Considerations for sociocultural adaptations of a mindfulness-based program within a low socioeconomic setting in Cape Town, South Africa.

BackgroundDespite the successful rollout of anti-retroviral therapy (ART) and steep declines in HIV incidence in South Africa, this has not been the case for adolescents (10–19 years). Adolescents on HIV treatment have lower rates of viral load suppression and adherence compared to adults and children.ObjectivesThis article reports on the adherence challenges faced by adolescents receiving ART in a primary health care clinic in a low socio-economic urban setting in Cape Town.MethodAn exploratory qualitative design was employed where data were collected through four focus group discussions with adolescents (n = 15) who received ART at a primary health care clinic in a low socio-economic urban setting in Cape Town and followed up with eight individual, semi-structured interviews with two adolescents from each focus group. Two key informant interviews were conducted with health workers at the clinic. Audio data were digitally recorded and transcribed verbatim. Data were analysed using content analysis.ResultsSchool commitments, strained teacher–learner relationships, negative household dynamics and ill treatment by non-biological caregivers were reported as major barriers to adherence. In addition, poor service delivery, missing or misplaced files and long waiting times came under major criticism. Fear of unintended disclosure of HIV status, stigma and discrimination, treatment fatigue and having unstructured lives negatively influenced adherence. Having a strong social support system and having life goals and ambitions were motivators to remain adherent.ConclusionThis study highlighted the complexity of ART adherence in the midst of juggling school, home life and personal life goals and aspirations. Interventions to improve adherence should address psychosocial factors such as treatment fatigue, disclosure and family and household dynamics, in addition to streamlining service delivery between the school and clinic.

BackgroundPregnant and postnatal adolescent women are a high-risk group for common mental disorders (CMDs); however, they have low levels of engagement and retention with mental health services. Negative consequences of CMDs have been documented for both mother and child.AimThe study aimed to explore the barriers and facilitators to service access for adolescents in low-resource settings.SettingWe interviewed 12 adolescents, aged 15–19 years, from low-resource settings in Cape Town, South Africa. Participants had previously engaged with a mental health service, integrated into maternity care.MethodsTwelve semi-structured, individual interviews were used for this qualitative study. Interviews were recorded, transcribed and coded. A framework analysis was employed for data analysis.ResultsAdolescents perceived considerable stigma around both teenage pregnancy and mental illness, which inhibited use of mental health services. Other barriers included fearing a lack of confidentiality as well as logistical and environmental obstacles. Service uptake was facilitated by support from other adults and flexible appointment times. Face-to-face individual counselling was their preferred format for a mental health intervention.ConclusionSeveral key components for adolescent-friendly mental health services emerged from our findings: integrate routine mental health screening into existing obstetric services to de-stigmatise mental health problems and optimise screening coverage; coordinate obstetric and counselling appointment times to rationalise the use of limited resources; and sensitise care providers to the needs of adolescents to reduce stigma around adolescent sexual activity and mental illness. A non-judgemental, caring and confidential relationship between counsellors and clients is crucial for successful interactions.

Post-apartheid, understanding and management of intellectual disability remain poor in South Africa, complicated by various contextual and cultural explanations used to describe and conceptualize this condition. We conducted 20 semi-structured interviews with primary caregivers and parents of children with intellectual disability residing in Khayelitsha, a low-income setting in Cape Town, South Africa. We used Kleinman's Explanatory Models (EMs) of illness to explore terms used to describe and conceptualize this condition. Carers' explanatory models included biomedical causes, injuries during pregnancy or birth, as well as spiritual causes. It was reported that there were significant difficulties in accessing services and support, and difficulties with coping in the context of extreme poverty and deprivation. Current findings highlight a need for collaboration between the biomedical and alternative healthcare systems in educating carers and parents regarding intellectual disability.

