Browsing by Subject "Epidemiology and Biostatistics"

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    A cross-sectional analysis on the association between pain and making tradeoffs for survival using a multidimensional health assessment tool among older adults living in low-to middle-income areas in Cape Town, South Africa
    (2021) Steyn, Simone; Malaba, Thokozile; Geffen, Leon
    Introduction Globally, the population of older adults is ageing rapidly, due to increased longevity and decreasing fertility rates. With the rapidly accelerating growth of this ageing population in low-to-middle income countries, the health systems are not well resourced to manage this rapid growth that are required to accommodate older multimorbid populations. Multimorbidity presents as an elevated risk for the health and wellbeing of older populations and occurs when more than one chronic condition is present. Globally pain is a common symptom among older adults that impairs health with severe consequences especially when multimorbidity is present. Some evidence has shown that living under poverty-stricken conditions is associated with increased pain, particularly among vulnerable populations such as older adults. There is limited evidence in Cape Town on the relationship between living in low-to middle income areas and poverty indicators such as making financial trade-offs for survival with increased reports of pain in older adults. Methods In this cross-sectional analysis, adults aged 60 years and above seeking care from four selected primary health care clinics and health clubs were enrolled in an ongoing longitudinal study (Wellbeing Study). Data was used from an existing study that commenced in March 2018. Data were collected using a multidimensional geriatric instrument called the Check-Up Self-Report (interRAI). The researcher assessed the relationship between financial trade-offs made for survival (as a proxy for poverty) and pain in the last three days (as a proxy for pain) overall, and according to study sites. Permission for the parent study was sought and granted by the University of Cape Town's Health Research Ethics Committee (UCT-HREC, Ref: 790/2017) as well as by the Western Cape Department of Health. Results The results highlighted that overall and by site, no associations were observed between pain and financial trade-offs after adjusting for various health-related variables (aOR: 1.17, 95% CI: 0.97 – 1.42). Of the 1813 older adults included in this analysis (64% female, median age 68 years (IQR: 64-74)) 51% reported making financial trade-offs and 46% reported experiencing pain in the last three days. Overall, a moderate proportion of participants (27%) reported daily pain, which was categorised as not severe (11%), severe (12%) and excruciating (4%). When assessed by site a significantly higher proportion of participants reported daily pain in Khayelitsha (43%) and Woodstock (40%). Conclusion In this study the need to make financial trade-offs for survival and pain were prevalent in this population. Although an association was not found between making financial trade-offs and recent pain, the results provided valuable information that can drive future research studies and policy. The use of this multidimensional tool which collects information from various health categories and provides broad and less in-depth data may have played a role in the nullified results. Further research is needed to evaluate the association of poverty indicators on pain in this population using more detailed pain and poverty assessment tools.
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    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.
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    Depression and HIV risk among female sex workers in Nelson Mandela Bay Municipality, South Africa: Results from a respondent-driven sampling study
    (2019) Rossouw, Johannes; Myer, Landon
    Sex workers have a higher risk of acquiring and transmitting HIV as a result of social, structural, biomedical and behavioural factors. Many recent studies have highlighted that sex workers and other key populations experience higher levels of depression compared to the general population. Evidence is also emerging that mental health issues such as depression are related to HIV risk behaviour as well as the social and structural factors that leave sex workers vulnerable to bio-behavioural risks. The study protocol is described in Part A of this mini-dissertation. The study from which these data were derived is discussed in detail. Particular attention is placed on the use of respondent-driven sampling as a probabilistic method to estimate population proportion for hidden populations. The primary outcome, depression, and how it is measured through the Patient Health Questionnaire 9, is discussed in detail. The objective of measuring the prevalence of depression and assessing how it relates to risk factors is noted. The protocol argues that most research on sex workers focuses only on social, structural and bio-behavioural risk factors and rarely includes intrapersonal factors such as mental health. Based on this gap, it is argued that this research will help elucidate how depression, as an intrapersonal factor, relates to HIV risk. The literature review in Part B expands the argument that mental health in general and depression in particular are not given the attention they deserve as there are very few studies that measure mental health variables and even fewer that attempt to make any link between mental health, bio-behavioural risk and social vulnerabilities. The journal article in Part C offers empirical evidence that depression is higher among female sex workers than the general population and that depression is strongly associated with bio-behavioural and social risk factors. The article argues for more integration of mental health in research and programme implementation among sex workers.
