Scaling up antiretroviral therapy in Malawi-implications for managing other chronic diseases in resource-limited countries.

The national scale-up of antiretroviral therapy (ART) in Malawi is based on the public health approach, with principles and practices borrowed from the successful DOTS (directly observed treatment, short course) tuberculosis control framework. The key principles include political commitment, free care, and standardized systems for case finding, treatment, recording and reporting, and drug procurement. Scale-up of ART started in June 2004, and by December 2008, 223,437 patients were registered for treatment within a health system that is severely underresourced. The Malawi model for delivering lifelong ART can be adapted and used for managing patients with chronic noncommunicable diseases, the burden of which is already high and continues to grow in low-income and middle-income countries. This article discusses how the principles behind the successful Malawi model of ART delivery can be applied to the management of other chronic diseases in resource-limited settings and how this paradigm can be used for health systems strengthening

Developing district health systems in the rural Transvaal Issues arising from the Tintswalo/Bushbuckridge experience

District health systems are increasingly acknowledged as a foundation for national health services based on primary health care. Initial efforts to institute a demonstration district health system in the Bushbuckridge area of the eastern Transvaal are described. These include efforts to overcome the organisational and administrative fragmentation caused by homeland and provincial boundaries. Close attention needs to be given to districtlevel health management, the complementary roles of district and regional health authorities, working relationships and accountability among professional staff from different disciplines, involvement of the community in a district health authority and the district health system as an element oflocal government

Causes de décès dans une zone rurale d'Afrique du Sud comparées à deux autres situations (Sénégal et France)

L'étude compare le profil des causes de décès dans une zone rurale de l'Afrique du Sud (Agincourt, 1992-1995) à une autre zone rurale d'Afrique de l'Ouest (Niakhar, 1983-1989) et à un pays développé ayant la même espérance de vie (la France de 1951). Cette comparaison permettra d'identifier les causes de décès ayant une fréquence particulièrement forte (ou faible) et par conséquent de dégager des priorités pour les futures actions de santé publique. Dans les deux sites africains, les causes de décès sont déterminées par autopsie verbale, alors que dans le cas de la France les données sur les causes de décès proviennent de l'enregistrement régulier par le corps médical. Dans les trois cas, les taux comparatifs de mortalité par cause ont été calculés. Sur le site d'Afrique du Sud, l'espérance de vie à la naissance était estimée à 66 ans au cours de la période 1992-1995, pratiquement identique à celle de la France de 1951, mais beaucoup plus élevée que celle de Niakhar dans les années 1983-1989 (49 ans). Les causes déterminant une mortalité particulièrement élevée à Agincourt sont les morts violentes (homicide et suicide), les accidents (accidents de la route et accidents domestiques), certaines maladies infectieuses (sida, tuberculose, diarrhée et dysenterie), et certaines maladies non-transmissibles (cancers des organes génitaux, cirrhose du foie, hémorragie gastrique, mortalité maternelle, épilepsie, rhumatisme articulaire aigu, pneumoconiose), ainsi que la malnutrition des jeunes enfants (kwashiorkor). Les causes de décès déterminant une mortalité particulièrement faible sont les maladies respiratoires (pneumonie, bronchite, grippe, cancer du poumon), les autres cancers, les maladies vaccinables (rougeole, coqueluche, tétanos) et le marasme... (D'après résumé d'auteur

A hidden menace: Cardiovascular disease in South Africa and the costs of an inadequate policy response

The cardiovascular disease (CVD) burden in South Africa (SA) is increasing amongst all age groups and is predicted to become the prime contributor to overall morbidity and mortality in the over 50-year age group. Several factors contribute to this – an epidemiological transition, which has seen a rise in chronic non-communicable disease, and a demographic transition with much reduced fertility and a growing proportion of the population above 60 years. In parallel with unfolding urbanisation, the population burden of vascular risk factors namely hypertension, hypercholesterolemia, diabetes and obesity has increased. The scale of CVD burden poses a threat to the health system and calls for timely intervention. This paper discusses the burden of CVD in SA and current initiatives to address it. Evidence is presented from studies that focus on prevention including salt reduction and trans-fatty acids legislation. The economic and clinical impact of an inadequate private and public sector response is summarised. The paper documents lessons from other countries and proposes health systems strengthening measures that could improve care of patients with CVD

Social patterns and differentials in the fertility transition in the context of HIV/AIDS: evidence from population surveillance, rural South Africa, 1993 - 2013.