Adapting a Behavioral Intervention for Alcohol Use and HIV Medication Adherence for Lay Counselor Delivery in Cape Town, South Africa: A Case Series

Factors contributing to and causes of hospital readmissions have been investigated worldwide, but very few studies have been performed in South Africa (SA) and none in the Western Cape Province. To investigate possible preventable and non-preventable factors contributing to readmissions to the Department of Internal Medicine at Tygerberg Hospital (TBH), Cape Town, within 30 days of hospital discharge. The researchers tested a risk-stratification tool (the LACE index) to evaluate the tool's performance in the TBH system. A retrospective analysis was conducted of all 30-day readmissions (initial hospitalisation and rehospitalisation within 30 days) to the Department of Internal Medicine at TBH for the period 1 January 2014 - 31 March 2015. Potential risk factors leading to readmission were recorded. A total of 11 826 admissions were recorded. Of these patients, 1 242 were readmitted within 30 days, representing a readmission rate of 10.5%. The majority of patients (66%) were readmitted within 14 days after discharge. The most important risk factor for readmission was the number of comorbidities, assessed using the Charlston score. The study also identified a large burden of potentially avoidable causes (35% of readmissions) due to system-related issues, premature discharge being the most common. Other reasons for 30-day readmission were nosocomial infection, adverse drug reactions, especially warfarin toxicity, inadequate discharge planning and physician error. Despite TBH being a low-resource, high-turnover system, the 30-day readmission rate was calculated at 10.5%. Global readmission rates vary from 10% to 25%, depending on the reference article/source used. We found that 35% of 30-day readmissions were potentially avoidable. Venous thromboembolism was a minor contributor to readmission but was associated with a very high mortality rate. A secondary outcome evaluated was the utility of the LACE and modified LACE (mLACE) index in the TBH environment. The risk tool performed well in the TBH population, and a high LACE and mLACE score correlated with an increased risk of 30-day readmission (p<0.001).

BackgroundThe use of mobile phones to deliver health care (mHealth) is increasing in popularity due to the high prevalence of mobile phone penetration. This is seen in developing countries, where mHealth may be particularly useful in overcoming traditional access barriers. Non-communicable diseases may be particularly amenable to mHealth interventions, and hypertension is one with an escalating burden in the developing world.ObjectiveThe objective of this study was to test whether the dissemination of health information via a short message service (SMS) led to improvements in health knowledge and self-reported health-related behaviors.MethodsA mixed methods study was carried out among a cohort of 223 hypertension clinic patients, in a resource-poor setting in Cape Town, South Africa, in 2012. Hypertensive outpatients were recruited at the clinic and administered a baseline questionnaire to establish existing knowledge of hypertension. Participants were then randomly assigned to intervention or control groups. The intervention group received 90 SMSes over a period of 17 weeks. Thereafter, the baseline questionnaire was readministered to both groups to gauge if any improvements in health knowledge had occurred. Those who received SMSes were asked additional questions about health-related behavior changes. A focus group was then conducted to obtain in-depth feedback about participants’ experience with, and response to, the SMS campaign.ResultsNo statistically significant changes in overall health knowledge were observed between the control and intervention groups. The intervention group had positive increases in self-reported behavior changes. These were reaffirmed by the focus groups, which also revealed a strong preference for the SMS campaign and the belief that the SMSes acted as a reminder to change, as opposed to providing new information.ConclusionsAlthough the content of the SMSes was not new, and did not improve health knowledge, SMSes were effective in motivating positive self-reported behavior change among hypertensive patients.Trial RegistrationPan African Clinical Trials Registry Number: PACTR201412000968462. Registered 18 December 2014 (Archived by WebCite at http://www.webcitation.org/6fhtyLRcO).

Background. The Griffiths Mental Developmental Scales (GMDS) is a developmental tool commonly used in South Africa (SA). The most recent version, the GMDS III (Griffiths III) was standardised in the UK and the Republic of Ireland and published in 2016. Objectives. To describe neurodevelopmental scores using the Griffiths III, demographics and confounding variables, in children aged 8 - 10 months, living in an urban setting in Cape Town, SA. To compare the scores between children who were HIV-exposed and -uninfected (CHEU) and children who were HIV-unexposed and -uninfected (CHUU). Method. We conducted a retrospective cross-sectional data analysis of 85 infants with completed Griffiths III assessments at 8 to 10 months of age. This is a substudy of a prospective, longitudinal descriptive study describing neuroimaging and neurodevelopmental outcomes in 31 CHUU and 54 CHEU. Results. Across all Griffiths III subscales, SA infants tested between average and very superior ranges in raw and quotient scores and between 63rd and 76th percentiles. They outperformed the UK normative sample. Caregivers of CHUUs highest level of education was significantly higher than caregivers of CHEU (p=0.002). CHUU scored higher on the eye and hand coordination scale compared with CHEU (p=0.02). Conclusion. Due to favourable developmental scores achieved by South African children in comparison to the standardised sample, the revision of the Griffiths Scales to the Griffiths III is likely to have clinical use in SA infants.