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    Descriptive analysis of routine childhood immunisation timelines in the Western Cape, South Africa
    (2021) Blose, Ntombifuthi J; Amponsah-Dacosta, Edina; Kagina, Benjamin M; Muloiwa, Rudzani
    Background: Adherence to the recommended age-specific immunisation schedules is critical in ensuring vaccine effectiveness against vaccine preventable diseases (VPDs). Delays in the uptake of routine childhood immunisations lead to an increase in children susceptible to VPDs. Catch-up vaccination campaigns are strategies aimed at minimising the time at risk of VPDs and alleviating missed immunisation opportunities. However, there is limited data on immunisation timeliness in the Western Cape to contribute to developing effective catch-up vaccination campaigns. Therefore, this study sought to assess the timeliness of age-specific routine childhood immunisation within the Western Cape province of South Africa. Methods: We reviewed 709 participant records from a prospective health-facility based study conducted between 2012 and 2016 in Cape Town, South Africa. The primary outcome of interest was receiving age-specific immunisations ≥ 4 weeks (28 days) of that recommended for age as per the South African Expanded Programme on Immunisation (EPI) schedule. Using secondary data, the prevalence of delayed uptake of immunisations and time-at-risk for each vaccine was determined using proportions and medians and interquartile range (IQR). Multivariable logistic regression (p< 0.05) was used to determine the association between potential socio-economic risk factors and delayed uptake of routine childhood immunisations. Results: A total of 652/709 (91.9%) participants with a median age of 11 [IQR 4.5 – 28.0] months were eligible for analysis in this study. A trend of decreasing immunisation coverage with increasing age was observed among study participants. Notably, a trend of increasing delay in the uptake of routine vaccines and an increasing median time-at-risk of VPDs in age-specific immunisations was observed with increasing age. The highest delay in the uptake of vaccine doses was observed among the 3rd dose of the DTP3 vaccine 163 (34.6%), while the lowest was seen among the birth doses [(BCG – 40 (6.5%) and OPV – 43 (7%)]. The longest median time-at-risk of VPDs, was with the 2nd dose of the measles vaccine dose [12.9 (IQRs 6.7-38.6) weeks] and the lowest was OPV birth dose [6.3 (5.3-9.1) weeks]. Multivariable logistic regression analysis showed that participants who attended pre-school or creche compared to those who did not, were protected against delaying uptake of the 3 rd dose of the Hepatitis B vaccine and 2nd dose of the measles vaccine. While those who had adult caregivers compared to those who had adolescent caregivers, were protected against delaying the uptake of the 1 st rotavirus vaccine dose. Participants from households of low and upper-middle socio-economic IQR compared to high socio-economic status (SES) based on SES scores calculated from household data (i.e., availability and sources of amenities such as water, fuel, toilets, and level of maternal education) were more likely to delay uptake of the 3 rd does of the Pneumococcal Conjugate Vaccine and the 1 st dose of the measles vaccine, respectively. Conclusion: Using DTP3 coverage as proxy for national immunisation coverage, immunisation coverage in this population fell below the recommended 95% immunisation coverage rate. Additional population delays in the uptake of vaccine doses increases the time during which infants and children are susceptible to potential fatal VPDs. The observed increase in delayed immunisation and increased time-at-risk of VPDs, calls for an urgent need to address timing of vaccination particularly in late infancy and in the second year of life. There is an urgent need to develop strategies aimed at mitigating factors associated with delay in uptake of routine childhood vaccines in the Western Cape Province. Since creche attendance conferred protection against the delay in uptake of vaccines, mitigation strategies implemented upstream by the department of basic education, as well as health and immunisation service providers should strengthen collaborations to ensure that timely vaccine uptake among creche attendees is regularly monitored. Where delays are identified, catch-up strategies can be implemented at educational facilities or referrals to immunization clinics. It is important that this strategy is coupled with caregiver and healthcare worker vaccine education on the importance of timely immunisation uptake. Education about timely vaccine uptake will aid in the provision of informed council from healthcare providers to – not only adult caregivers - but adolescent caregivers as well, with the aim to reduce delayed uptake of vaccine amongst those raised by adolescent caregiver. The health system and the Expanded Programme of Immunisation on South Africa (EPISA) should couple these interventions with effective mobile reminder systems. These reminder systems will particularly serve the purpose to remind those caregivers whose delay uptake of vaccines as a result of a busy schedule. This could improve adherence to the recommended childhood immunisation schedule. Generally, for such interventions to work, effective monitoring and surveillance of immunisation services and vaccines is critical in achieving a high immunisation coverage and timely uptake of vaccines. Future studies should continuously monitor immunisation coverage and timeliness data in the Western Cape Province and South Africa as a whole to support evidence-based strengthening of provincial and national immunisation services.
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    Determinants of sexual risk behaviour among HIV-infected individuals across different health service settings in Cape Town
    (2009) Stinson, Kathryn Lee; Myer, Landon
    Sexual risk behaviour is the underlying driving force of HIV transmission. The discovery and introduction of antiretroviral therapy (ART) has led to significant changes in the treatment and management of HIV, the benefits of which manifest as reduced viral load and consequently attenuated morbidity and mortality in HIV-infected individuals. As the benefits of ART are realized, prevention research is increasingly focusing on the sexual risk behaviour of subpopulations of HIV-infected individuals with known positive serostatus, who are at high risk of transmitting HIV. This study examines the levels of sexual risk behaviour of HIV-infected individuals seeking care across different service settings in Cape Town, South Africa. Furthermore, it seeks to understand the risk factors associated with sexual activity that could lead to secondary transmission.
