes Mellitus is a worldwide public health issue that affects millions of people. It is among the ten-leading causes of death worldwide. In 2019, the International Diabetes Federation projected that 463 million adults had diabetes and 4.2 million died from the disease and its complications. Given that diabetes can be effectively controlled with education, counselling, and the adaptation of healthy lifestyles, as well as drug therapy, the number of deaths is high. Increasing evidence of alarmingly low adherence rates, which limit clinical benefits, suggests that improving the effectiveness of adherence interventions can impact public health much better than any advancement in definitive medical therapies. The World Health Organisation has strongly supported the recommendations for evaluating the effectiveness of health interventions in practice, especially those addressing adherence. Methods: This is a systematic review that aims to undertake a quantitative review of interventions to improve adherence to anti-diabetic medications for adults with type 2 diabetes in subSaharan Africa, and the impact of these interventions in achieving good glycaemic control. For the evaluation of these interventions, only randomized controlled trials will be considered. We will perform electronic searches of all published papers available on PubMed. The reference lists of all relevant articles, abstracts, and conference published records will be manually searched. A search of Grey literature sites such as Google and Google scholar, as well as the Networked Digital Library of Theses and Dissertations, will be undertaken. A data extraction form will be used. All studies will be screened by two independent reviewers for articles that meet the inclusion criteria. Relevant data will be extracted, and the methodological quality of all included studies will be assessed based on selection, performance, attrition, detection, and reporting biases. We will perform a meta-analysis on the included studies. The statistical heterogeneity in the included studies will be determined using the Chi-squared test (χ2) test of homogeneity and quantified using I 2 statistic. A narrative summary of findings will be presented if data is too heterogeneous. Discussion: This review will provide evidence to assist policymakers and public health experts in making decisions and prioritizing effective interventions that have been identified.
Open Access
Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study
(BioMed Central, 2017-08-22) Constant, Deborah; Harries, Jane; Moodley, Jennifer; Myer, Landon
Background: The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs) , and explores providers’ and CHWs’ perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. Methods: We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. Results: Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. Conclusions: If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women’s privacy needs and address healthcare workers’ concerns on managing any procedural risk.
Open Access
Adherence in HIV-positive women entering antenatal care on antiretroviral therapy: A cross-sectional study
(2015) O'Sullivan, Briana Jean; Myer, Landon
Proper implementation of and adherence to antiretroviral therapy (ART) is significantly associated with better health and longer life in HIV-positive individuals. Consistent, adequate adherence has been shown to lead to a suppressed viral load. A low viral load delays the virus's progression and leads to better health outcomes for the individual. Adequate adherence is especially important among HIV-positive pregnant women. How well a woman adheres to her ART can not only improve her health during pregnancy but can protect the infant from HIV by preventing in utero transmission of the virus. Continuing ART protects against transmission via breastmilk later in the infant's life. While the benefits of good adherence are undeniable, the definition of adequate adherence varies widely in the literature. Taking 80 to 100% of pills as prescribed is commonly used as the threshold for adequate adherence levels. Various methods exist for measuring ART adherence, and while some are more reliable than others, there is no gold standard. This ambiguity in ART research extends to pregnant women, with even less known about HIV infected women established already on ART who then become pregnant. Changes in treatment protocols in the Western Cape and improvement of ART delivery throughout South Africa have resulted in this group of long-term users growing in size. Without more research into the barriers of ART adherence in these women, efforts to scale up treatment programs and to end mother to child transmission of HIV will ultimately fail. This dissertation is an exploration of these ideas. It begins to fill the gap in current knowledge related to ART compliance in pregnant women, and gives new insights into how specific barriers to adherence can adversely affect this specific group of established ART users.
