Family medicine and primary health care: the role of undergraduate training on current practices and future considerations of junior doctors in South Africa

Research Report For Masters of Public Health 30 March 2015Introduction: The South African government recently began the implementation of the new National Health Insurance (NHI) and Re-engineering of Primary Health Care (PHC) policy proposals (green paper) in order to achieve universal health coverage and health equity. One of the vital aspects of these policy proposals is the recruitment and retention of doctors within PHC in the public sector. This study therefore aims to examine the training, current practices and future intentions of doctors completing community service in 2010, 2011 and 2012 in order to ascertain which factors may be associated with employment in PHC. Methodology: The study was designed as a cross sectional study with an analytical component. Doctors in the cohorts of interest were contacted via email and requested to fill in an anonymous self-administered online survey. Univariate analysis was done to describe socio-demographic characteristics, current employment status and future intentions. Bivariate analysis was done to examine any associations between exposure to family medicine and PHC during undergraduate training, internship and community service, and employment in PHC. Results: The database yielded a sample of 350 doctors, of which 61 responded. Of the respondents, 35.59% worked as a private general practitioner whilst 11.86% work in public PHC. The study showed no statistically significant association between exposure to family medicine and PHC and employment in PHC but female gender was the socio-demographic variable found to be associated with PHC employment (p=0.02). Factors that deterred doctors from pursuing a specialization in family medicine were related to employment conditions such as poor resources and under staffing and not to factors related to the specialty itself such as an unchallenging scope of work or poor professional perception of the specialty. Conclusion: Whilst the study showed no association between exposure to family medicine and PHC and career choices in that field, it has highlighted that the conditions within the public service are the biggest deterrent to doctors. Thus whilst medical school admissions should aim to increase the number of students with characteristics positively associated with PHC employment such as female gender, it is important that the Department of Health in South Africa aims to Mosam, Atiya. 0003032K. MPH 2015 ensure that the conditions within the public service are optimized in order to recruit and retain as many doctors as possible in light of the human resource requirements of the new policy

Cutaneous manifestations of HIV/AIDS: Part I

Human immunodeficiency virus (HIV) infection can lead to a variety of clinical cutaneous manifestations. These cutaneous disorders occur universally during the course of HIV infection. Cutaneous manifestations of HIV are very diverse. The course and clinical presentation of HIV in individuals who have access to highly active antiretroviral therapy (HAART) is completely different from that in those who do not. Many of the HIV cutaneous presentations seen in South Africa become chronic and progressive. There is a marked reduction in the incidence of opportunistic infections and neoplasms in North America, Western Europe and Australia, where there is access to HAART. Approximately 90% of patients will develop one or more skin diseases during the course of their illness. It is therefore crucial that health professionals become familiar with and are able to recognise the various skin manifestations of HIV Southern African Journal of HIV Medicine Vol. 5 (4) 2004: 12-1

Cutaneous manifestation of HIV/AIDS: Part 2

The insidious damage to the immune system by the human immunodeficiency virus results in increasing susceptibility to opportunistic viral infections. These can be localised, widespread, confined to the skin, or systemic. They can cause mild though disfiguring lesions such as molluscum contagiosum (MCV), or lead to life-threatening infections such as human papillomavirus (HPV-induced squamous cell carcinoma. Southern African Journal of HIV Medicine Vol. 6 (1) 2005: pp. 12-1

Drug reactions and the skin in HIV/AIDS

Drug reactions are common in HIV-positive individuals, approximately 100 times as common as in the general population, and they increase with increasing immunodeficiency.1 Factors associated with drug reactions in HIV disease are polypharmacy to deal with opportunistic infections, the nature of drugs prescribed for AIDS-related illnesses, slow acetylator status, relative glutathione deficiency, CD4 count 25 cells/μl,2 latent cytomegalovirus and Epstein-Barr virus infections3 and high CD8+ cell counts (> 460 cells/μl). The majority of reactions involve the following agents: ■ trimethoprim-sulfamethoxazole ■ other sulfonamide drugs, and ■ various penicillins. These drugs account for 75% of all adverse drug reactions. Trimethoprim-sulfamethoxazole adverse reactions are the commonest, the prevalence increasing from approximately 2 - 8% in the general population to 43% in HIV-positive individuals and to approximately 69% in patients with AIDS.4-6 One reason suggested for the striking incidence of reactions to trimethoprim-sulfamethoxazole is the systemic glutathione deficiency in individuals with HIV/AIDS, which increases the likelihood of accumulation of toxic intermediates such as the hydroxylamine derivatives in the circulation, hence inciting adverse drug reactions.7 Other agents implicated are antituberculosis drugs, antiretrovirals, non-steroidal anti-inflammatory drugs (NSAIDs) and anticonvulsants. Southern African Journal of HIV Medicine Vol. 7 (1) 2006: pp. 18-2