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    The effect of the Violence Prevention through Urban Upgrading (VPUU) intervention on violence-related injuries presenting to health facilities in Khayelitsha and Nyanga
    (2016) Trupe, Lydia; Matzopoulos, Richard; Bloch, Kimberly
    Background: Violence is one of the leading causes of morbidity and mortality in South Africa's Western Cape province. Recent efforts, both globally and locally, have focused on using emergency room surveillance systems to collect data on violent injuries and to use these data to inform comprehensive, sustainable interventions such as urban upgrading. Drawing on insights from criminology, these urban upgrading interventions have sought to use environmental design to ameliorate socio-ecological factors related to violence. Objective: To use injury surveillance data in order to describe the pattern of violent injuries presenting to health facilities in the communities of Khayelitsha and Nyanga and to assess the effect of the Violence Prevention through Urban Upgrading programme (VPUU) on risk of violent non-fatal injury in these two areas. Methods: We conducted a case-control study using data from a series of semi-annual rapid assessments to compare violent and non-violent injuries in adults presenting to five heath facilities in Khayelitsha and Nyanga between September 2013 and October 2015. Multivariable logistic regression was used to assess the risk of violent injury with respect to demographic and behavioural characteristics and exposure to the VPUU intervention. Results: Multivariable analysis of 1,753 complete cases revealed that living in a VPUU intervention area was protective against presentation for violent injury when controlling for other risk factors (OR=0.75, p=0.022). Age, gender, race, and alcohol consumption were also found to be significantly associated with presentation for violent injury. There was a statistically significant interaction effect between alcohol and gender; the association between alcohol consumption and violent injury was stronger in women than in men. Conclusion: This study highlights the demographic and behavioural factors associated with violent injury and provides preliminary evidence of the reduction of violent injury risk in VPUU intervention areas.
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    Epidemiologic synergy - the contribution of heterosexual HIV transmission to the spread of HIV among men who have sex with men (MSM) in South Africa
    (2016) Mulongeni, Pancho; Johnson, Leigh F
    Background: Could heterosexual HIV transmission be a driver of HIV infections that occur in men who have sex with men (MSM)? Noting the disproportionately high HIV prevalence among MSM across a variety of settings, this subpopulation is often considered as sources of new infections, overlooking the possibility of HIV transmission from the heterosexual – general – population to MSM. Objective: To assess the relative contribution of heterosexual transmission of HIV for onwards transmission of HIV from one man to another. Method: An agent based model of heterosexual transmission of HIV in South Africa was extended to simulate the HIV epidemic among MSM from 1990 to 2012. The model included gay men (who only have sex with men), bisexual men (who have partners of both sexes) in addition to men who have sex with women. HIV prevalence and sexual behaviour data collected among MSM in South Africa served as calibration data. Results: The model estimated that 28.7% (IQR: 27.4-28.9%) of MSM were HIV positive in 2010. By simulating a counterfactual HIV epidemic in South Africa, where HIV only spreads via male-male sex, we observe a decline in HIV incidence occurring in MSM by 56% over the period of 1990-2010, relative to the historical reality of HIV spreading via heterosexual and male-male sex. Analogously, HIV prevalence among MSM in 2010 under the counterfactual scenario reached only 10.0% (IQR 2.8- 17.4%), substantially less than HIV prevalence estimates from samples of MSM in South Africa. Conclusion: Roughly half of the HIV infections among MSM in South Africa can be attributed to the high levels of HIV prevalence in the general population. Scale up of interventions to target high risk behaviours with male partners should dispel possible misconceptions of bisexually active or heterosexual MSM as lower risk partners, relative to those MSM in gay communities.
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    Genetic polymorphisms and organophosphate neurotoxicity amongst emerging farmers in the Western Cape
    (2016) Glass, Tracy; Dalvie, Mohamed Aqiel; Holtman, Zelda; Ramesar, Raj
    BACKGROUND: Long-term exposure to organophosphates (OPs) can cause chronic neurotoxic effects which may be modulated by genetic polymorphisms of xenobiotic metabolising enzymes (XMEs). No previous study investigated XME modulation of neurotoxicity outcomes. OBJECTIVES: To investigate whether XMEs polymorphisms modulate OP neurotoxicity among emerging farmers. METHODS: A cross-sectional study of 301 emerging farmers was conducted in the rural Western Cape of South Africa. Neurotoxicity testing included the World Health Organisation Core Test Battery (digit span forward and backward) and vibration sensitivity testing. Questionnaire items included demographic data, potential confounders and work history of pesticide exposures. Blood samples were analysed for genetic polymorphisms of the following XMEs; glutathione S-transferases (GST), N-acetyltransferases (NAT) and Paraoxonase (PON1). RESULTS: Median age was 39 (30-48) and most had 9 years of education or less (65.5%). 54% of the participants were OP pesticide applicators. There was a low prevalence of the GST null genotype (GSTT-1% and GSTM-16%) and the GA and GG genotype for NAT (10%). Modulation of OP exposure and neurotoxic outcome relationships by NAT, PON1 at position 192 and GST was indicated in multivariate analysis. The strongest evidence of modification was by NAT on the relationship between pesticide poisoning and impaired vibration sense. Poisoned individuals with the GG genotype were more likely to suffer from impaired vibration sense compared to GA and AA genotypes. CONCLUSION: Genetic polymorphisms of NAT, PON1 (at position 192) and GSTM may modify the relationship between OP exposure and neurotoxicity. Larger longitudinal studies are required to determine whether preventive strategies can be developed to improve health amongst the identified vulnerable groups.