Open Access
Adherence to antiretroviral treatment (ART) among HIV-infected pregnant women starting treatment immediately vs delayed: a cohort study
(2016) Langwenya, Nontokozo; Myer, Landon; Phillips, Tammy
Introduction: Use of highly effective antiretroviral drugs to eliminate new paediatric HIV infections is the keystone of all prevention of mother-to-child transmission (PMTCT) programmes. Time on antiretroviral treatment (ART) before delivery reduces maternal viral load and decreases the risk of transmission in utero, during labour and whilst breastfeeding. Currently, many PMTCT programmes across Africa initiate HIV-infected pregnant women on lifelong antiretroviral therapy (ART) on the first day of antenatal care ("same-day" initiation). However concerns have been raised regarding patient readiness and whether same-day initiation in pregnancy may contribute to subsequent ART non-adherence. Methods: As part of a larger study of ART in pregnancy, consecutive ART-eligible pregnant women making their first antenatal care (ANC) visit at a primary care facility in Cape Town, South Africa were enrolled into a prospective cohort between March 2013 and June 2014. Before July 2013, eligibility was based on CD4 cell count ≤350 cells/μL ("Option A"), with a 1-2 week delay from the first ANC visit to ART initiation; thereafter all women were eligible regardless of CD4 cell count ("Option B+") and typically offered ART on the same day as first ANC visit. All women received standardized counselling before starting a fixed-dose regimen. Study interviews were conducted separately from the ART service through one week postpartum with self-reported adherence from 30- day recall. Results: Among 625 consecutive ART-eligible women (median age, 28 years; median gestation, 21 weeks; 55% newly diagnosed with HIV), 72% of women started ART same-day; this proportion was higher under "Option B+" versus "Option A" (p< 0.001). Of those with adherence assessments data available (n=618), 29% reported at least one missed ART dose during pregnancy. Missed doses were reported more frequently among women with previous use of PMTCT (p=0.014), of younger age (p=0.029) and starting ART under Option B+ (p=0.019). In women initiating ART same-day, 31% reported a missed dose compared to 23% among women who delayed ART start following first ANC visit (odds ratio, 1.07; 95% CI: 0.61 – 1.88). This finding did not vary after adjustment for demographic and clinical measures, and was consistent when restricted to women with CD4 cell counts ≤350 cells/μL. Conclusions: These results suggest same-day ART initiation in pregnant women is not associated with increased non-adherence during the antenatal period. While these results are reassuring for ART programmes implementing "Option B+", further research is required to examine adherence over time, particularly postpartum.
Open Access
Admission trends at Red Cross War Memorial Children's Hospital, Cape Town: 2004 to 2013
(2016) Isaacs, Yumnah; Myer, Landon; Zar, Heather J
Background: Hospital database research has the potential to provide useful insights into health systems functioning, population health, clinical conditions and epidemiological trends thereof. This type of research is routinely done in countries that have large national hospital databases where results are usually extrapolated to the national population. South Africa does not have a national hospital database, but individual healthcare institutions, such as the Red Cross War Memorial Children's Hospital (RCCH) in Cape Town, collects routine patient data in a computerised database that if tapped should yield valuable information about child health of the catchment population as well as of the functioning of that health institution. Methods: Selected data from the RCCH database were converted into spreadsheet format and then exported into a statistical programme, Stata. Variables included patient demographic details, ICD-10 diagnostic codes, length of hospital stay and outcomes at discharge. Stata was used to clean and code the data and perform basic descriptive analyses of contained variables. Medians and interquartile ranges described numerical variables. Frequencies, proportions and percentages described categorical variables. Appropriate tests of statistical significance were performed where applicable. Admission and mortality trends were analysed across a decade and common conditions were explored. Findings and Conclusions: Overall admissions to RCCH increased by 9.3% across a decade while the number of new patients decreased by 8.6%, indicating an increase in readmissions. In-patient mortality decreased consistently across a decade despite an increase in admissions, which suggests an improvement in quality of care. The median ages of admissions and deaths increased across the decade, which correlates with less HIV and improved management thereof. Infections remain the commonest causes of in-hospital mortality. Admissions and mortality for diarrhoea and pneumonia displayed a consistent decline across 6 years corresponding with the introduction of new vaccines; however, diarrhoea and lower respiratory tract illness remained the commonest causes of medical admission. Injuries were the commonest reason for surgical admissions. Computerised hospital databases contain useful information for healthcare research.
Open Access
Adverse outcomes associated with timing of antenatal care initiation a retrospective cohort study of pregnancies in Cape Town, South Africa
(2012) Beauclair, Roxanne; Myer, Landon
The medical community tends to advocate for early initiation of antenatal care (ANC) for the prevention of adverse birth outcomes. Despite this suggestion, the population impact of early ANC remains unclear. To this end, we have undertaken a retrospective cohort study of pregnant women using public perinatal services in Cape Town, South Africa. The study includes all women (n=35,473) from the CRADLE database who gave birth between 01 January 2007 and 31 December 2009 and had a booking examination between 01 April 2006 and 31 March 2009.