Background: Brief Motivational Interviewing (BMI) is an approach to motivating behaviour change in general health care settings. The relevance and applicability of BMI has not been fully assessed in low- or middle-income country settings. This study explored the application of BMI by general practitioners (GPs) in a public sector primary care setting in Cape Town, South Africa. Methods: How BMI should be adapted and applied was explored by means of a cooperative inquiry group of GPs. This participatory action research involved four action-reflection cycles over a five-month period during which GPs were trained to use BMI skills in their practice and to document and reflect on their experience. Results: GPs found the emphasis on self-evaluation, personal choice and control particularly useful. Skills in open questioning, exchanging information carefully, assessing ambivalence and readiness to change were also helpful. They had mixed experiences with skills for agenda setting and reducing resistance. The use of specific scaling questions and decision balance sheets were not useful. Conclusions: BMI has great potential, as the skills learnt were mostly useful and the process had benefits for the participants. If the full potential of BMI is to be realised, the content will need to be adapted to local clinical conditions. BMI needs to be taught using a participatory educational style and its implementation must be accompanied by support from colleagues and management. Future research on this issue should evaluate the process of implementing BMI skills in different primary care settings and sustaining any positive changes that may occur.

Antenatal depression and adversity in urban South Africa

Conventional urban drainage systems are designed to reinforce human dominance over the biophysical environment resulting in contaminated surface runoff being discharged into urban waterways. It is widely recognized that poor stormwater quality is one of the main contributing factors to the deterioration of urban rivers. The result is that bluegreen corridors of urban open spaces are compromised by the cumulative impacts of pollution that alter productive ecosystem services and are no longer able to support biodiversity. The problem is partly caused by conventional stormwater infrastructure, which is designed to remove runoff as quickly and efficiently as possible. Yet the condition of an urban waterway cannot be understood simply as a cause and effect relationship, but emerges from interactions between people, drainage and ecological systems. This study aimed to understand the linkage between biophysical and social systems in an urban setting in Cape Town, South Africa. Surface water flowing into roadside catchpits was analysed using multiple water quality parameters. Surveys, interviews and observations explored how local residents understand their impacts on the quality of an urban river. The results show that runoff is highly variable and some environmental conditions, such as rainfall, antecedent dry days and season, are the primary drivers of water quality. However, residents have a poor understanding of the linkages between what they do on the land and impacts on urban rivers. The findings suggest that the predominant focus on technological solutions and flood prevention do not persuade citizens to account for actions that result in deterioration of waterway conditions. Drainage infrastructure fails to connect citizens with their downstream impacts on environmental systems and services. The implication is that most residents 'miss the link' – between their actions on land, their impacts on runoff and river water quality, and, in turn, their ability to influence societal patterns and processes.Keywords: stormwater drainage, social-ecological systems, environmental impacts, human behaviour, urban ecology