Acne in South African black adults: A retrospective study in the private sector

Background. Acne vulgaris is the most common skin disorder affecting teenagers and young adults, and is becoming increasingly common in middle-aged women. It affects all skin types and ethnic groups, but dark-skinned individuals are burdened by post-inflammatory hyperpigmentation (PIH) as a sequela. PIH causes distress in acne patients even after the inflammatory lesions have resolved.Objective. To describe the characteristics of acne in black South African adults in the private health sector in Durban, KwaZulu-Natal Province.Methods. A retrospective study of records of patients attending two large private dermatology clinics in central Durban, mainly catering for black patients, was performed. Data were collected for the period January - December 2014. Records with acne as a diagnosis were retrieved and analysed with regard to age, demographics, type and severity of acne, therapy, HIV status and outcomes.Results. Of a total of ~3 000 charts available for the 12-month period, 242 had acne as a diagnosis and were retrieved and analysed. Of these patients, 204 (84.3%) were female and the remainder were male. The mean age was 28.5 years (under-18s were excluded from the study). Inflammatory acne was the most frequently encountered form (58.6%). Fifteen patients (6.2%) were on topical treatment only, and 226 (93.4%) were on topical plus systemic treatment. PIH was the most common sequela (81.0% of patients).Conclusions. The majority of the patients were young females with inflammatory acne, and PIH was the most common sequela. Early and vigorous treatment of acne may minimise its complications, including those seen mainly in black patients

A rare case of cervical ectopic pregnancy: complicated by haemorrhagic shock

Cervical ectopic pregnancy is a rare condition that accounts for less than 0.1% of all ectopic pregnancies with high morbidity and mortality rate. We present a case of a 25 years old G5P3L2A1D1 with history of 9 weeks amenorrhoea and previous 3 caesarean sections (CS) presented with bleeding per vaginum for 2 days. Ultrasound examination revealed a ballooned-out cervical canal with a gestational sac containing foetus with cardiac activity present and an empty uterus with thickened endometrium with a typical hour-glass configuration of the uterus. Thus, the diagnosis of cervical ectopic pregnancy was made. Patient was complicated by haemorrhagic shock. Immediately hysterectomy was performed. Inj. PCV 4 unit and FFP 6 units were given and post-op- patient was shifted to ICU on ventilation support. In ICU, patient was kept on ventilation support for 4 days with vasopressor supports. Antibiotics, antacids, antiemetics, IV fluids, supportive care given. Patient was discharged on post-op day-7 with stable hemodynamics and healthy vaginal vault and stitch line. Improved ultrasound resolution and earlier detection has led to the development of more conservative treatments in non-severe cases that attempt to limit morbidity and preserve fertility

HAART in hand: The change in Kaposi’s sarcoma presentation in KwaZulu-Natal, South Africa

Background. HIV/AIDS-related Kaposi’s sarcoma (HIV-KS) is a public health problem in South Africa (SA). It is AIDS defining. There have been no studies evaluating its prevalence since the national roll-out of highly active antiretroviral therapy (HAART).Objective. To evaluate the effect of HAART on the disease profile of HIV-KS in KwaZulu-Natal Province (KZN), SA.Methods. Charts of patients with histologically confirmed HIV-KS were reviewed at an oncology clinic in KZN. The significance of associations of HAART with age, gender, CD4 count, urban/rural residence, fungating lesions, ulceration and lymphoedema, and treatment delay, was determined by t-tests for normally distributed continuous variables and χ2 tests for categorical variables. Logistic regression models were used to analyse the association of HAART with CD4 count.Results. Of 198 patients, 194 were documented as HIV-positive; 168 (86.6%) were on HAART at the time of their KS diagnosis. The mean CD4 count of 266 cells/μL was higher than that in previous studies at this site. The mean age at presentation was 36.6 (standard deviation 10.1) years. Females presented at a younger mean age than males (p<0.001). The mean age of females on HAART was 34.7 years and that of males 39.0 years (p=0.003). HAART-naive patients were three times more likely than those receiving HAART (15.4% v. 4.8%) to have visceral involvement (p=0.03).Conclusions. HAART use has resulted in outcome improvement. Mean age at presentation has increased in the group as a whole and for females in particular. The trend in mean CD4 counts has shown positive growth. Females no longer shoulder a disproportionate burden of disease

Community pharmacists’ knowledge, attitude and practices towards the use of complementary and alternative medicines in Durban, South Africa

Background: Atopic eczema (AE) is a common skin disease with an increasing worldwide prevalence, which has almost doubled over the last decade in South Africa. Many patients commonly explore complementary and alternative medicines (CAM) for AE and often initially seek advice from their local pharmacists. Aim: To explore the knowledge, attitude and practices amongst community pharmacists regarding CAM. Setting: The study was conducted amongst pharmacists working in community pharmacies in Durban, South Africa. Methods: During 2016, a cross-sectional study was conducted amongst 158 randomly selected pharmacists, of which 82 responded. Respondents were sent an email with a link to the questionnaire. Where logistically possible, questionnaires were hand-delivered. Results: The majority of respondents were male (n = 46; 56%), aged between 31 and 40 years. Despite most pharmacists not being familiar with various CAMs for AE, many (43%) recommend them, and 50% were amenable to referring patients to CAM practitioners. Despite 51% reporting that patients do ask about CAM for AE, 54% are not confident discussing or initiating discussions with patients. More than half of the pharmacists (55%) had no CAM training but believed it is essential for inclusion in the undergraduate pharmacy curriculum. Most were interested in broadening their knowledge on CAM and felt it would better prepare them in counselling their patients. Conclusions: The study demonstrated poor knowledge and communication about CAM for AE between pharmacists and patients, although pharmacists exhibited strong interests in learning more about CAM. There is a continuing need for education programmes and inclusion into undergraduate curricula that would assist pharmacists to advise patients on different types of CAMs