Open Access
Antiretroviral therapy use during pregnancy and adverse birth outcomes in South African women
(2017) Malaba, Thokozile Rosemary; Myer, Landon
Background Studies suggest antiretroviral therapy (ART) use during pregnancy may be associated with adverse pregnancy outcomes. Given the large numbers of pregnancies exposed to ART, better understandings of potential associations with commonly used ART regimens and adverse pregnancy outcomes is critical. With the number of women on ART initiated before conception rapidly increasing, understanding how current recommended regimens and timing of ART initiation may influence pregnancy outcomes is critically important. Methods This mini-dissertation presents a research protocol (Section A), literature view (Section B) and journalformatted manuscript (Section C) for a study of ART use and birth outcomes among HIV-infected women and a comparator cohort of HIV-uninfected women. Pregnant women seeking care at the Gugulethu MOU, a primary-level antenatal care facility in Cape Town, South Africa were enrolled between March 2013 and August 2015. Pregnancy dating was based on research ultrasound, or last menstrual period/clinical exam where ultrasound was unavailable. Women were followed from their 1st antenatal visit through delivery. Analyses compared birth outcomes (preterm (PTD), low birthweight (LBW) and small for gestational age (SGA) deliveries) between HIV-infected and uninfected women; and between women on ART initiated before conception versus those initiating ART during pregnancy. Results In 1554 women with live singleton births (mean birthweight, 3079g; 21% preterm; 13% LBW; 12% SGA), a higher prevalence of PTD (22% vs 13%, p=0.001) and LBW (14% vs 9%, p=0.030) were observed in the HIV-infected compared to HIV-uninfected women. Adverse birth outcomes (PTD, LBW and SGA) did not vary systematically among the HIV-infected women regardless of ART initiation timing (initiated ART before conception or initiated ART to during pregnancy). The absence of associations between the adverse birth outcomes and timing of ART initiation persisted after adjusting for maternal age, parity, height, CD4 cell count and viral load at 1st visit. Conclusions Levels of adverse birth outcomes, in particular PTD, remain high among HIV-infected women, however our findings from a routine care cohort demonstrate that the timing of initiation of widely used regimens before conception or during pregnancy do not appear to be associated with an increased risk in adverse pregnancy outcomes.
Open Access
Association between depression and perceived parental traits : results from a nationally representative South African survey
(2011) Srubisky, Catherine Filippa; Myer, Landon
With a growing burden of disease and disability stemming from mental disorders in South Africa, additional research into this area may be justified, with specific reference to depression. The effects of parental influences have been explored in the literature as a relevant and valid risk factor in the development and presence of depression. The literature has suggested two main underlying themes of parental styles that included parental overprotection and care. The concept of overprotection has been associated with depression. This thesis explored these constructs in their association with depression whilst highlighting the influence of control. Furthermore the influences of parental depression were also included.
Open Access
Association between high body mass index and adverse birth outcomes by HIV and ART status in Cape Town, South Africa
(2019) Madlala, Hlengiwe Pretty; Myer, Landon; Malaba, Thokozile R.
Background: Tested independently, studies report that obesity and HIV infection and/or ART use in pregnancy are associated with adverse birth outcomes. However, there is limited data on the combined impact of these maternal factors on adverse birth outcomes. Given the high prevalence of obesity and HIV infection in Sub-Saharan Africa (SSA), understanding these associations is important. This study examined the association of the double burden of high maternal body mass index and HIV infection/ART use in pregnancy with adverse birth outcomes. Methods: Part A of this mini-dissertation presents the study protocol which outlines the rationale, aim and objectives of the study; the research methodology, analysis plan and ethical considerations. Part B is the literature review of studies conducted in SSA which investigated the relationship between BMI and HIV infection and adverse birth outcomes of interest. Part C is the journal-formatted manuscript which presents the results and discussion of the study findings in relation to other scholars. The referencing style used for the whole thesis is Vancouver as required by the journal chosen for the formatting of the manuscript. We used data collected from a large observational Prematurity Study that enrolled HIV-infected and HIV-uninfected women seeking antenatal care at Gugulethu MOU in Cape Town between April 2015 and October 2016. A subset of HIV-infected women who booked early (≤24weeks) was prospectively followed through delivery and was used to study gestational weight gain (GWG) and