BackgroundRates of violence against women are reported to be highest in Africa compared to other continents. We aimed to determine associations between mental illness, demographic, psychosocial and economic factors with experience of intimate partner violence (IPV) among pregnant women in a low resource setting in Cape Town and to explore the contextual elements pertaining to domestic violence.MethodsWe recruited adult women attending antenatal services at a primary-level maternity facility. Demographic, socioeconomic and psychosocial data were collected by questionnaire. The Expanded Mini- International Neuropsychiatric Interview (MINI) Version 5.0.0 was used to assess mental health status and the Revised Conflict Tactic Scale (CTS2) used to assess IPV in the six months prior to the study. Non-parametric tests, Wilcoxon sum of rank test, Fisher Exact and two sample T test and multicollinearity tests were performed. Descriptive, bivariate and logistic regression analyses were conducted to identify associations between the outcome of interest and key predictors. A probability value of p ≤ 0.05 was selected. From counselling case notes, a thematic content analysis was conducted to describe contextual factors pertaining to forms of domestic violence (DV).ResultsThe prevalence of IPV was 15% of a sample of 376 women. Women who were food insecure, unemployed, in stable but unmarried relationships, had experienced any form of past abuse and were not pleased about the current pregnancy were more likely to experience IPV. MINI-defined mental health problems and a history of mental illness were significantly associated with IPV. Qualitative analysis of 95 counselling case notes revealed that DV within the household was not limited to intimate partners and, DV in this context was often perceived as ‘normal’ behaviour by the participants.ConclusionsThis study contributes towards a greater understanding of the risk profile for IPV amongst pregnant women in low-income settings. Adversity, including food insecurity and mental ill-health are closely associated with IPV during the antenatal period. Advocates against violence against pregnant women are advised to consider that violence in the home may be perpetrated by non-intimate partners and may by enabled by a pervasive belief in the acceptability of the violence.

There is increasing evidence from tuberculosis high-burden settings that exogenous reinfection contributes considerably to recurrent disease. However, large longitudinal studies of endogenous reactivation (relapse) and reinfection tuberculosis are lacking. We hypothesize a relationship between relapse vs reinfection and the time between treatment completion and recurrent disease. Population-based retrospective cohort study on all smear-positive tuberculosis cases successfully treated between 1996 and 2008 in a suburban setting in Cape Town, South Africa. Inverse gaussian distributions were fitted to observed annual rates of relapse and reinfection, distinguished by DNA fingerprinting of Mycobacterium tuberculosis strains recultured from diagnostic samples. Paired DNA fingerprint data were available for 130 (64%) of 203 recurrent smear-positive tuberculosis cases in the 13-year study period. Reinfection accounted for 66 (51%) of 130 recurrent cases overall, 9 (20%) of 44 recurrent cases within the first year, and 57 (66%) of 86 thereafter (P < .001). The relapse rate peaked at 3.93% (95% confidence interval [CI], 2.35%-5.96%) per annum 0.35 (95% CI, .15-.45) years after treatment completion. The reinfection tuberculosis rate peaked at 1.58% (95% CI, .94%-2.46%) per annum 1.20 (95% CI, .55-1.70) years after completion. To our knowledge, this is the first study of sufficient size and duration using DNA fingerprinting to investigate tuberculosis relapse and reinfection over a lengthy period. Relapse occurred early after treatment completion, whereas reinfection dominated after 1 year and accounted for at least half of recurrent disease. This temporal relationship may explain the high variability in reinfection observed across smaller studies. We speculate that follow-up time in antituberculosis drug trials should take reinfection into account.

BackgroundRecent interferon gamma (IFN-γ)-based studies have identified novel Mycobacterium tuberculosis (M.tb) infection phase-dependent antigens as diagnostic candidates. In this study, the levels of 11 host markers other than IFN-γ, were evaluated in whole blood culture supernatants after stimulation with M.tb infection phase-dependent antigens, for the diagnosis of TB disease.Methodology and Principal FindingsFive M.tb infection phase-dependent antigens, comprising of three DosR-regulon-encoded proteins (Rv2032, Rv0081, Rv1737c), and two resucitation promoting factors (Rv0867c and Rv2389c), were evaluated in a case-control study with 15 pulmonary TB patients and 15 household contacts that were recruited from a high TB incidence setting in Cape Town, South Africa. After a 7-day whole blood culture, supernatants were harvested and the levels of the host markers evaluated using the Luminex platform. Multiple antigen-specific host markers were identified with promising diagnostic potential. Rv0081-specific levels of IL-12(p40), IP-10, IL-10 and TNF-α were the most promising diagnostic candidates, each ascertaining TB disease with an accuracy of 100%, 95% confidence interval for the area under the receiver operating characteristics plots, (1.0 to 1.0).ConclusionsMultiple cytokines other than IFN-γ in whole blood culture supernatants after stimulation with M.tb infection phase-dependent antigens show promise as diagnostic markers for active TB. These preliminary findings should be verified in well-designed diagnostic studies employing short-term culture assays.