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    Growth, infectious morbidity, and neurodevelopment of HIV-exposed and HIV-unexposed infants in the context of lifelong maternal antiretroviral therapy and breastfeeding: a prospective cohort study
    (2021) Le Roux, Stanzi Maria; Myer, Landon; Donald, Kirsten A
    Background In 2019, 1 million in utero-HIV-exposed but -uninfected children (CHEU) were born in sub-Saharan Africa. In the absence of breastfeeding and maternal antiretroviral therapy (ART), HIV-exposed uninfected children (CHEU) have higher risks of mortality, growth faltering, infectious morbidity, and developmental delay than the general population, but data are limited on these outcomes among breastfed CHEU born to women who received universal (not restricted by disease severity) ART in pregnancy. This thesis addresses these knowledge gaps by comparing health outcomes of breastfed CHEU to breastfed CHU in the first year of life. Methods This research incorporates data from two prospective, linked cohort studies of pregnant women living with HIV (Maternal Child Health Antiretroviral, MCH-ART study, 2013-2016) and without HIV (HIV-unexposed uninfected, HU2 study; 2014-2017) in Gugulethu, Cape Town, South Africa. Enrolled at first antenatal visit at a primary care clinic, women were followed-up during pregnancy and postpartum with their breastfed infants, through 12 months with ~3-monthly study visits. Study staff administered questionnaires addressing maternal and child health, infant feeding, psycho-social and behavioural factors; and measured maternal-infant anthropometry [expressed as Z-scores for age: weight-for-age, WAZ; length-for-age, LAZ; head circumference-for-age, HCAZ]; WLHIV provided blood for repeated HIV viral load. At 12 months, the Bayley Scales of Infant Development, 3rd edition (BSID-III) was used to assess neurodevelopment. Findings WLHIV (100% antenatal ART) reported worse living conditions and higher risks of alcohol use and intimate partner violence than HIV-negative women. Similar proportions of CHEU and CHU were born preterm (11%) or small-for-gestational-age (10%). Exclusive breastfeeding was more common among CHEU than CHU, but overall duration of breastfeeding was shorter among CHEU. However, unless otherwise reported, adjustment for confounders did not change inferences below. In analysis of child growth, weight and head circumference trajectories were similar for CHEU and CHU from 6 weeks to 12 months. Both groups exhibited rapid weight gain with increasing WAZ over time; by 12 months, almost one-fifth of all children were overweight. Length trajectories for CHEU and CHU diverged after 6 months, with onset of linear growth faltering occurring earlier and more rapidly among the CHEU; by 12 months, stunting risk was doubled among CHEU vs CHU. Stratified by birth size, differences in LAZ between CHEU and CHU were magnified for those born small-forgestational age and absent for those born appropriate-for-gestational age. Infectious morbidity analyses revealed greater risks among CHEU than CHU in the first 6 months with not thereafter. Between 7 days and 3 months of life, CHEU (vs CHU) experienced three times more infection-related hospitalisations; rates for CHEU with healthier mothers (lower viral load, higher CD4 count, ART started early in pregnancy) approximated those of CHU, while CHEU of mothers with late ART initiation and advanced disease had four-fold more infectious-cause hospitalization. Breastfeeding and complete vaccinations were protective. At 12 months, mean composite cognitive, motor and language scores were within normal range and similar for both groups. Overall, risks of any developmental delays were low but slightly higher among CHEU than CHU in cognitive and motor domains. Compared to term HU, term HEU children had similar odds of motor delay, preterm HU children had 5-fold increased odds of delay and preterm HEU children, 16-fold. In CHEU, cumulative maternal viremia was associated with lower average scores and increased risk of moderate delays in motor and language domains. Conclusion Subtle health outcome differences persisted between CHEU and CHU despite breastfeeding and universal maternal ART in pregnancy. Reassuringly, the magnitudes of differences were small and predominantly associated with preventable factors including late ART initiation, advanced maternal disease stage, lack of breastfeeding, and incomplete vaccination. CHEU born too soon or too small were at highest risk of adverse outcomes, suggesting fetal origins of disease in the context of maternal HIV.
