National Health Laboratory Service Database Research Articles

Gaps in the type 2 diabetes care cascade: a national perspective using South Africa’s National Health Laboratory Service (NHLS) database

BackgroundResearch out of South Africa estimates the total unmet need for care for those with type 2 diabetes mellitus (diabetes) at 80%. We evaluated the care cascade using South Africa’s National Health Laboratory Service (NHLS) database and assessed if HIV infection impacts progression through its stages.MethodsThe cohort includes patients from government facilities with their first glycated hemoglobin A1c (HbA1c) or plasma glucose (fasting (FPG); random (RPG)) measured between January 2012 to March 2015 in the NHLS. Lab-diagnosed diabetes was defined as HbA1c ≥ 6.5%, FPG ≥ 7.0mmol/l, or RPG ≥ 11.1mmol/l. Cascade stages post diagnosis were retention-in-care and glycaemic control (defined as an HbA1c < 7.0% or FPG < 8.0mmol/l or RPG < 10.0mmol/l) over 24-months. We estimated gaps at each stage nationally and by people living with HIV (PLWH) and without (PLWOH).ResultsOf the 373,889 patients tested for diabetes, 43.2% had an HbA1c or blood glucose measure indicating a diabetes diagnosis. Amongst those with lab-diagnosed diabetes, 30.9% were retained-in-care (based on diabetes labs) and 8.7% reached glycaemic control by 24-months. Prevalence of lab-diagnosed diabetes in PLWH was 28.6% versus 47.3% in PLWOH. Among those with lab-diagnosed diabetes, 34.3% of PLWH were retained-in-care versus 30.3% PLWOH. Among people retained-in-care, 33.8% of PLWH reached glycaemic control over 24-months versus 28.6% of PLWOH.ConclusionsIn our analysis of South Africa's NHLS database, we observed that 70% of patients diagnosed with diabetes did not maintain in consistent diabetes care, with fewer than 10% reaching glycemic control within 24 months. We noted a disparity in diabetes prevalence between PLWH and PLWOH, potentially linked to different screening methods. These differences underscore the intricacies in care but also emphasize how HIV care practices could guide better management of chronic diseases like diabetes. Our results underscore the imperative for specialized strategies to bolster diabetes care in South Africa.

The prevalence and spectrum of thyroid dysfunction among children with Down syndrome attending the paediatric services at two tertiary hospitals in Pretoria, South Africa

Background. Down syndrome (DS) is the most common chromosomal abnormality in the paediatric setting, and thyroid dysfunction is more commonly encountered in this population than among the general population. The literature shows that the most common type of thyroid dysfunction seen in these children is subclinical hypothyroidism.Objective. The purpose of this study was to establish the prevalence and spectrum of thyroid disease in this population with the aim of establishing easy-to-follow protocols. Method. A retrospective study was conducted in children with DS who were seen at the paediatric genetic clinic at two academic hospitals. Data were collected from the hospital files and the results were extracted from the National Health Laboratory Service database system. Results. A total of 158 children were recruited; 25 children were excluded as they had had no thyroid function tests done. From the total of 133 included children, 70 (52.6%) were male. Babies born in one of the two hospitals numbered 60 (45.1%), whereas 54.9% were born in the other hospital. A total of 77 (57.9%) were found to have thyroid dysfunction; 55.8% of these patients were male. The most common thyroid abnormality was subclinical hypothyroidism in n=66/133 (49.6%), accounting for 85.7% of the causes of the thyroid dysfunction. Most children (n=45/133 (33.8%)) had their first thyroid function test done before the age of 2 months, followed by the age group of 1 - 5 years (n=34/133 (25.56%)). The total number of children started on treatment for their thyroid dysfunction was n=5/77 (6.49%). Conclusion. Thyroid dysfunction is seen more commonly in children with DS compared with the general population, which was very evident in the present study. A standardised protocol will have a significant impact on the early management of these children, to prevent further cognitive impairment, especially in developing countries and at any level of healthcare. The recommendations for thyroid dysfunction screening by the American Academy of Pediatrics can be adjusted and tailored for the South African population. Early diagnosis and referral of children with DS to a secondary- or tertiary-level facility is of utmost benefit for these children for screening and treatment of comorbidities and complications.

