Rheumatoid arthritis - clinical aspects: 134. Predictors of Joint Damage in South Africans with Rheumatoid Arthritis

Background: Rheumatoid arthritis (RA) causes progressive joint damage and functional disability. Studies on factors affecting joint damage as clinical outcome are lacking in Africa. The aim of the present study was to identify predictors of joint damage in adult South Africans with established RA. Methods: A cross-sectional study of 100 black patients with RA of >5 years were assessed for joint damage using a validated clinical method, the RA articular damage (RAAD) score. Potential predictors of joint damage that were documented included socio-demographics, smoking, body mass index (BMI), disease duration, delay in disease modifying antirheumatic drug (DMARD) initiation, global disease activity as measured by the disease activity score (DAS28), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and autoantibody status. The predictive value of variables was assessed by univariate and stepwise multivariate regression analyses. A p value <0.05 was considered significant. Results: The mean (SD) age was 56 (9.8) years, disease duration 17.5 (8.5) years, educational level 7.5 (3.5) years and DMARD lag was 9 (8.8) years. Female to male ratio was 10:1. The mean (SD) DAS28 was 4.9 (1.5) and total RAAD score was 28.3 (12.8). The mean (SD) BMI was 27.2 kg/m2 (6.2) and 93% of patients were rheumatoid factor (RF) positive. More than 90% of patients received between 2 to 3 DMARDs. Significant univariate predictors of a poor RAAD score were increasing age (p = 0.001), lower education level (p = 0.019), longer disease duration (p < 0.001), longer DMARD lag (p = 0.014), lower BMI (p = 0.025), high RF titre (p < 0.001) and high ESR (p = 0.008). The multivariate regression analysis showed that the only independent significant predictors of a higher mean RAAD score were older age at disease onset (p = 0.04), disease duration (p < 0.001) and RF titre (p < 0.001). There was also a negative association between BMI and the mean total RAAD score (p = 0.049). Conclusions: Patients with longstanding established RA have more severe irreversible joint damage as measured by the clinical RAAD score, contrary to other studies in Africa. This is largely reflected by a delay in the initiation of early effective treatment. Independent of disease duration, older age at disease onset and a higher RF titre are strongly associated with more joint damage. The inverse association between BMI and articular damage in RA has been observed in several studies using radiographic damage scores. The mechanisms underlying this paradoxical association are still widely unknown but adipokines have recently been suggested to play a role. Disclosure statement: C.I. has received a research grant from the Connective Tissue Diseases Research Fund, University of the Witwatersrand. All other authors have declared no conflicts of interes

An Outcome Evaluation of the Health Information Management and Applied Epidemiology (HIMAE) course in South Africa

Thesis (Master's)--University of Washington, 2019Background: Health Information Systems (HIS) can provide accurate and reliable data for patient monitoring, disease surveillance, program evaluation, and resource allocation at varying levels of a national health system. South Africa has been making poor progress on meeting targets for HIV epidemic control due to a lack of data capturers at the facility-level and poor data quality. Blended learning has been identified as one feasible option to address this gap. This paper evaluates the Health Information Management and Applied Epidemiology (HIMAE) course designed to train frontline healthcare workers in South Africa. Methods: The ten module HIMAE course was disseminated through a Demonstration Programme (DP) and Open Choice Programme (OCP). Participants had access to e-learning, USB, and workbook modalities. Pre- and post-test scores were used to evaluate change in knowledge over the first five modules of the course which was defined as course completion. Completer and non-completer interviews were conducted to assess participant attitudes towards course delivery and uptake and measure translation into daily practice. Descriptive statistics, t-tests, and linear regressions were calculated to determine differences within and across dissemination groups. Interviews were coded and analyzed for common themes based on findings from the quantitative analysis. Results: A total of 331 participants took part in the study. 39 participants were enrolled in the DP and 292 were enrolled in the OCP. DP participants were 3.9 (95% CI: 2.2-6.7, p <0.001) times more likely to complete the first five modules than those in the OCP. On average, DP participants’ test-scores improved by 24.2 percentage-points and the OCP improved by 21.0 percentage-points. There were no significant differences in mean post-test scores across dissemination groups or mean score differences among cadres. The DP model increased motivation to complete the course but did not change the types of uptake barriers faced by participants. Conclusion: Overall, the course significantly improved participant knowledge in data literacy. Interview participants also indicated several ways they applied knowledge gained from the course into their daily practice. Based on these findings, the HIMAE course can provide an approach to remove barriers of poor data quality and large frontline health worker knowledge gaps as well as assist South Africa to make improved progress to meeting targets for HIV control

Responding to a surge in overdose deaths: perspectives from US syringe services programs

Abstract Background US overdose deaths have reached a record high. Syringe services programs (SSPs) play a critical role in addressing this crisis by providing multiple services to people who use drugs (PWUD) that help prevent overdose death. This study examined the perspectives of leadership and staff from a geographically diverse sample of US SSPs on factors contributing to the overdose surge, their organization’s response, and ongoing barriers to preventing overdose death. Methods From 2/11/2021 to 4/23/2021, we conducted semi-structured interviews with leadership and staff from 27 SSPs sampled from the North American Syringe Exchange Network directory. Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process. Results Respondents reported that increased intentional and unintentional fentanyl use (both alone and combined with other substances) was a major driver of the overdose surge. They also described how the COVID-19 pandemic increased solitary drug use and led to abrupt increases in use due to life disruptions and worsened mental health among PWUD. In response to this surge, SSPs have increased naloxone distribution, including providing more doses per person and expanding distribution to people using non-opioid drugs. They are also adapting overdose prevention education to increase awareness of fentanyl risks, including for people using non-opioid drugs. Some are distributing fentanyl test strips, though a few respondents expressed doubts about strips’ effectiveness in reducing overdose harms. Some SSPs are expanding education and naloxone training/distribution in the broader community, beyond PWUD and their friends/family. Respondents described several ongoing barriers to preventing overdose death, including not reaching certain groups at risk of overdose (PWUD who do not inject, PWUD experiencing homelessness, and PWUD of color), an inconsistent naloxone supply and lack of access to intranasal naloxone in particular, inadequate funding, underestimates of overdoses, legal/policy barriers, and community stigma. Conclusions SSPs remain essential in preventing overdose deaths amid record numbers likely driven by increased fentanyl use and COVID-19-related impacts. These findings can inform efforts to support SSPs in this work. In the face of ongoing barriers, support for SSPs—including increased resources, political support, and community partnership—is urgently needed to address the worsening overdose crisis