adverse birth outcomes. Data was obtained from review of medical records and study questionnaires. Logistic regression was used to compare birth outcomes by BMI status: preterm delivery (PTD), low/high birthweight (LBW/HBW) and small/large gestational age (SGA/LGA) between HIV-uninfected and -infected women; and between HIV-infected women who initiated ART before pregnancy and those who initiated ART during pregnancy. Using the subset of HIV-infected women who booked early (≤24weeks), we compared the adverse birth outcomes between low, adequate and high GWG. Results: Of the 2779 participants included in the analysis, 20% had normal BMI, 29% were overweight, 51% were obese and 39% were HIV-infected. Overall, there was no association between obese BMI and PTD (aOR 1.06, 95% CI 0.75-1.49). Instead, obese BMI was negatively associated with LBW (aOR 0.53; CI: 0.39-0.72) and SGA infants (aOR 0.55, 95% CI 0.41-0.75) compared to normal BMI women. Stratifying by HIV infection showed similar results for LBW (aOR 0.54; CI: 0.35-0.83) and SGA (aOR 0.60, 95% CI 0.38-0.94) in obese HIV-infected women compared to corresponding women with normal BMI. However, comparison of obese HIV-uninfected and obese HIV-infected women showed a higher incidence of LBW and SGA infants in obese HIV-infected women (12% vs 8%). The association of obese BMI and LBW and SGA in HIV-infected women did not differ by timing of ART initiation. In terms of HBW and LGA, overall, obese BMI was positively associated with HBW (aOR 2.00; CI: 1.13-3.57) and LGA infants (aOR 1.98, 95% CI 1.40-2.80) compared to normal BMI women. Stratifying by HIV infection also showed a positive association between obese BMI and HBW (aOR 2.54; CI: 1.17-5.53) and LGA (aOR 2.30; CI: 1.46-3.62) in HIV-uninfected women. Although a similar positive association was also obtained in obese HIV-infected women, the strength of this association was weaker for both HBW (aOR 1.41; CI: 0.59-3.34) and LGA (aOR 1.58; CI: 0.91-2.72). When the analysis was restricted to HIV-infected women by timing of ART initiation we found that obese women who initiated ART during pregnancy had 3-fold likelihood of having LGA infants (aOR 3.26; CI: 1.32-8.09) and those who initiated ART before pregnancy had a reversed effect (aOR 0.87; CI: 0.43-1.78) compared to respective normal BMI women. However, restricting the analysis to obese HIV-infected women only revealed a counter effect of the two conditions where the frequencies of both LGA and SGA are high. Abnormal gestational weight gain had no association with PTD, LBW, HBW and SGA. However, we showed that GWG lower than the IOM recommended values reduced the likelihood of having LGA infants (aOR 0.29; CI: 0.12-0.70) compared to adequate GWG. Conclusions: Obese HIV-infected women appear to be cushioned by their BMI against LBW and SGA when compared to normal BMI. However, comparison of these outcomes amongst women who are either obese or HIV-infected reveal a higher burden of both SGA and LGA infants in obese HIV-infected women, regardless of ART initiation status.
Open Access
The association between hypertension and depression and anxiety disorders: results from a nationally-representative sample of South African adults
(Public Library of Science, 2009) Grimsrud, Anna; Stein, Dan J; Seedat, Soraya; Williams, David; Myer, Landon
Objective: Growing evidence suggests high levels of comorbidity between hypertension and mental illness but there are few data from low- and middle-income countries. We examined the association between hypertension and depression and anxiety in South Africa. METHODS: Data come from a nationally-representative survey of adults (n = 4351). The Composite International Diagnostic Interview was used to measure DSM-IV mental disorders during the previous 12-months. The relationships between self-reported hypertension and anxiety disorders, depressive disorders and comorbid anxiety-depression were assessed after adjustment for participant characteristics including experience of trauma and other chronic physical conditions. RESULTS: Overall 16.7% reported a previous medical diagnosis of hypertension, and 8.1% and 4.9% were found to have a 12-month anxiety or depressive disorder, respectively. In adjusted analyses, hypertension diagnosis was associated with 12-month anxiety disorders [Odds ratio (OR) = 1.55, 95% Confidence interval (CI) = 1.10-2.18] but not 12-month depressive disorders or 12-month comorbid anxiety-depression. Hypertension in the absence of other chronic physical conditions was not associated with any of the 12-month mental health outcomes (p-values all <0.05), while being diagnosed with both hypertension and another chronic physical condition were associated with 12-month anxiety disorders (OR = 2.25, 95% CI = 1.46-3.45), but not 12-month depressive disorders or comorbid anxiety-depression. CONCLUSIONS: These are the first population-based estimates to demonstrate an association between hypertension and mental disorders in sub-Saharan Africa. Further investigation is needed into role of traumatic life events in the aetiology of hypertension as well as the temporality of the association between hypertension and mental disorders.