Assessing very advanced HIV disease in adolescent girls and young women

Background: South Africa has the largest HIV epidemic globally, with ~7.5 million people living with HIV in 2021. Adolescent girls (AG) and young women (YW), aged 15–19 years and 20–24 years, are twice as likely to be living with HIV as their male counterparts. The national HIV prevalence for young women was 9.1% (2021), with limited data on disease severity.Objectives: This study assessed very advanced HIV disease (CD4 100 cells/μL) in adolescent girls and young women (AGYW) in South Africa.Method: A retrospective descriptive study analysed data collated from the National Health Laboratory Service database for 2017 to 2021 calendar years for AGYW. National and provincial specimen volumes, the percentage of tests with a CD4 100 cells/μL and ≥ 100 cells/μL, and the median and interquartile ranges, were calculated. Logistic regression determined the odds ratio for a CD4 100 cells/μL, controlling for age category.Results: Data for 1 199 010 CD4 specimens indicated a significant decrease in volumes of 34% from 287 410 (2017) to 189 533 (2021). The percentage of samples with a count 100 cells/μL ranged from 4.9% to 5.2% for YW versus 5.6% to 6.1% for AG. Provincial data for a CD4 count 100 cells/μL ranged between 4.5% and 8.3% in AG and 3.6% to 6.3% for YW. Logistic regression indicated a 24% higher likelihood for AG having a CD4 count 100 cells/μL.Conclusion: The study reported a higher proportion of very advanced HIV disease for AG versus YW nationally, with provincial disparity needing further analysis.

59 Where are the viral loads? Searching for additional HIV laboratory results in South Africa’s National Health Laboratory Services Database

OBJECTIVES/GOALS: Guidelines suggest people with HIV (PWH) receive routine HIV viral load (VL) testing at least yearly and upon diagnosis with multidrug-resistant tuberculosis (MDR-TB). Many PWH and MDR-TB in South Africa seem to be missing VL results. This study’s goal was to find results which may be available from the National Health Laboratory Service (NHLS). METHODS/STUDY POPULATION: We abstracted HIV laboratory results, specifically baseline VL and CD4 count and VL at MDR-TB cure, from PWH enrolled in a cluster-randomized clinical trial of nurse case management for PWH and MDR-TB in South Africa who were cured of MDR-TB. For any participant missing one or more of these results, we thoroughly searched the electronic NHLS database using multiple separate searches varying terms including patient name, surname, date of birth, medical record number where available, and South African identification number. Returned results were compared to results abstracted from the parent study and any additional results were entered into the parent study data. RESULTS/ANTICIPATED RESULTS: Of 929 PWH cured of MDR-TB, 879 (94.6%) were missing at least one expected VL or CD4 result in the parent study database. Though our search strategy was successful in identifying participants and returning CD4 and VL results, we rarely found additional results that were not already in the parent study database. Following the search and entry of the few additional results retrieved, 116 (12.4%) participants were missing a baseline CD4, 309 (33.3%) missing baseline VL, and 385 (41.4%) missing VL at MDR-TB cure, representing 572 individuals or 61.6% of participants with at least one unavailable result. This high level of unavailability of key laboratory results used to guide MDR-TB and HIV treatment suggests that these tests were either not ordered, not collected, or not completed due to electronic gatekeeping at NHLS. DISCUSSION/SIGNIFICANCE: Unknown CD4 count or VL leaves PWH open to including MDR-TB treatment failure and death. Our search strategy found additional results but was time-consuming and cumbersome. Limitations included lack of information on why laboratory results were missing, which limits our ability to make recommendations for better collection and reporting.

Cross-municipality migration and spread of tuberculosis in South Africa

Human migration facilitates the spread of infectious disease. However, little is known about the contribution of migration to the spread of tuberculosis in South Africa. We analyzed longitudinal data on all tuberculosis test results recorded by South Africa’s National Health Laboratory Service (NHLS), January 2011–July 2017, alongside municipality-level migration flows estimated from the 2016 South African Community Survey. We first assessed migration patterns in people with laboratory-diagnosed tuberculosis and analyzed demographic predictors. We then quantified the impact of cross-municipality migration on tuberculosis incidence in municipality-level regression models. The NHLS database included 921,888 patients with multiple clinic visits with TB tests. Of these, 147,513 (16%) had tests in different municipalities. The median (IQR) distance travelled was 304 (163 to 536) km. Migration was most common at ages 20–39 years and rates were similar for men and women. In municipality-level regression models, each 1% increase in migration-adjusted tuberculosis prevalence was associated with a 0.47% (95% CI: 0.03% to 0.90%) increase in the incidence of drug-susceptible tuberculosis two years later, even after controlling for baseline prevalence. Similar results were found for rifampicin-resistant tuberculosis. Accounting for migration improved our ability to predict future incidence of tuberculosis.

Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa.

Despite South Africa’s substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL <12 weeks before delivery accounted for 83% (n=119/143) of study-derived high-risk exposures and 81% (n=60/74) of missed high-risk exposures. Fewer mothers of high-risk infants had >4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks’ gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infants.

Infant HIV Testing Amid the COVID-19 Pandemic and Evolving PMTCT Guidelines in Johannesburg, South Africa.

Background: The COVID-19 pandemic impacted HIV programmes with the diversion of resources and lockdown measures. We assessed the impact of COVID-19 on infant HIV diagnosis in the context of updated 2019 prevention of mother-to-child transmission of HIV (PMTCT) guidelines in Johannesburg, South Africa. Methods: HIV PCR data for children <2 years were extracted from the National Health Laboratory Service database from October 2018 to September 2021, inclusive. Trends in the total number of tests performed and the total number of children with HIV diagnosed, stratified by age, were determined to assess the effect of different COVID-19 lockdown levels and updated guidelines. Results: When comparing three 12-month periods ending September 2019–2021, respectively, the total number of HIV PCR tests performed increased (from 41 879 to 47 265 to 56 813), and the total number of children with HIV decreased (from 659 to 640 to 620), year-on-year. There was a substantial increase in 6-month testing in response to updated guidelines. Excluding 6-month testing, the year-on-year increase in total tests was maintained with birth and 10-week testing closely approximating total live births to women living with HIV. A decrease in the total number of children with HIV diagnosed was noted in Q2 2020, coinciding with the most restrictive lockdown, followed by a rebound in cases. Conclusions: Despite the restrictions and diversion of resources associated with COVID-19, there was a successful implementation of PMTCT guideline updates and minimal disruption to infant HIV testing. However, much work remains in order to achieve the elimination of mother-to-child transmission of HIV.

Using text mining techniques to extract prostate cancer predictive information (Gleason score) from semi-structured narrative laboratory reports in the Gauteng province, South Africa

BackgroundProstate cancer (PCa) is the leading male neoplasm in South Africa with an age-standardised incidence rate of 68.0 per 100,000 population in 2018. The Gleason score (GS) is the strongest predictive factor for PCa treatment and is embedded within semi-structured prostate biopsy narrative reports. The manual extraction of the GS is labour-intensive. The objective of our study was to explore the use of text mining techniques to automate the extraction of the GS from irregularly reported text-intensive patient reports.MethodsWe used the associated Systematized Nomenclature of Medicine clinical terms morphology and topography codes to identify prostate biopsies with a PCa diagnosis for men aged > 30 years between 2006 and 2016 in the Gauteng Province, South Africa. We developed a text mining algorithm to extract the GS from 1000 biopsy reports with a PCa diagnosis from the National Health Laboratory Service database and validated the algorithm using 1000 biopsies from the private sector. The logical steps for the algorithm were data acquisition, pre-processing, feature extraction, feature value representation, feature selection, information extraction, classification, and discovered knowledge. We evaluated the algorithm using precision, recall and F-score. The GS was manually coded by two experts for both datasets. The top five GS were reported, with the remaining scores categorised as “Other” for both datasets. The percentage of biopsies with a high-risk GS (≥ 8) was also reported.ResultsThe first output reported an F-score of 0.99 that improved to 1.00 after the algorithm was amended (the GS reported in clinical history was ignored). For the validation dataset, an F-score of 0.99 was reported. The most commonly reported GS were 5 + 4 = 9 (17.6%), 3 + 3 = 6 (17.5%), 4 + 3 = 7 (16.4%), 3 + 4 = 7 (14.7%) and 4 + 4 = 8 (14.2%). For the validation dataset, the most commonly reported GS were: (i) 3 + 3 = 6 (37.7%), (ii) 3 + 4 = 7 (19.4%), (iii) 4 + 3 = 7 (14.9%), (iv) 4 + 4 = 8 (10.0%) and (v) 4 + 5 = 9 (7.4%). A high-risk GS was reported for 31.8% compared to 17.4% for the validation dataset.ConclusionsWe demonstrated reliable extraction of information about GS from narrative text-based patient reports using an in-house developed text mining algorithm. A secondary outcome was that late presentation could be assessed.

Cancer risk in adolescents and young adults living with HIV in South Africa: a nationwide cohort study.