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    Health service utilisation prior to out-of-hospital natural deaths among children under five in Metro West, Cape Town in 2018: a retrospective analysis of data from the Child Death Review
    (2022) Jacobs, Solomon M; Mathews, Shanaaz; Hendricks, Michael; Phillips, Tammy
    Background In the Metro West geographical service area within the City of Cape Town district the under-five mortality rate in the Metro West GSA decreased from 25 per 1000 live births in 2010 to 22 deaths per 1000 live births in 2013, but the rate of decrease slowed down in part because of the amount of child deaths outside of health facilities. Fifty-five percent of under-five deaths occur out-of-hospital in South Africa, with a similar percentage in the Metro West (49-52% in 2010 to 2015). Describing factors that enable or prevent health service usage among natural under-five deaths is an important precursor for effective interventions. Objectives and Methods A retrospective cross-sectional design utilised secondary, routinely collected data from 1 January to 31 December 2018 on under-five out-of-hospital natural deaths reported to Salt River Mortuary. We used the data, which included routine interviews with the caregivers, together with social and medical data collated by the Child Death Review, to describe the cause of death, the socio-demographic profile, and the routine and prior-to-death health service usage. Dimensions of health service access according to the WHO and Anderson, respectively, were used as a heuristic lens to describe the applicable variables and to formulate a priori multivariable logistic regression models to compare those who did and did not seek care before death. These dimensions include physical accessibility, financial affordability, the health needs of the child as well as the existing health behaviour of the caregiver. Results Of the 187 cases described, 68% died of lower respiratory tract infections and 8% of diarrhoea. Fifty four percent of cases were younger than 3 months, and 40% were born prematurely. In terms of the residential health sub-district, 37% resided in Mitchells Plain, 29% in Klipfontein, 18% in Western and 14% in Southern; 52% resided in needy or very needy areas. Mothers were single (69%), unemployed (73%) and lived in informal housing (46%). Of the cases who were alive at the time, immunisation coverage was 79%, 70% and 68% at the 6-, 10- and 14-week visits. However, only 23% of mothers sought health care prior to the child's death. Overall, 51% of the mothers recognised symptoms of illness prior to death and symptoms were recognised in 95% of the mothers who sought health care compared to 37% of the mothers who did not seek health care (p-value < 0.001). Multivariable logistic regression models showed the importance in recognising symptoms in seeking health care (aOR 18.28, 95% CI 3.67-90.93), and that, while not statistically significant, the recognition of symptoms was less likely at younger ages (aOR 0.28, 95% CI 0.07-1.14 for cases younger than 3 months compared to those older than 6 months) Conclusion The study identified key risk factors implicated in the out-of-hospital deaths in Metro West and the need for mothers to identify and seek health care when their child is symptomatic. There should be focused support during the first 1000 days for mothers identified as being at-risk, namely: those who are single, unemployed, lack social support and abuse substances, and for babies with prematurity and HIV-exposure. Counselling should emphasise the recognition of LRTI symptoms and health care seeking to prevent child deaths and reduce the under-five mortality. Further research is needed to consolidate which provincial geographical areas should be prioritized for targeted interventions that impact on health care seeking behaviour, as well as the most effective child health education and messaging. Data paucity on medical history may be addressed by data augmentation from the Provincial Health Data Centre and improvements should be made for capturing children's anthropometry.
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    How accurately do routinely reported HIV viral load suppression proportions reflect progress towards the 90-90-90 target in the population on ART in Khayelitsha, South Africa?
    (2018) Euvrard, Jonathan George; Davies, Mary-Ann; Schulz, Tanja
    Background: In 2016, Khayelitsha reported almost 89% viral load (VL) suppression but less than 56% completion on routine quarterly reports, casting doubt on the validity of reported suppression. Objectives: To assess the validity of reported VL suppression as a measure of progress towards the 90-90-90 target and identify barriers to routine VL completion. Methods: A retrospective cohort study including all patients on antiretroviral treatment (ART) in Khayelitsha with a routine VL expected between 1 July 2015 and 30 June 2016 was conducted. ART programme and laboratory data were obtained and a sample of 1 035 patient folders were reviewed. Suppression was calculated using laboratory data and compared to reported suppression. A VL cascade from “expected” to “done”, “filed”, “noted” and “captured” was constructed to reflect the steps a VL must complete to be included in reported suppression and successful progression to each step was estimated. Logistic regression models were used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (95%CI) for completion among different patient groups. Results: Using laboratory data, VL suppression was estimated to be 82%, 87%, 89% and 91% at the 50, 200, 400 and 1 000 copies/mL thresholds respectively, but reported suppression would have been 80%, 86%, 88% and 89% at those thresholds. Of 22 991 patients with a routine VL due in the study period, 84% were done, 79% filed, 76% noted, and 55% captured. Routine VL were more likely to be done among children< 15 years old (aOR 1.89, 95%CI 1.45–2.48) and pregnant women (aOR 1.90, 95%CI 1.28–2.81) compared to adult men, adjusted for facility. Conclusion: Despite low reported completion, actual completion was high and reported suppression was similar to suppression calculated using laboratory data, thus providing an accurate measure of progress towards the 90-90-90 target. More work is needed to reach the 16% of patients missed by routine testing. Most of the VL done were available to the clinician at the next assessment, and further research is needed to assess how effectively these VL results are used in clinical decision-making.