Open Access
The association between timing of initiation of antenatal care and stillbirths: a retrospective cohort study of pregnant women in Cape Town, South Africa
(BioMed Central, 2014-06-13) Beauclair, Roxanne; Petro, Greg; Myer, Landon
Background: There is renewed interest in stillbirth prevention for lower-middle income countries. Early initiation of and properly timed antenatal care (ANC) is thought to reduce the risk of many adverse birth outcomes. To this end we examined if timing of the first ANC visit influences the risk of stillbirth. Methods: We conducted an analysis of a retrospective cohort of women (n = 34,671) with singleton births in a public perinatal service in Cape Town, South Africa. The main exposure was the gestational age at the first ANC visit. Bivariable analyses examining maternal characteristics by stillbirth status and gestational age at the first ANC visit, were conducted. Logistic regression, adjusting for maternal characteristics, was conducted to determine the risk of stillbirth. Results: Of the 34,671 women who initiated ANC, 27,713 women (80%) were retained until delivery. The population stillbirth rate was 4.3 per 1000 births. The adjusted models indicated there was no effect of gestational age at first ANC visit on stillbirth outcomes when analyzed as a continuous variable (aOR 1.01; 95% CI: 0.99-1.04) or in trimesters (2nd Trimester aOR 0.78, 95% CI: 0.39-1.59; 3rd Trimester OR 1.03, 95% CI: 0.50-2.13, both with 1st Trimester as reference category). The findings were unchanged in sensitivity analyses of unobserved outcomes in non-retained women. Conclusion: The timing of a woman’s first ANC visit may not be an important determinant of stillbirths in isolation. Further research is required to examine how quality of care, incorporating established, effective biomedical interventions, influences outcomes in this setting.
Open Access
Availability of antiretroviral therapy is associated with increased uptake of HIV testing services
(2005) Mfundisi, Coceka; Chiranjan, Nirasha; Rodrigues, Charl; Kirchner, Launel; Bock, Peter; Myer, Landon
Voluntary counselling and testing (VCT) is an important tool in HIV prevention efforts and in the identification of HIV-infected individuals for care and treatment services. But despite the central role of VCT in the response to HIV/AIDS, less than 20% of South Africans have been tested for HIV. Although there are substantial barriers to seeking VCT, including quality of services and AIDS-related stigma, improving VCT rates remains a critical part of the response to the HIV/AIDS epidemic. Recently there has been particular interest in the potential influence of access to antiretroviral therapy (ART) on demand for HIV testing services. It has been suggested that the availability of effective treatment for HIV/AIDS may help motivate individuals to find out their HIV status. However, this possibility remains largely hypothetical and there have been few studies investigating this question. In light of the importance of VCT as an entry point to HIV prevention interventions and treatment services, the possible impact of ART availability on VCT uptake has major implications for the public health response to HIV/AIDS in South Africa. We investigated whether the availability of ART was associated with HIV testing among individuals attending the site B day hospital in Khayelitsha near Cape Town, the setting for a well-publicised antiretroviral pilot.
Open Access
Bacterial disease and antimicrobial susceptibility patterns in HIV-infected, hospitalized children: a retrospective cohort study
(Public Library of Science, 2008) Jaspan, Heather B; Huang, Lyen C; Cotton, Mark F; Whitelaw, Andrew; Myer, Landon
BACKGROUND: Serious bacterial infections are a major source of morbidity and mortality in HIV-infected children. The spectrum of disease is wide, and responsible organisms vary according to setting. The use of antibiotic prophylaxis and the emergence of multi-drug resistant bacteria necessitate examination of responsible organisms and their antibiotic susceptibility. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective cohort study of all HIV-positive pediatric admissions at an urban public sector hospital in Cape Town between January 2002 and June 2006 was conducted. Children between the ages of one month and nine years with laboratory confirmed HIV status, serious bacterial infection, and a hospital length of stay of 5 days or more, were eligible for inclusion. Organisms isolated from blood, urine, and cerebral spinal fluid cultures and their antimicrobial susceptibility were examined, and compared according to timing of isolation to distinguish nosocomial versus community-acquired. One hundred and forty-one children were identified (median age 1.2 years), 39% of whom were on antiretrovirals started before or during this hospitalization. Bacterial infections involved all organ systems, however pneumonia was most common (67%). S. pneumoniae and S. aureus were the most common gram positive and K. pneumoniae was the most common gram negative organism. K pneumoniae isolates were resistant to many first and second line antibiotics, and were all considered nosocomial. All S. aureus isolates were methicillin resistant, some of which were community-acquired. Conclusions/Significance Bacterial infections are an important source of co-morbidity in HIV-infected children in resource-limited settings. Clinicians should have a low threshold to initiate antibiotics in children requiring hospitalization. Broad-spectrum antibiotics should be used judiciously. Clinicians caring for HIV-infected children should be cognizant of the most common organisms affecting such children, and of their local antimicrobial susceptibilities, when treating empirically for serious bacterial infections.