Literature on cancer in adolescents and young adults (AYA; aged 15-24 years) living with HIV is scarce. We studied cancer incidence in AYA living with HIV in South Africa between 2004 and 2014. In this nationwide cohort study, we included individuals between 15 and 24 years old who had at least two HIV-related laboratory measurements on separate days between Jan 1, 2004, and Dec 31, 2014, recorded in the National Health Laboratory Service database. We used privacy-preserving probabilistic record linkage methods to identify HIV-related laboratory records that most likely belonged to the same individual and to then link these individuals to cancer diagnoses from the National Cancer Registry. We computed incidence rates for the most common cancers in AYA living with HIV, and we assessed associations between these cancers and sex, age, calendar year, and CD4 cell count using Cox proportional hazards models and adjusted hazard ratios (aHRs). We included 782 454 AYA living with HIV (698 066 [89·2%] women) with 1 428 114 person-years of follow-up. Of those, 867 developed incident cancer (incidence rate 60·7 per 100 000 person-years), including 429 who developed Kaposi sarcoma (30·0 per 100 000 person-years), 107 non-Hodgkin lymphoma (7·5 per 100 000 person-years), 48 Hodgkin lymphoma (3·4 per 100 000 person-years), 45 cervical cancer (3·4 per 100 000 woman-years), and 32 leukaemia (2·2 per 100 000 person-years). Kaposi sarcoma was more common in the 20-24 year age group than the 15-19 year age group (aHR 1·39, 95% CI 1·03-1·86). Male sex was associated with higher rates of Kaposi sarcoma (2·06, 1·61-2·63), non-Hodgkin lymphoma (3·17, 2·06-4·89), Hodgkin lymphoma (4·83, 2·61-8·93), and leukaemia (unadjusted HR 5·90, 95% CI 2·87-12·12). Cancer rates decreased over the study period, driven by declining Kaposi sarcoma rates. Lower baseline CD4 cell counts were associated with higher rates of Kaposi sarcoma, cervical cancer, non-Hodgkin lymphoma, and Hodgkin lymphoma, but not leukaemia. Infection-related cancers were the most common cancer types in AYA living with HIV in South Africa, and their incidence rates increased with lower CD4 cell counts. Therefore, innovative strategies to maintaining high CD4 cell counts are needed to reduce the cancer burden in this vulnerable population. US National Institutes of Health and Swiss National Science Foundation.

Determining the prevalence of tuberculosis in emergency departments in the Eastern Cape region of South Africa and the utility of the World Health Organization tuberculosis screening tool

Background. South Africa (SA) faces a significant tuberculosis (TB) burden complicated by high rates of HIV-TB co-infection. In SA, emergency departments (EDs) play an important role in screening for TB. Objectives. To determine the prevalence of TB in the ED and the effectiveness of the World Health Organization (WHO) TB screening tool. Methods. This was a cross-sectional observational study, conducted in the ED at Livingstone Hospital, Port Elizabeth, from 4 June to 15 July 2018. All patients aged >18 years and able to consent were administered the WHO TB screening questions and underwent a point-of-care HIV test and demographic data collection. Patients were followed up for 1 year and tracked in the National Health Laboratory Service database to determine TB status using laboratory testing. Results. Over the study period, 790 patients were enrolled. Overall, 121 patients (15.3%) were TB-positive, with 46 (38.0%) diagnosed after presenting to the ED and 75 (62.0%) with a previous TB history determined by self-report or confirmed laboratory testing. A greater proportion of the TB-positive patients were HIV-positive (49.6%) compared with the TB-negative population (24.8%). TB-positive individuals were more likely to present to the ED with a chief complaint of shortness of breath (SoB) (18.2%) compared with the TB-negative population (10.5%). Overall, the WHO TB screening tool had poor sensitivity (46.5%) and specificity (62.5%) for identifying TB-positive patients in the ED. A multiple logistic regression analysis, controlled for age and sex, showed HIV status (odds ratio (OR) 2.81; p <0.001) and SoB (OR 2.19; p <0.05) to be significant predictors of TB positivity. Adding positive HIV status and a presenting complaint of SoB increased sensitivity to 78.3%. Conclusions. EDs in SA face a high burden of TB. While WHO screening guidelines identify some of these patients, including routine HIV testing in the ED could significantly affect the number of TB diagnoses made.

