Hepatitis B and HIV co-infection in South Africa: just treat it!

There are an estimated 350 million hepatitis B carriers worldwide. The prevalence of mono-infection with hepatitis B in South Africa has been estimated at approximately 10% for the rural population and 1% in urban areas.1,2 The transmission routes of hepatitis B and HIV are similar, but hepatitis B is more efficient. Co-infection with HIV and hepatitis B is therefore not unusual. Recent studies have shown that the prevalence of HIV/HBV co-infection (using HBV surface antigen (HBsAg) as a marker for HBV) in South Africa ranges from 4.8% to 17%, depending on the population studied.The guidelines for the South African HIV Comprehensive Care,  anagement and Treatment (CCMT) programme do not include viral hepatitis studies.6 Hepatitis B serology is usually done only if serum aminotransferases are evaluated in the absence of another known cause (e.g. tuberculosis and concomitant medications). The clinical sequelae of HIV/HBV co-infection are multiple and can cause an increase in morbidity and mortality. Awareness of HBV/HIV co-infection with appropriate diagnosis and management is imperative for improved care of our HIV patients.

Awareness, perceived risk and practices related to cervical cancer and Pap smear screening: A crosssectional study among HIV-positive women attending an urban HIV clinic in Johannesburg, South Africa

Background. Cervical cancer is a major cause of cancer-related deaths, especially in the context of the HIV epidemic.Objective. To examine awareness, perceived risk and practices related to cervical cancer screening among HIV-positive women.Methods. Interviewer-administered structured questionnaires were administered to HIV-positive women (aged ≥18 years) enrolled in a cervical cancer screening study at the Themba Lethu Clinic, Johannesburg, South Africa, from November 2009 to December 2011. Modified Poisson regression with robust standard errors was used to identify factors at enrolment associated with awareness, perceived risk and adequate practice related to cervical screening. Adjusted relative risks (aRRs) with 95% confidence intervals (CIs) are presented.Results. Of the 1 202 women enrolled, 71.3% and 18.2% were aware of the Pap smear and HPV, respectively. Of the 1 192 participants with data evaluated, 76.5% were worried and 23.5% were not worried about cervical cancer; 28.6% of the women had adequate screening practice. Older age (40 - 49 years or ≥50 years v. 18 - 29 years) (aRR 1.63, 95% CI 1.12 - 2.37; aRR 2.22, 95% CI 1.44 - 3.41), higher education (tertiary v. less than grade 10) (aRR 1.39, 95% CI 1.00 - 1.93), initiation on combination antiretroviral therapy (aRR 1.36, 95% CI 1.00 - 1.85) and awareness of Pap smear screening (aRR 16.18, 95% CI 7.69 - 34.01) were associated with adequate screening practice.Conclusions. High levels of Pap smear awareness and low levels of Pap smear screening uptake were observed. However, Pap smear awareness was associated with adequate screening practice. More research into effective health education programmes to address these gaps is needed

A call to action: Addressing the reproductive health needs of women with drug-resistant tuberculosis

Although there is substantial risk to maternal and neonatal health in the situation of pregnancy during treatment for rifampicin-resistant tuberculosis (RR-TB), there is little evidence to guide clinicians as to how to manage this complexity. Of the 49 680 patients initiated on RR-TB treatment from 2009 to 2014 in South Africa, 47% were women and 80% of them were in their reproductive years (15 - 44). There is an urgent need for increased evidence of the safety of RR-TB treatment during pregnancy, increased access to contraception during RR-TB treatment, and inclusion of reproductive health in research on the prevention and treatment of TB

Delay to diagnosis and breast cancer stage in an urban South African breast clinic

Background. Breast cancer is the most common cancer in women in many low- and middle-income countries, and often presents at an advanced stage that affects prognosis irrespective of the care available. Although patient-related delay is commonly cited, the reasons for delay and the relationship of delay to stage are still poorly documented, especially in Africa.Objectives. To identify where patient-related socioeconomic delays occur and how these relate to stage at presentation.Methods. Consecutive women with a new breast cancer diagnosis were prospectively invited to complete a questionnaire on their socioeconomic characteristics and ability to access care. Clinical stage at presentation was documented.Results. Over 14 months, 252 women completed the questionnaire (response rate 71.6%). Their median age was 55 years (interquartile range 44 - 65), with 26.5% aged <45 years. Stage at presentation was stage 1 in 15.5% of patients, stage 2 in 28.5% and stage 3 in 56.0%. Almost a third of the patients (30.4%) presented with a T4 tumour (6.1% inflammatory). Total delay in presenting to the breast clinic was significantly associated with locally advanced stage at presentation (p=0.021). Average delay differed between early stage (1.5 months) and locally advanced (2.5 months), and most delay occurred between acknowledging a breast symptom and seeking care. The least delay was between attending a health service and presenting at the open-access breast clinic, with 75.0% presenting within 1 month. Factors associated with delay were difficulties with transport, low level of education and fear of missing appointments due to work.Conclusions. Most women delayed in seeking breast care. Facilitating direct access to specialist breast clinics may reduce delays in presentation and improve time to diagnosis and care