Open Access
Brachytherapy and endoresection in the treatment of choroidal melanoma a review of patients treated in South Africa
(2012) Rice, James C; Myer, Landon
This study is a retrospective cohort analysis of patients undergoing two different treatment modalities (brachytherapy and endoresection) for medium sized choroidal melanoma. Study methods involve the collection of baseline and follow-up data from three sources: 1) A database collected by the department of Radiation Oncology at Groote Schuur Hospital; 2) Private physicians responsible for patient follow-up following brachytherapy; 3) Private physicians responsible for endoresection surgery and patient follow-up. To date there has been limited publication of the outcomes of patients treated for choroidal melanoma in South Africa. The study aims to compare the outcomes of these procedures to help identify the possible benefits of each form of treatment.
Open Access
A brief intervention to promote IUD use among women in Cape Town
(2013) Trasada, Phumelele; Myer, Landon
While the Copper T intrauterine device (IUD) is one of the most used methods of contraception around the world, only 1% of women in sub-Saharan Africa use this method. The IUD is a safe and highly effective form of long-acting contraception that provides protection for up to 10 years and has a lowrisk of pregnancy (less than 1% during the first year of use). The IUD is highly beneficial in that it can provide protection for women who want to delay or space childbearing and unlike methods such as the injectable or oral contraceptive, does not require users to make numerous visits to their health care facility or obtain a further supply. The IUD is free in the public sector in South Africa, but remains an unpopular choice among women. The purpose of this study was to test the effectiveness of a brief counselling intervention on the uptake of the IUD among women in Cape Town, South Africa. Part A of this dissertation (Protocol) is comprised of a proposal that was accepted by the University of Cape Town (UCT) Human Research Ethics Committee (HREC) and the Provincial Government of the Western Cape (PGWC). It describes the study background and methods. Part B (Literature Review) presents the current state of IUD use in sub-Saharan Africa as well as the level ofunmet need for contraception in the region. It illustrates the effectiveness of the IUD and gives a summary of interventions related to IUD uptake. It also discusses the need for increased use of the long acting and permanent methods in sub-Saharan Africa. Part C (Article) presents the results as a journal article. The incidence of the primary outcome was lower than expected. Five percent of women assigned to the control group went to family planning to make an appointment for IUD insertion, while 4% of those in the intervention group made an IUD insertion appointment. Knowledge of the IUD was not high with only 46% of women having heard of the method. After being given a description of the IUD, 36% of women said they would consider using the IUD. Twenty-seven percent of women stated that they would be interested in receiving an IUD that day. The method was not often mentioned to clients as only 16% reported having discussed the IUD with a health provider. Chi-squared analysis identified characteristics which were related to a participant being aware of the IUD. In this regard, being older and having higher gravidity were both significantly associated factors. The results suggest that IUD is a method that women are interested in learning more about and potentially using. It is clear that a more intensive and comprehensive campaign is needed in order to increase demand for the IUD in South Africa.