BACKGROUND: Literature is limited on the effects of high prevalence HIV on fertility in the absence of treatment, and the effects of the introduction of sustained access to antiretroviral therapy (ART) on fertility. We summarize fertility patterns in rural northeast South Africa over 21 years during dynamic social and epidemiological change. METHODS: We use data for females aged 15-49 from the Agincourt health and socio-demographic surveillance system (1993-2013). We use discrete time event history analysis to summarize patterns in the probability of any birth. RESULTS: Overall fertility declined in 2001-2003, increased in 2004-2011, and then declined in 2012-2013. South Africans showed a similar pattern. Mozambicans showed a different pattern, with strong declines prior to 2003 before stalling during 2004-2007, and then continued fertility decline afterwards. There was an inverse gradient between fertility levels and household socioeconomic status. The gradient did not vary by time or nationality. CONCLUSIONS: The fertility transition in rural South Africa shows a pattern of decline until the height of the HIV/AIDS pandemic, with a resulting stall until further decline in the context of ART rollout. Fertility patterns are not homogenous among groups

Social patterns and differentials in the fertility transition in the context of HIV/AIDS: evidence from population surveillance, rural South Africa, 1993 – 2013

BACKGROUND: Literature is limited on the effects of high prevalence HIV on fertility in the absence of treatment, and the effects of the introduction of sustained access to antiretroviral therapy (ART) on fertility. We summarize fertility patterns in rural northeast South Africa over 21 years during dynamic social and epidemiological change. METHODS: We use data for females aged 15–49 from the Agincourt health and socio-demographic surveillance system (1993–2013). We use discrete time event history analysis to summarize patterns in the probability of any birth. RESULTS: Overall fertility declined in 2001–2003, increased in 2004–2011, and then declined in 2012–2013. South Africans showed a similar pattern. Mozambicans showed a different pattern, with strong declines prior to 2003 before stalling during 2004–2007, and then continued fertility decline afterwards. There was an inverse gradient between fertility levels and household socioeconomic status. The gradient did not vary by time or nationality. CONCLUSIONS: The fertility transition in rural South Africa shows a pattern of decline until the height of the HIV/AIDS pandemic, with a resulting stall until further decline in the context of ART rollout. Fertility patterns are not homogenous among groups.Thanks are due to key funding partners of the MRC/Wits Rural Public Health and Health Transitions Research Unit who have enabled the ongoing Agincourt Health and Socio-demographic Surveillance System: the Wellcome Trust, UK (grants 058893/Z/99/A, 069683/Z/02/Z, and 085477/Z/08/Z); the Medical Research Council, University of the Witwatersrand, and Anglo-American Chairman’s Fund, South Africa; the William and Flora Hewlett Foundation (grant 2008–1840), the Andrew W. Mellon Foundation, and the National Institute on Aging (NIA) of the National Institutes of Health (NIH), USA (grants 1R24AG032112-01 and 5R24AG032112- 03)

Reducing the sodium content of high-salt foods: Effect on cardiovascular disease in South Africa