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    Hypertension and common mental disorders in a nationally-representative sample of South African adults
    (2007) Grimsrud, Anna; Myer, Landon
    This thesis examines the associations between self-reported hypertension diagnosis and Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) defined a) anxiety disorders b) depressive disorders and c) comorbid anxiety-depression, both lifetime and 12-month, adjusting for potential confounding variables.
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    Hypertension in Cape Town clothing industry clinics: Does treatment match risk?
    (2001) Sephton_E_A; Bachmann, Max
    Background: The management of hypertension according to the patient' s absolute risk of cardiovascular disease. rather than their blood pressure in isolation from other risk factors, is now widely advocated because it targets treatment at those with most to gain. In South Africa blood pressure is traditionally managed according to the patient's level of blood pressure. Main Objective: To identify the proportion of traditionally treated hypertensive patients who may benefit from cessation or intensification of treatment as judged by a risk-based approach to their management. Design: A cross sectional descriptive survey of patients and their medical records with assessment of absolute risk of cardiovascular disease using Framingham risk equations. Setting: Eight Clothing Industry Health Benefit Fund clinics in Cape Town, South Africa. Participants: 382 women and men, predominantly coloured, attending for the treatment of hypertension Main outcome measure: The proportions of patients in whom the predicted risk of a cardiovascular event within 5 years is less than 10% and those in whom the risk within five years is greater than 20%. Results: 65% of participants (CI 60 - 70%) were at less than 10% risk of a cardiovascular event in the next 5 years and 19% (Cl 15-23%) were at more than 20% risk of a cardiovascular event despite current treatment. 5% (CI 3.2-7.9%) were at greater than 20% risk of a cardiovascular event in the next 5 years having no previous history of a cardiovascular event. 14% (CI 10-17%) were at greater than 20% risk of a cardiovascular event in the next 5 years because of a previous history of a cardiovascular event. 1.3% (CI 0.4-3%) were at less than 10% risk of a cardiovascular event within the next 5 years, despite having a systolic blood pressure over 170mmHg. Conclusion: Assessment of the cardiovascular risk of patients treated for hypertension identifies those patients at most and least risk. Resources could therefore be targeted at those with the most to gain from treatment and the unwanted side effects of antihypertensive medication avoided in those at low risk. Almost two thirds of patients currently being treated for hypertension were at less than 10% risk of developing a cardiovascular event within the next 5 years. A trial of medication reduction or cessation in this group is justified and the resources could be redirected at those 5% whose risk remains very high despite current levels of treatment.
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    Interventions for Improving Adherence and Retention in HIV-Infected Women on ART During Antenatal and Postnatal Care: A Systematic Review
    (2021) Hoosen, Nikhat; Myer, Landon
    Introduction Universal access to antiretroviral therapy (ART) during pregnancy and breastfeeding has implications for retention in HIV care and adherence to ART. Retention and adherence may be especially challenging during antenatal and postnatal periods, where women living with HIV have competing responsibilities between infant care, self-care and personal responsibilities. Lifelong ART also highlights the role interconception care (ICC) and preconception care (PCC) interventions can play in improving maternal outcomes. While the latter exist for other health topics, ICC and PCC interventions targeting women living with HIV has the potential to maintain retention in care and adherence to ART during, after, and in between pregnancies. This systematic review evaluates interventions that aim to improve retention and adherence in pregnant and postpartum women. Methods The Cochrane Library; MEDLINE via PubMed; Web of Science; and EBSCOHOST (Africa Wide, Academic Search Premier, CINAHL, PsychArticles, Health Source Nursing Academic, PsychInfo) and conference databases were searched for articles in English published between 1990 to 2020. All study designs, intervention types and geographic locations were included. Data were extracted using a standardized tool, and effect sizes recalculated for all studies. Risk of bias was conducted using tools suited to specific study designs, and the PRECIS-2 tool assessed intervention applicability in real-world settings. The protocol was registered with PROSPERO (ID: CRD42020185196). Results Thirty-one studies were identified, of which 31 and 16 provided retention and adherence data, respectively. No interconception or preconception care interventions were found. Interventions were predominantly from Sub-Saharan Africa, except one from the USA. Intervention types varied and included integration of services, peer support, mhealth and multicomponent interventions. The definitions of retention and adherence used for outcome assessment varied widely across studies, but almost all were scored as pragmatic in real-world settings. Due to high heterogeneity, a narrative approach was used based on study reported data and the effect sizes. Conclusion Overall, heterogeneity of identified studies make definitive recommendations for interventions scale up difficult. Future interventions will benefit from consistent study designs, outcome definitions, outcome measurements, validated tools, and longer retention time points will strengthen the evidence base. Ongoing studies being conducted show promise in addressing some of these points.