Background: Epstein-Barr virus (EBV) infection is an established causal factor for Hodgkin lymphoma (HL). MicroRNAs (miRNAs) are master regulators of gene expression and are ideal biomarkers. We profiled the circulating expression of 42 EBV miRNAs in HL patients to determine if EBV miRNA(s) can be a noninvasive biomarker for EBV+ HL or disease severity. Method: Plasma was obtained from 11 patients with HL in a tuberculosis and HIV-endemic setting in Cape Town, South Africa. EBV infection in HL tumor cells were confirmed using a clinical PCR assay. The expression of 42 miRNAs were measuring using a qPCR-based Mirxes ID3EALTM EBV miRNA panel. Wilcoxon test or Fisher’s test were used to compare data between two groups. Spearman’s rho was used for correlation analysis. Fold changes were calculated using the 2^-ΔΔCT method. Results: EBV+ HL patients were significantly older (p=0.04; Table 1). No miRNA was associated with EBV or prognostic factors at FDR&amp;lt;0.05. Of interest, miR-BART20-3p expression was 33% lower in EBV+ patients compared to EBV- patients (p=0.052) and did not correlate with age (rho=0.39, p=0.23). MiR-BART17-3p was inversely correlated with stage (rho=-0.61, p=0.047). MiR-BART2-5p correlated with International Prognostic Score (IPS; rho=0.72, p=0.01). miR-BART14-3p was inversely correlated with Eastern Cooperative Oncology Group (ECOG) score (rho=-0.60, p=0.049). MiR-BART11-5p and miR-BART14-5p were higher in patients that reported B-symptoms (11.2-fold p=0.01 and 2.5-fold p=0.02, respectively). In contrast, MiR-BART14-3p and miR-BART17-3p were 33% and 41% lower in patients with B-symptoms (both p=0.03). No miRNA was associated with HIV. Conclusion: Circulating EBV miRNAs were associated with HL disease severity but not EBV status. Further investigations into these candidate miRNAs will increase our understanding of HL disease progression as well as explore the potential of these miRNAs as therapeutics or therapeutic targets. Table 1. Citation Format: Soo Mi Lee, Cristina S. Bogsan, Jason T. Howard, Abigail G. Wandoff, Meng-Xuan Wu, Estelle Verburgh, Maxine van der Schyff, Frank J. Slack, Yujing J. Heng, Katherine Antel. Circulating Epstein-Barr virus microRNAs associated with Hodgkin lymphoma prognosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 6682.

The high cost of viral load (VL) testing limits its use for antiretroviral therapy (ART) adherence support. A low-cost lateral flow urine tenofovir (TFV) rapid assay predicts pre-exposure prophylaxis breakthroughs, but has not yet been investigated in HIV treatment. We therefore evaluated its utility in a pilot cross-sectional study of TFV-containing ART recipients at an increased risk of virologic failure (VF). Participants who had a treatment interruption ≥30 days or had ≥1 episode of viremia (VL ≥400 copies/mL) in the previous year were recruited from a public health setting in Cape Town, South Africa. Self-reported adherence data were collected, the urine TFV assay performed, and concurrent TFV-diphosphate analyzed in dried blood spots. VL testing was done concurrently and, if viremic, genotypic HIV drug resistance testing was performed. Of 48 participants, 18 (37.5%) had VL (>400 copies/mL) at the time of the study, including 16 of 39 receiving efavirenz (EFV), 2 of 6 receiving protease inhibitors, and 0 of 3 receiving dolutegravir. Resistance testing succeeded in 17/18, of which 14 had significant mutations compromising ≥2 agents of the current EFV-based regimen. Of these 14, all had detected urine TFV. Urine TFV was undetectable in two out of three without regimen-relevant resistance; p = .02. In participants on EFV-based regimens returning to care, VF was largely due to viral resistance, where detectable urine TFV had 100% sensitivity (14/14 participants) in predicting resistance. Conversely, when undetectable, the urine-based assay could be used to preclude participants with poor adherence from undergoing costly HIV drug resistance testing.