Delay to diagnosis and breast cancer stage in an urban South African breast clinic

Background. Breast cancer is the most common cancer in women in many low- and middle-income countries, and often presents at an advanced stage that affects prognosis irrespective of the care available. Although patient-related delay is commonly cited, the reasons for delay and the relationship of delay to stage are still poorly documented, especially in Africa.Objectives. To identify where patient-related socioeconomic delays occur and how these relate to stage at presentation.Methods. Consecutive women with a new breast cancer diagnosis were prospectively invited to complete a questionnaire on their socioeconomic characteristics and ability to access care. Clinical stage at presentation was documented.Results. Over 14 months, 252 women completed the questionnaire (response rate 71.6%). Their median age was 55 years (interquartile range 44 - 65), with 26.5% aged <45 years. Stage at presentation was stage 1 in 15.5% of patients, stage 2 in 28.5% and stage 3 in 56.0%. Almost a third of the patients (30.4%) presented with a T4 tumour (6.1% inflammatory). Total delay in presenting to the breast clinic was significantly associated with locally advanced stage at presentation (p=0.021). Average delay differed between early stage (1.5 months) and locally advanced (2.5 months), and most delay occurred between acknowledging a breast symptom and seeking care. The least delay was between attending a health service and presenting at the open-access breast clinic, with 75.0% presenting within 1 month. Factors associated with delay were difficulties with transport, low level of education and fear of missing appointments due to work.Conclusions. Most women delayed in seeking breast care. Facilitating direct access to specialist breast clinics may reduce delays in presentation and improve time to diagnosis and care

Tree-Based Methods for Discovery of Association between Flow Cytometry Data and Clinical Endpoints

We demonstrate the application and comparative interpretations of three tree-based algorithms for the analysis of data arising from flow cytometry: classification and regression trees (CARTs), random forests (RFs), and logic regression (LR). Specifically, we consider the question of what best predicts CD4 T-cell recovery in HIV-1 infected persons starting antiretroviral therapy with CD4 count between 200 and 350 cell/μL. A comparison to a more standard contingency table analysis is provided. While contingency table analysis and RFs provide information on the importance of each potential predictor variable, CART and LR offer additional insight into the combinations of variables that together are predictive of the outcome. In all cases considered, baseline CD3-DR-CD56+CD16+ emerges as an important predictor variable, while the tree-based approaches identify additional variables as potentially informative. Application of tree-based methods to our data suggests that a combination of baseline immune activation states, with emphasis on CD8 T-cell activation, may be a better predictor than any single T-cell/innate cell subset analyzed. Taken together, we show that tree-based methods can be successfully applied to flow cytometry data to better inform and discover associations that may not emerge in the context of a univariate analysis

A twostep qualityimprovement intervention to address Pap smear quality at public health facilities in South Africa

Background. The endocervical component of a Pap smear is an important indicator of sample quality – or ‘adequacy’. However, only 6 of 52 districts in South Africa (SA) meet the Department of Health (DoH) performance benchmark: a 70% adequacy rate. We implemented a quality-improvement (QI) intervention to address suboptimal Pap smear quality in Tshwane District, Gauteng Province, SA.Objectives. To determine whether training with the wooden Ayre spatula (step 1) or introduction of the cytobroom (step 2) resulted in greater improvements in Pap smear adequacy rates.Methods. Two Tshwane District health facilities participated in our QI project between May 2016 and February 2017. In step 1, staff received training on the Ayre spatula. In step 2, the spatula was replaced with the cytobroom. Pap smear volumes, adequacy rates and results are reported for the pre-intervention period and after each QI step. We compared adequacy rates using Fisher’s exact test, with a significance level of p=0.05.Results. In the pre-intervention period, 304 of 965 Pap smears were deemed adequate (32%; 95% confidence interval (CI) 29 - 35%). After step 1, the proportion increased to 109 of 191 (57%; 95% CI 50 - 64%; p<0.01). Similarly, after step 2, the proportion increased to 155 of 192 (81%; 95% CI 74 - 86%; p<0.01). The proportion of abnormal smears increased from 13% before the QI intervention to 17% after step 1 and 22% after step 2.Conclusion. Although training in Pap smear collection using the Ayre spatula resulted in modest improvements in quality, facilities only achieved the DoH benchmark of a 70% adequacy rate after the introduction of the cytobroom