Adolescent HIV treatment in South Africa's national HIV programme: a retrospective cohort study

The number of South African adolescents receiving HIV care and treatment in South Africa is growing. By use of routinely collected laboratory data from South Africa's National HIV Programme, we aimed to quantify the numbers of adolescents accessing HIV care and treatment over time, characterise the role of perinatal infection in these trends, and estimate proportions of adolescents seeking HIV care and antiretroviral therapy (ART) in South Africa's public sector. We did a retrospective, descriptive cohort study of children and adolescents aged 1-19 years accessing care in South Africa's public sector HIV treatment programme from 2005 to 2016 with a CD4 cell count or viral load recorded in South Africa's National Health Laboratory Service database. We estimated the total number of children and adolescents entering HIV care with a CD4 cell count or viral load test result by calendar period, as well as the proportion in care and receiving ART with at least one viral load test result. We stratified analyses by gender and by whether the patient entered care at younger than 15 years (probably perinatally infected) or at 15-19 years (probably infected in adolescence). We identified 730 882 patients aged 1-19 years at entry to care between Jan 1, 2005, and Dec 31, 2016. 209 205 (54%) of 388 439 patients entering care younger than 15 years and 301 242 (88%) of 342 443 patients entering care aged 15-19 were female. During the study period, the number of virologically monitored patients aged 15-19 years receiving ART increased from 7949 in 2005-08 to 80 918 in 2013-16. 92 783 (66%) of 140 028 patients aged 15-19 years seeking care started ART by 2016, well below UNAID's target of ART for 90% of those diagnosed. We project that the number of adolescents on ART will continue to rise. The many adolescents aged 15-19 years receiving ART reflect the ageing of children entering care at ages 1-14 years, and increases in care-seeking among horizontally infected adolescents aged 15-19 years. However, many adolescents seeking care do not start ART, suggesting an urgent need for interventions to increase uptake of ART and improve services for this population. US National Institutes of Health, and the President's Emergency Plan for AIDS Relief through the US Agency for International Development.

Hepatitis A seroprevalence in Western Cape Province, South Africa: Are we in epidemiological transition?

Hepatitis A virus (HAV) is the most common cause of viral hepatitis worldwide. Hepatitis A vaccine is not included in the Expanded Programme on Immunisation in South Africa (EPI-SA), as the country is considered to be highly endemic for hepatitis A. To determine the seroprevalence of hepatitis A infection in Western Cape Province (WCP), South Africa. We conducted a cross-sectional seroprevalence study in the 1 - 7-year age group in WCP. Our samples (N=482) were blood specimens left over after laboratory testing obtained from referral hospitals between August and October 2015. A Siemens enzyme immunoassay was used to test for total hepatitis A antibodies. We also analysed hepatitis A immunoglobulin G antibody results from the National Health Laboratory Service (NHLS) Disa*Lab database at Groote Schuur Hospital from 2009 to 2014, and included 2009 - 2014 acute hepatitis A (immunoglobulin M-positive) surveillance data from the National Institute for Communicable Diseases to look at trends in notified acute infections over the same period. Our cross-sectional study showed 44.1% seroprevalence in the 1 - 7-year age group. Hepatitis A data from the NHLS database indicated a seroprevalence of &lt;90% up to age 10 years, indicating intermediate endemicity. The surveillance data showed that a substantial number of symptomatic hepatitis A infections occurred in the 7 - 40-year age group, suggesting that an increasing proportion of the population is susceptible to HAV infection. These results suggest an urgent need for detailed evidence-based considerations to introduce hepatitis A vaccine into the EPI-SA.

Improving Linkage to and Retention in Care in Newly Diagnosed HIV-Positive Patients Using Smartphones in South Africa: Randomized Controlled Trial.

BackgroundSouth Africa provides free antiretroviral therapy for almost 5 million people living with HIV, but only 71% of the eligible people are on treatment, representing a shortfall in the care cascade, especially among men and youth. Many developing countries have expanded access to smartphones; success in health apps raises the possibility of improving this cascade.ObjectiveSmartLink is a health app for Android smartphones providing HIV-related laboratory results, information, support, and appointment reminders to engage and link patients to care. This study aimed to evaluate the ability of SmartLink to improve linkage to care for HIV-positive smartphone owners.MethodsThis study was a multisite randomized controlled trial in Johannesburg. The intervention arm received the app (along with referral to a treatment site) and the control arm received the standard of care (referral alone). Linkage to care was confirmed by an HIV-related blood test reported on the National Health Laboratory Service database between 2 weeks and 8 months after initiation.ResultsA total of 345 participants were recruited into the study; 64.9% (224/345) of the participants were female and 44.1% (152/345) were aged less than 30 years. In addition, 46.7% (161/345) were employed full time, 95.9% (331/345) had at least secondary school education, and 35.9% (124/345) were from Zimbabwe. Linkage to care between 2 weeks and 8 months was 48.6% (88/181) in the intervention arm versus 45.1% (74/164) in the control (P=.52) and increased to 64.1% (116/181) and 61.0% (100/164) (P=.55), respectively, after the initial 8-month period. Moreover, youth aged 18 to 30-years showed a statistically significant 20% increase in linkage to care for the intervention group.ConclusionsYouth aged less than 30 years have been historically difficult to reach with traditional interventions, and the SmartLink app provides a proof of concept that this population reacts to mobile health interventions that engage patients in HIV care.Trial RegistrationClinicalTrials.gov NCT02756949; https://clinicaltrials.gov/ct2/show/NCT02756949 (Archived by WebCite at http://www.webcitation.org/6z1GTJCNW)

Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator.

IntroductionCross‐sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV‐1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations.MethodsLongitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self‐report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and HIV‐1 RNA at nine months were extracted from the South Africa National Health Laboratory Service database. Two path analyses were estimated, one testing associations between internalized stigma, avoidant coping and ART initiation, and the other testing associations between internalized stigma, avoidant coping and HIV‐1 RNA suppression.ResultsParticipants were 36 years old, on average, and 63% identified as female, 18% as Zulu and 65% as Xhosa. The two path models fit the data well (ART initiation outcome: X 2(7) = 8.14, p = 0.32; root mean square error of approximation (RMSEA) = 0.02; comparative fit index (CFI) = 0.92; HIV‐1 RNA suppression outcome: X 2(7)  = 6.58, p = 0.47; RMSEA = 0.00; CFI = 1.00). In both models, internalized stigma one week after diagnosis was associated with avoidant coping at three months, controlling for avoidant coping at one week. In turn, avoidant coping at three months was associated with lower likelihood of ART initiation at six months in the first model and lower likelihood of HIV‐1 RNA suppression at nine months in the second model. Significant indirect effects were observed between internalized stigma with ART non‐initiation and unsuppressed HIV‐1 RNA via the mediator of avoidant coping.ConclusionsInternalized stigma experienced soon after HIV diagnosis predicted lower likelihood of ART initiation and HIV‐1 RNA suppression over the first year following HIV diagnosis. Avoidant coping played a role in these associations, suggesting that PLWH who internalize stigma engage in greater avoidant coping, which in turn worsens medication‐ and health‐related outcomes. Interventions are needed to address internalized stigma and avoidant coping soon after HIV diagnosis to enhance treatment efforts during the first year after HIV diagnosis.

Do Incarcerated Populations Serve as a Reservoir for Tuberculosis in South Africa?

Tuberculosis (TB) prevalence among incarcerated populations is as much as 1,000 times higher than in the general population. This study evaluates whether correctional facilities serve as a reservoir through which TB is transmitted to surrounding communities. Tuberculosis test data were extracted from the South African National Health Laboratory Service database for patients tested for TB between 2005 and 2011. We conducted graphical analysis to assess the relationship of TB rates between incarcerated and non-incarcerated populations over time. We performed generalized linear modeling with a log link function to assess TB risk in communities surrounding correctional facilities, net of confounders. We assessed linkages between incarcerated and non-incarcerated populations over time using Granger causality analysis. Tuberculosis prevalence among incarcerated populations was four times higher than in the general population. Tuberculosis incidence rates in incarcerated and non-incarcerated populations followed similar trends over time. The presence of a correctional facility in a municipality was associated with 34.9% more detected TB cases (confidence interval: 11.6-63.2; P < 0.01), controlling for potential confounders. Detected TB in incarcerated populations did not have predictive power in explaining detected TB rates in the non-incarcerated population after controlling for serial correlation in the time series data. Despite high TB prevalence, trends in correctional facilities do not appear to be driving temporal trends in the general population. However, correctional facilities still act as a TB reservoir that raises the overall TB risk in the vicinity. Intensified TB control policies for correctional facilities, formerly incarcerated individuals, and surrounding communities will reduce TB prevalence overall.

The usefulness of routine histological examination of appendicectomy specimens in a South African tertiary centre.