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    Investigating the intention of pregnancy among women living with HIV and its effect on the early development of their HIV exposed infants
    (2020) Moyo, Chido; Brittain, Kirsty
    Background: The increase in access and coverage of ART, including through prevention of mother-to-child transmission (PMTCT) programmes in Africa, has resulted in the reduction of vertical transmission, which has led to >95% of infants born to women living with HIV (WLHIV) in South Africa being born HIV uninfected. Concerns have however been raised regarding the health and development of HIV exposed and uninfected (HEU) infants. WLHIV in South Africa are more likely to have an unintended pregnancy compared HIV negative women. Unintended pregnancies continue to be a challenge towards the on-going strides and achievement of PMTCT goals. There is however a paucity of data on the investigations in research for the effect of unplanned pregnancy and early child development in South Africa. This research study focused on early infant development health outcomes of HIV exposed but uninfected (HEU).The aim of the study was to investigate the association between the intention of pregnancy among pregnant WLHIV, and the subsequent early child development of their HEU infants in Gugulethu, South Africa. Methods: This study used data from the “Long-term Adherence and Care Engagement” study (LACE; May 2017-Apr 2018), which provided long-term data from women who had initiated antiretroviral therapy (ART) during pregnancy. During pregnancy, the London Measure of Unplanned Pregnancy was used to assess pregnancy intentions. At 36-60 months postpartum, child development was assessed across six developmental domains using the Ages & Stages questionnaire (ASQ). Multivariate Linear regression models were used to examine the association between pregnancy intentions and subsequent child development, with results reported as regression coefficients (β) with 95% confidence intervals (CI). Results: A total of 250 mother-infant pairs completed assessments and were included in analysis. At enrolment, the median age for the women was 28.3 years, and 38% were married and/or cohabiting. Overall, based on the women's responses 58% of pregnancies were categorised as unplanned. Upon analysis, no associations were observed between pregnancy intention and all early child development domains p>0.05. Overall, infants with evidence of early developmental delay that scored below threshold (ASQ-3) were 8% for the gross motor domain, 19% for fine motor, 4% for communication, 15% for problem solving, and 7% for personal social domain. Whilst for the social emotional domain (ASQ: SE-2), two percent of infants scored above threshold and hence, had evidence of early developmental delay. Conclusions: Among women initiating ART during pregnancy, we observed no significant association between pregnancy intention and the early child development of their HEU infants. The findings of this research accentuate the need for targeted strategies towards psychosocial issues, and educational interventions for WLHIV and, for informed fertility decisions. Furthermore, the need for exploration of interventions to encourage infant-parent attachment and interaction for development, as well as the impact of pregnancy intentions on parenting behaviours.
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    Maternal body mass index and proinflammatory immune markers in HIV-infected pregnant woman on antiretroviral treatment in Cape Town, South Africa
    (2023) More, Jessica; Malaba, Thokozile
    Background. High maternal body mass index (BMI) and the timing of antiretroviral (ART) initiation in pregnant women living with human immunodeficiency virus (HIV) (WLWH) may affect the controlled systemic inflammation during pregnancy. Proinflammatory immune markers during pregnancy and the impact of maternal BMI in WLWH initiating ART in pregnancy or preconception will be evaluated. Methods. In this mini-dissertation is a protocol (Part A), journal formatted manuscript (Part B) and Appendices (Part C) for a study on maternal BMI and inflammation in WLWH. A subset cohort from the Prematurity Immunology in HIV-infected Mothers and their infants Study (PIMS) study had three plasma immune markers (c-reactive protein (CRP), interferon-gamma inducible protein-10 (IP-10) and serum amyloid A (SAA)) and maternal weight measured from April 2015 to October 2016, at four antenatal care visits (visit 1, 2 (two weeks post-ART initiation in those initiating in pregnancy), 3 and 4). The association with maternal BMI by ART initiation (on ART preconception or initiated during current pregnancy) was assessed. Results. Among 526 pregnant WLWH, those on preconception ART had CRP and IP-10 levels lower compared to those who initiated ART in pregnancy. CRP was higher in obese WLWH (irrespective of timing of ART initiation) than those with a normal or overweight BMI. IP-10 was elevated in the 2nd trimester and SAA levels were highest in WLWH with a normal BMI. Conclusion. Immune marker level elevation is dependent on timing of ART exposure and pregnancy trimester. The timing of ART initiation and maternal BMI may adversely impact systemic inflammation in pregnant WLWH.