Open Access
CareConekta: study protocol for a randomized controlled trial of a mobile health intervention to improve engagement in postpartum HIV care in South Africa
(2020-03-12) Clouse, Kate; Phillips, Tamsin K; Camlin, Carol; Noholoza, Sandisiwe; Mogoba, Phepo; Naidoo, Julian; Langford, Richard; Weiss, Martin; Seebregts, Christopher J; Myer, Landon
Abstract Background South Africa is home to the world’s largest antiretroviral therapy program but sustaining engagement along the HIV care continuum has proven challenging in the country and throughout the wider region. Population mobility is common in South Africa, but there are important research gaps in describing this mobility and its impact on engagement in HIV care. Postpartum women and their infants in South Africa are known to be at high risk of dropping out of HIV care after delivery and are frequently mobile. Methods In 2017, we developed a beta version of a smartphone application (app) - CareConekta - that detects a user’s smartphone location to allow for prospective characterization of mobility. Now we will adapt and test CareConekta to conduct essential formative work on mobility and evaluate an intervention - the CareConekta app plus text notifications and phone calls and/or WhatsApp messages - to facilitate engagement in HIV care during times of mobility. During the 3-year project period, our first objective is to evaluate the feasibility, acceptability, and initial efficacy of using CareConekta as an intervention to improve engagement in HIV care. Our second objective is to characterize mobility among South African women during the peripartum period and its impact on engagement in HIV care. We will enroll 200 eligible pregnant women living with HIV and receiving care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Discussion This work will provide critical information about mobility during the peripartum period and the impact on engagement in HIV care. Simultaneously, we will pilot test an intervention to improve engagement with rigorously assessed outcomes. If successful, CareConekta offers tremendous potential as a research and service tool that can be adapted and evaluated in multiple geographic regions, study contexts, and patient populations. Trial registration ClinicalTrials.gov: NCT03836625. Registered on 8 February 2019.
Open Access
CD4 cell count recovery among HIV-infected patients with very advanced immunodeficiency commencing antiretroviral treatment in sub-Saharan Africa
(BioMed Central Ltd, 2006) Lawn, Stephen; Myer, Landon; Bekker, Linda-Gail; Wood, Robin
BACKGROUND:Patients accessing antiretroviral treatment (ART) programmes in sub-Saharan Africa frequently have very advanced immunodeficiency. Previous data suggest that such patients may have diminished capacity for CD4 cell count recovery. METHODS: Rates of CD4 cell increase were determined over 48 weeks among ART-naive individuals (n = 596) commencing ART in a South African community-based ART programme. RESULTS: The CD4 cell count increased from a median of 97 cells/mul at baseline to 261 cells/mul at 48 weeks and the proportion of patients with a CD4 cell count <100 cells/mul decreased from 51% at baseline to just 4% at 48 weeks. A rapid first phase of recovery (0-16 weeks, median rate = 25.5 cells/mul/month) was followed by a slower second phase (16-48 weeks, median rate = 7.7 cells/mul/month). Compared to patients with higher baseline counts, multivariate analysis showed that those with baseline CD4 counts <50 cells/mul had similar rates of phase 1 CD4 cell recovery (P = 0.42), greater rates of phase 2 recovery (P = 0.007) and a lower risk of immunological non-response (P = 0.016). Among those that achieved a CD4 cell count >500 cells/mul at 48 weeks, 19% had baseline CD4 cell counts <50 cells/mul. However, the proportion of these patients that attained a CD4 count 200 cells/mul at 48 weeks was lower than those with higher baseline CD4 cell counts. CONCLUSION: Patients in this cohort with baseline CD4 cell counts <50 cells/mul have equivalent or greater capacity for immunological recovery during 48 weeks of ART compared to those with higher baseline CD4 cell counts. However, their CD4 counts remain <200 cells/mul for a longer period, potentially increasing their risk of morbidity and mortality in the first year of ART.
Open Access
Chronic morbidities in perinatally HIV-acquired adolescents on antiretroviral therapy
(2022) Mahtab, Sana; Zar, Heather; Myer, Landon