Background. Average salt intake in South African (SA) adults, 8.1 g/day, is higher than the recommended 4 - 6 g/day recommended by the World Health Organization. Much salt consumption arises from non-discretionary intake (the highest proportion from bread, with contributions from margarine, soup mixes and gravies). This contributes to an increasing burden of hypertension and cardiovascular disease (CVD). Objectives. To provide SA-specific information on the number of fatal (stroke, ischaemic heart disease and hypertensive heart disease) and non-fatal CVD events that would be prevented each year following a reduction in the sodium content of bread, soup mix, seasoning and margarine. Methods. Based on the potential sodium reduction in selected products, we calculated the expected change in population-level systolic blood pressure (SBP) and mortality due to CVD and stroke. Results. Proposed reductions would decrease the average salt intake by 0.85 g/person/day. This would result in 7 400 fewer CVD deaths and 4 300 less non-fatal strokes per year compared with 2008. Cost savings of up to R300 million would also occur. Conclusions. Population-wide strategies have great potential to achieve public health gains as they do not rely on individual behaviour or a well-functioning health system. This is the first study to show the potential effect of a salt reduction policy on health in SA

Ubiquitous burden: the contribution of migration to AIDS and Tuberculosis mortality in rural South Africa

The paper aims to estimate the extent to which migrants are contributing to AIDS or tuberculosis (TB) mortality among rural sub-district populations. The Agincourt (South Africa) health and socio-demographic surveillance system provided comprehensive data on vital and migration events between 1994 and 2006. AIDS and TB cause-deleted life expectancy, and crude death rates by gender, migration status and period were computed. The annualised crude death rate almost tripled from 5∙39 [95% CI 5∙13–5∙65] to 15∙10 [95% CI 14∙62–15∙59] per 1000 over the years 1994-2006. The contribution of AIDS and TB in returned migrants to the increase in crude death rate was 78∙7% [95% CI 77∙4–80∙1] for males and 44∙4% [95% CI 43∙2–46∙1] for females. So, in a typical South African setting dependent on labour migration for rural livelihoods, the contribution of returned migrants, many infected with AIDS and TB, to the burden of disease is high.

Assessing health and well-being among older people in rural South Africa

Background: The population in developing countries is ageing, which is likely to increase the burden of noncommunicable diseases and disability. Objective: To describe factors associated with self-reported health, disability and quality of life (QoL) of older people in the rural northeast of South Africa. Design: Cross-sectional survey of 6,206 individuals aged 50 and over. We used multivariate analysis to examine relationships between demographic variables and measures of self-reported health (Health Status), functional ability (WHODASi) and quality of life (WHOQoL). Results: About 4,085 of 6,206 people eligible (65.8%) completed the interview. Women (Odds Ratio (OR) 1.30, 95% CI 1.09, 1.55), older age (OR2.59, 95% CI 1.97, 3.40), lower education (OR1.62, 95% CI 1.31,2.00), single status (OR1.18, 95% CI 1.01, 1.37) and not working at present (OR1.29, 95% CI 1.06, 1.59) were associated with a low health status. Women were also more likely to report a higher level of disability (OR1.38, 95% CI 1.14, 1.66), as were older people (OR2.92, 95% CI 2.25, 3.78), those with no education (OR1.57, 95% CI 1.26, 1.97), with single status (OR1.25, 95% CI 1.06, 1.46) and not working at present (OR1.33, 95% CI 1.06, 1.66). Older age (OR1.35, 95% CI 1.06, 1.74), no education (OR1.39, 95% CI 1.11, 1.73), single status (OR1.28, 95% CI 1.10, 1.49), a low household asset score (OR1.52, 95% CI 1.19, 1.94) and not working at present (OR1.32; 95% CI 1.07, 1.64) were all associated with lower quality of life. Conclusions: This study presents the first population-based data from South Africa on health status, functional ability and quality of life among older people. Health and social services will need to be restructured to provide effective care for older people living in rural South Africa with impaired functionality and other health problems

External injuries, trauma and avoidable deaths in Agincourt, South Africa : a retrospective observational and qualitative study

Acknowledgments We thank Chodziwadziwa Kabudula (MRC/Wits Rural Public Health and Health Transitions Research Unit—School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg/Acornhoek, South Africa) for his assistance with assembling the Agincourt HDSS data set for our use. The research presented in this paper was in part funded by the Health Systems Research Initiative from the Department for International Development (DFID)/ Medical Research Council (MRC)/Wellcome Trust/Economic and Social Research Council (ESRC) (MR/P014844/1).Peer reviewedPublisher PD