It is accepted surgical practice to send all appendicectomy specimens for histological examination, but the usefulness and cost associated with this practice have not been established in our setting, a tertiary hospital in KwaZulu-Natal Province, South Africa (SA). To determine the histological diagnoses of appendicectomy specimens in our centre, and the cost of identifying an alternative histological diagnosis requiring further treatment. Clinical data on patients undergoing appendicectomy for suspected acute appendicitis during the study period December 2012- August 2015 were retrospectively retrieved from the hybrid electronic medical registry. Histological data were then extracted from the National Health Laboratory Service database. The cost of an appendicitis histology report was sourced from a private laboratory service. A total of 290 patients were identified during the study period. Males had a significantly higher risk (p&lt;0.0001) than females of histologically confirmed appendicitis (odds ratio 3.2, 95% confidence interval 1.7 - 5.8). The negative appendicectomy rate was 22.4% (65/290). In 5.9% of specimens (17/290) an alternative diagnosis was made on histological examination, which influenced the management plan. These were parasitic co-infections in 13 cases (4.5%), premalignant conditions in 2 and tuberculosis in 2. The average cost of processing each appendicectomy specimen was ZAR871. The cost of identifying each patient with an alternative diagnosis that required treatment was ZAR14 858 ([290 × ZAR871]/17). This audit correlates with other SA studies showing that the aetiological differential for appendicitis is broad. Histological examination therefore remains critical in the management of patients with suspected acute appendicitis in our clinical setting.

Complementary surveillance strategies are needed to better characterise the epidemiology, care pathways and treatment outcomes of tuberculosis in children

BackgroundTuberculosis (TB) in young and HIV-infected children is frequently diagnosed at hospital level. In settings where general hospitals do not function as TB reporting units, the burden and severity of childhood TB may not be accurately reflected in routine TB surveillance data. Given the paucibacillary nature of childhood TB, microbiological surveillance alone will miss the majority of hospital-managed children. The study objective was to combine complementary hospital-based surveillance strategies to accurately report the burden, spectrum and outcomes of childhood TB managed at referral hospital-level in a high TB burden setting.MethodsWe conducted a prospective cohort study including all children (< 13 years) managed for TB at a large referral hospital in Cape Town, South Africa during 2012. Children were identified through newly implemented clinical surveillance in addition to existing laboratory surveillance. Data were collected from clinical patient records, the National Health Laboratory Service database, and provincial electronic TB registers. Descriptive statistics were used to report overall TB disease burden, spectrum, care pathways and treatment outcomes. Univariate analysis compared characteristics between children identified through the two hospital-based surveillance strategies to characterise the group of children missed by existing laboratory surveillance.ResultsDuring 2012, 395 children (180 [45.6%] < 2 years) were managed for TB. Clinical surveillance identified 237 (60%) children in addition to laboratory surveillance. Ninety (24.3%) children were HIV co-infected; 113 (29.5%) had weight-for-age z-scores <− 3. Extra-pulmonary TB (EPTB) was diagnosed in 188 (47.6%); 77 (19.5%) with disseminated TB. Favourable TB treatment outcomes were reported in 300/344 (87.2%) children with drug-susceptible and 50/51 (98.0%) children with drug-resistant TB. Older children (OR 1.7; 95% CI 1.0–2.8), children with EPTB (OR 2.3; 95% CI 1.5–3.6) and in-hospital deaths (OR 5.4; 95% CI 1.1–26.9) were more frequently detected by laboratory surveillance. TB/HIV co-infected children were less likely to be identified through laboratory surveillance (OR 0.3; 95% CI 0.2–0.5).ConclusionsThe burden and spectrum of childhood TB disease managed at referral hospital level in high burden settings is substantial. Hospital-based surveillance in addition to routine TB surveillance is essential to provide a complete picture of the burden, spectrum and impact of childhood TB in settings where hospitals are not TB reporting units.

A comparative study of human T-cell lymphotropic virus-associated myelopathy in HIV-positive and HIV-negative patients in KwaZulu-Natal