of children perinatally infected with HIV, with an increasing number surviving into adolescence, accompanied by the development of chronic comorbidities. However, there is limited knowledge on the spectrum of comorbidities, determinants, and risk factors among youth living with perinatally acquired HIV (YLPHIV) especially in sub-Saharan Africa, with most data from high-income countries. There is a critical need for data on health and chronic comorbidities among YLPHIV from countries with a high HIV prevalence. Aim: To investigate the spectrum and determinants of HIV-associated comorbidities among YLPHIV on ART in Cape Town, South Africa. Specific objectives were to investigate cardiovascular, musculoskeletal, mental health and metabolic outcomes in YLPHIV compared to HIV-uninfected adolescents. Method: In a prospective study YLPHIV on ART were enrolled in the Cape Town Adolescent Antiretroviral Cohort (CTAAC) from seven health-care sites in Cape Town, South Africa, between July 2013 – April 2015. Eligibility criteria were adolescents, 9-14 years old, with perinatally acquired HIV, been on ART for at least six months, and who were aware of their HIV status. A control group of HIVuninfected adolescents' frequency-matched by age and sex was also enrolled. The cohort was longitudinally followed for development or progression of comorbidities with clinical and laboratory measurements. Comorbidities assessed included: (1) cardiovascular health: echocardiography was used to investigate cardiac structure and endothelial peripheral arterial tonometry technique (EndoPAT) was used for endothelial function. The pathobiological determinants of atherosclerosis in youth (PDAY) risk score was used to assess long-term cardiovascular risk for atherosclerotic disease at the coronary artery (CA) and abdominal aorta (AA). A PDAY score ≥1 was regarded as elevated; (2) bone health: quantitative ultrasound was used to evaluate calcaneal stiffness index (SI); (3) mental health: the Child Behavior Checklist (CBCL) and BECK youth inventories were utilised. The association of mental health with metabolic abnormalities was investigated. Statistical analyses included descriptive data and regression modelling analysis, using the software, Stata® 14.2 to 16 (Stata Corp LP. College Station, Texas, USA). Results: Overall, 515 YLPHIV and 110 HIV-uninfected participants with median age 12.0 years (IQR 11.9, 10.7) and 11.8 years (IQR 11.7, 10.0) were enrolled; YLPHIV with median duration of ART of 7.6 years (IQR: 4.6–9.2), also had a median CD4 cell count of 713 cells/mm3 (IQR: 561.0–957.5), and 387 (75%) had a viral load (VL) of 500 cell/mm3 (RR 1.04, p=0.76), VL (RR 1.01, p=0.78) or current ART class (protease inhibitor-based vs non-nucleoside inhibitor-based, RR 0.90, p=0.186) were not associated with ED after adjustment. At 48 months of follow-up, among YLPHIV, 8% (n=17) had sustained viraemia, and 54% (n=118) had transient viraemia through this period. The median duration on ART was 12 years (IQR 8-14); 57% (n=124) were on a non-nucleoside reverse transcriptase inhibitor-based ART, while the rest received protease inhibitor-based ART. Few YLPHIV met the criteria for hypertension (2%, n=4) or hyperglycaemia (0.5%, n=1). None of the HIV-uninfected youth had hypertension or hyperglycaemia. Fewer YLPHIV smoked compared to the uninfected youth (15.6% vs 11.5%, p=0.50. Elevated PDAY scores for CA (30.3% [n=66] vs 31.3% [n=10], p=0.74) and AA (18.4% [n=40] vs 21.9% [n=7], p=0.20), respectively among YLPHIV and HIV-uninfected adolescents differed slightly but did not reach statistical significance. Among YLPHIV, sustained viraemia [adjusted odds ratio (aOR)=18.4, p50 copies/ml (OR=2.06, p=0.023) were associated with an increased risk of low SI, while the use of efavirenz (OR=0.41, p=0.009) was associated with a decreased risk of low SI. YLPHIV had more impairment in mental health in several domains: functional competence (40% vs 25%, p=0.02), self-concept (23% vs 9%, p=0.03), higher depression (6% vs 2%, p< 0.01), anger (6% vs 2%, p=0.04), and disruptive behaviour (4% vs 0%, p p<0.01). Among YLPHIV, higher levels of anger were associated with increased total cholesterol and low-density lipoprotein (LDL) levels (ß=0.010, p=0.041 and ß=0.012, p=0.048, respectively), higher disruptive behaviour with increased LDL levels (ß=0.010, p=0.043), and severer CBCL-internalizing problems with low albumin levels (ß=-0.067, p=0.052) after adjusting for age, sex, and BMI z-score. Conclusion: YLPHIV are at higher risk of having subclinical cardiac structural abnormality and ED compared to uninfected adolescents. Both groups had a substantial proportion with high PDAY scores reflecting increased aggregate atherosclerotic risk. Bone health was worse among YLPHIV. HIV-related factors such as ART initiation at an older age, advanced clinical disease, and specific ARTs were significant risk factors for these conditions. Mental health impairment was common and associated with increased lipid concentration in YLPHIV. These data highlight a high prevalence of chronic comorbidities in YLPHIV, specific risk factors associated with these and provide information for strengthened strategies to prevent or monitor HIV-associated illnesses.
Open Access
Clinical outcomes and women's experiences before and after the introduction of mifepristone into second-trimester medical abortion services in South Africa
(Public Library of Science, 2016) Constant, Deborah; Harries, Jane; Malaba, Thokozile; Myer, Landon; Patel, Malika; Petro, Gregory; Grossman, Daniel
Objective To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. METHODS: Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort. RESULTS: The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. CONCLUSION: The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.