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    Mathematical modelling of the population impact of screening for Chlamydia Trachomatis and Neisseria gonorrhoeae in South Africa
    (2018) Esra, Rachel; Johnson, Leigh
    A large proportion of chlamydial and gonococcal infections are asymptomatic. In lower- and middle-income countries like South Africa, where syndromic management is practiced, it is likely that a large proportion of curable STIs go untreated, as screening for asymptomatic STIs is rarely conducted. Due to the lack of empirical data on the efficacy of STI screening programs, dynamic mathematical modelling has been used to assess the impact of screening, but most previous modelling studies have focused on high-income settings. Here we utilize dynamic mathematical modelling to evaluate the potential impact of opportunistic STI screening programs on the incidence and prevalence of Chlamydia trachomatis and Neisseria gonorrhea in South Africa. We extended an existing agent-based model of heterosexual HIV and STI transmission in South Africa to investigate the impact of targeted screening strategies directed at high risk groups including youth, female sex workers, pregnant women and patients in HIV care. All four screening strategies resulted in reductions in general and key population STI transmission. Opportunistic STI screening of youth and ART patients were shown to be most effective and represent viable interventions for reducing STI transmission in the South African population. Additionally, we compared the modelled impact of a standardized screening program to results obtained from other published mathematical models of chlamydia screening. Differences between models could be attributed to differences in the modelled heterogeneity in sexual behaviour as well as differences in assumptions about immunity following chlamydia recovery.
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    Personality traits of alcohol and other drug users in Cape Town, South Africa
    (2015) Hendrickson, Blake Edward
    The Substance Use Risk Profile Scale (SURPS) is a relatively new questionnaire that assesses individual personality risk for substance-related problems. Preliminary findings have indicated that the SURPS is a useful measure for identifying characteristics predisposing some individuals to alcohol and other drug (AOD) use. High levels of hopelessness, anxiety sensitivity, sensation seeking, and impulsivity are each associated with specific patterns of substance use caused by underlying motivational susceptibilities. Furthermore, incorporating these traits into tailored prevention and treatment efforts have shown value in other countries. The present study enrolled a community sample in Cape Town, South Africa and asked respondents about their demographics, history of AOD use, personality as measured by the SURPS, and other mental health indicators. This information was used to identify personality risks in the local population and validate the utility of the SURPS for the first time in Sub-Saharan Africa. Results found that sensation seekers had a significantly higher risk for alcohol, tobacco, cannabis, cocaine, and hallucinogen use compared to other personality groups and controls. As expected, respondents demonstrating anxiety sensitivity also showed high-risk use of alcohol, but less high-risk illicit drug use . Finally, the hopelessness group exhibited a higher risk for opioid use but overall, hopelessness and impulsivity had little impact on concurrent substance use, which contrasts with other literature. Unlike findings from mostly European and North American samples that indicate generalizability, this study did not find structural or concurrent validity for the SURPS. This provides evidence against it being adopted as a culturally appropriate assessment tool in a diverse South African population.
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    Prediction of post-tuberculosis lung damage using CT lung imaging measures among adults in Malawi
    (2018) Gunsaru, Vester Poyamba; Lesosky, Maia
    The burden of tuberculosis (TB) is high globally and in sub-Saharan Africa (SSA). Although TB treatment regimens are now widely available, and with high success rates in most parts of the world, TB can lead to long-term health consequences. Evidence has shown that completion of TB treatment can mark the beginning of chronic lung damage and other sequelae. There is a need for early identification of individuals at risk of post-tuberculosis lung damage (PTLD) to necessitate its appropriate management. This study evaluated the significance of radiological features from computed tomography (CT) scan in describing PTLD patterns at treatment completion and predicting PTLD outcomes at 12 months post treatment, as a possible tool to detect risk of PTLD at an early stage. This thesis comprises three parts. Part A is the study protocol, which outlines the purpose, methods and ethical considerations of the proposed study. Part B is the literature review, which summarizes the existing literature on PTLD, the risk factors for PTLD, and the relationship between imaging data and PTLD. The objective of the literature review was to identify gaps in literature which would provide context for further research. Part C is the journal-ready manuscript, which provides the results of the conducted study and a discussion on the implication of these results. The results of the study showed that CT imaging features were important in determining concurrent abnormal spirometry at baseline in post-TB individuals. These features were not useful in predicting spirometry outcomes at 12 months after treatment completion. However, there is need for further validation of these results in other settings and the consideration of other lung damage outcomes.
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    The predictive value of a QuantiFERON conversion in the development of active tuberculosis disease in adolescents
    (2011) Machingaidze, Shingai; Mahomed, Hassan
    This study is an extension of a prospective epidemiological study of TB disease and infection in adolescents in the Worcester and surrounding areas in the Western Cape carried out from 2005 to 2009, in which 6363 participants were enrolled from local public schools. In this follow-on study, a subset of adolescents who were identified to have converted their QFT status during the original study will be followed up and observed for the occurrence of active TB disease over a period of two years. A similar sized, random sample of participants identified to have a QFT status that remained negative throughout the original study will be used as the control group.