Background: KwaZulu-Natal is an endemic area for HIV and human T-cell lymphotropic virus (HTLV) infection. The main neurological manifestation of HTLV is HTLV-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The effect of HIV co-infection in patients with HAM/TSP is not well documented.Aims: To determine the prevalence of HIV seropositivity in patients with HAM/TSP and compare the clinical, laboratory and radiological features of patients mono-infected with HTLV and those dually infected with HTLV and HIV.Methods: Adult patients referred to the Neurology Department at Inkosi Albert Luthuli Central Hospital in KwaZulu-Natal, South Africa, for the period 01 January 2004 to 31 December 2015 with a positive HTLV serology were identified from the National Health Laboratory Service database. A retrospective chart review was conducted to identify all patients who had a diagnosis of HAM/TSP and to record their HIV status. Clinical, laboratory and radiological data were compared for HIV-positive and HIV-negative patients.Results: A total of 52 patients with HAM/TSP were identified. HIV results were available in 44 patients of whom 23 (52%) patients were HIV co-infected. Patients who were HIV-positive had a younger age of presentation compared to HIV-negative patients (median: 31 vs 50 years, p = 0.002). HIV-positive patients had a median duration of symptoms at presentation of 12 months compared to 16 months for HIV-negative patients, but the difference did not reach statistical significance (p = 0.082). The CD4 cell counts of HIV-positive patients were well preserved with a median count of 781 cells/µL.Conclusions: HIV co-infection is commonly seen in the setting of HAM/TSP in KwaZulu-Natal. An interaction between the viruses may accelerate the development of HAM/TSP, leading to a younger age of presentation. Co-infection may have treatment implications because of CD4 counts being preserved in these patients.

Impact of Xpert MTB/RIF rollout on management of tuberculosis in a South African community.

The Xpert MTB/RIF test shortens the time to microbiological confirmation of pulmonary tuberculosis (TB) under research conditions. To evaluate the field impact of Xpert MTB/RIF rollout on TB diagnostic yield and time to treatment in a South African (SA) community. We compared TB investigation outcomes for 6-month calendar periods before and after Xpert MTB/RIF rollout in a semi-rural area of SA. The proportion of adult patients who tested positive by sputum smear microscopy, liquid culture or Xpert MTB/RIF and the proportion of positive sputum smear, liquid culture or Xpert MTB/RIF tests were compared. Secondary outcomes included time to laboratory diagnosis and treatment initiation. Data were collected from the National Health Laboratory Service database and from the Western Cape Provincial Department of Health TB register. Regional rollout of Xpert MTB/RIF testing occurred in 2013. Of the 15 629 patients investigated in the post-rollout period, 7.9% tested positive on GeneXpert, compared with 6.4% of the 10 741 investigated in the pre-rollout period who tested positive by sputum smear microscopy (p&lt;0.001). Median laboratory processing time was &lt;1 day for Xpert MTB/RIF (interquartile range (IQR) 0 - 1) compared with 1 day (IQR 0 - 16) for sputum smear microscopy (p=0.001). The median time to TB treatment initiation was 4 days (IQR 2 - 8) after rollout compared with 5 days (IQR 2 - 14) before (p=0.001). Patients investigated for suspected pulmonary TB were more likely to be diagnosed after rollout of Xpert MTB/RIF testing, although the benefit to diagnostic yield was modest, and Xpert MTB/RIF testing was associated with a marginal improvement in time to treatment initiation.

The prevalence and management of rifampicin-resistant tuberculosis among adults at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

Background . Early effective management of drug-resistant tuberculosis (TB) is important for the patient, and for infection control. The Xpert MTB/RIF (Cepheid, USA) assay detects Mycobacterium tuberculosis DNA and the presence of rifampicin resistance. Objective . To assess the prevalence and initial management of rifampicin-resistant pulmonary TB (PTB), confirmed by the Xpert MTB/RIF assay, in hospitalised adult patients. Methods. This retrospective descriptive study assessed adult patients from March 2011 to February 2013. Data was obtained from the National Health Laboratory Service database and patient records. Management comprised the submission of additional confirmatory sputum tests, initiation of appropriate anti-TB drug therapy, patient isolation, and proper referral. Results . The prevalence of rifampicin resistance was 10.6% (n=77) of 729 positive assays. The initial management was assessed for 70 patients with complete records. However, of these 70 patients, 12 patients had been discharged and 5 patients had died prior to receiving their results. The management of the total cohort, and of the 53 remaining inpatients, was analysed separately. The overall confirmatory sputum submission rates were 76%, 60%, 60% and 26% for TB microscopy, Line Probe Assay, TB culture, and drug-susceptibility testing, respectively, and 87%, 72%, 68% and 30%, respectively for the 53 remaining patients. Overall, 33% of patients received appropriate anti-TB treatment, 50% were isolated, and 49% were appropriately referred. For the 53 remaining patients, 43% received appropriate drug treatment, 66% were isolated, 64% were appropriately referred, and 19% were not referred. The inpatient mortality rate was 19%. Conclusions. Rifampicin-resistant TB prevalence in-hospital was more than double the national rate. The initial management of patients with rifampicin-resistant PTB was substandard. Submission of paired sputum samples and educating healthcare professionals and healthcare users are of paramount importance to improve the management of drug-resistant TB.