Is there a causal relationship between alcohol and HIV? Implications for policy, practice and future research.

There is now conclusive evidence of a causal linkage between heavy drinking patterns and/or alcohol use disorders and the worsening of the disease course for HIV. However, while alcohol usage is consistently associated with the prevalence and incidence of HIV, further research is needed to substantiate causality in terms of the acquisition of this disease. The burden attributable to alcohol use in South Africa in 2004 has been estimated to be 1.3 million years in terms of years lost though premature death caused by alcohol and years lived with an alcohol-related disability (or just over 6% of all years lost from all causes). Of all years lost through death and disability that can be attributed to alcohol, 10% for men and 28% for women can be directly attributed to alcohol’s impact on the progression of HIV in infected individuals. The implications of the above will be discussed in terms of research gaps that need to be addressed and broader policy responses that are needed in the health and social services sectors. In addition, emphasis will be given to specific practices that should be considered for rollout by agencies involved in substance abuse and HIV/AIDS treatment and prevention. Key Words: Alcohol, HIV and AIDS, South Afric

Codeine misuse and dependence in South Africa – learning from substance abuse treatment admissions

Background. Misuse of prescription and over-the-counter codeine-containing products is a global public health issue. Objectives. To investigate the extent of treatment demand related to the misuse of codeine or codeine dependence in South Africa (SA) and the profile of patients seeking treatment, so as to understand the nature and extent of the problem. Method. Data were collected from centres participating in the South African Community Epidemiology Network on Drug Use in 2014. A total of 17 260 admissions were recorded. Results. There were 435 recorded treatment admissions for codeine misuse or dependence as a primary or secondary substance of abuse (2.5% of all admissions). Of treatment admissions, 137 (0.8%) involved codeine as the primary substance of abuse; 74.9% of patients were males, with an even spread across population groups. Ages ranged from 11 to 70 years, with the highest proportion aged 20 - 29 years; > 40% were referred by self, family and/or friends, and 26.7% by health professionals; and 36.8% had received treatment previously. The majority reported misuse of tablets/capsules, with 17.6% reporting misuse of syrups. Oral use comprised 96.6% and daily use 63.1%. Conclusions. Data from treatment admissions related to codeine misuse and dependence are informative, but provide an incomplete picture of the nature and extent of codeine-related problems in SA. Other data sources must be considered before further regulatory/policy changes regarding codeine are implemented. © 2015, South African Medical Association. All rights reserved

Codeine misuse and dependence in South Africa – learning from substance abuse treatment admissions

Background. Misuse of prescription and over-the-counter codeine-containing products is a global public health issue.Objectives. To investigate the extent of treatment demand related to the misuse of codeine or codeine dependence in South Africa (SA) and the profile of patients seeking treatment, so as to understand the nature and extent of the problem.Method. Data were collected from centres participating in the South African Community Epidemiology Network on Drug Use in 2014. A total of 17 260 admissions were recorded.Results. There were 435 recorded treatment admissions for codeine misuse or dependence as a primary or secondary substance of abuse (2.5% of all admissions). Of treatment admissions, 137 (0.8%)  involved codeine as the primary substance of abuse; 74.9% of patients were males, with an even spread across population groups. Ages ranged from 11 to 70 years, with the highest proportion aged 20 - 29  years; >40% were referred by self, family and/or friends, and 26.7% by health professionals; and 36.8% had received treatment previously. The majority reported misuse of tablets/capsules, with 17.6% reporting misuse of syrups. Oral use comprised 96.6% and daily use 63.1%.Conclusions. Data from treatment admissions related to codeine misuse and dependence are  informative, but provide an incomplete picture of the nature and extent of codeine-related problems in SA. Other data sources must be considered before further regulatory/policy changes regarding codeine are implemented

Methamphetamine use and sexual risk behaviour in Cape Town, South Africa: A review of data from 8 studies conducted between 2004 and 2007

Objective: Community studies and studies of admissions to drug treatment centers indicate a dramatic increase in the prevalence of methamphetamine use in Cape Town since 2003. There has also been a substantial increase over this time period in the prevalence of HIV infection among women attending public antenatal clinics in the Western Cape province. This study aimed to review research conducted in Cape Town on the link between methamphetamine use and sexual risk behaviour. Method: A review of published research conducted in Cape Town between 2004 and 2007 was undertaken using PubMed, EBSCOhost and Science Direct. Results: Eight studies were identified, both quantitative and qualitative, and focusing on diverse populations, such as learners in school, out of school youth, adults in the community, men who have sex with men and sex workers. The total sample across the studies was 8153. Across multiple studies methamphetamine was fairly consistently associated with early vaginal sex, condom use during sex, having casual sex and other HIV risk behaviours. For some sub-groups the direction of the relationship was in an unexpected direction. Conclusion: The consistency of the findings across studies highlights the increased risk for contracting HIV among methamphetamine users, and reinforces the importance of interventions addressing both methamphetamine use and unsafe sexual behaviour among young people and other sectors of the population. The need for further research is also considered, particularly research that will explain some of the racial differences that were found.Keywords: Methamphetamine; Sexual behaviour; HIV; South Afric

Conflict of interest: A tenacious ethical dilemma in public health policy, not only in clinical practice/research

In addition to the ethical practice of individual health professionals, bioethical debate about conflict of interest (CoI) must include theinstitutional ethics of public policy-making, as failure to establish independence from powerful stakeholder influence may pervert publichealth goals. All involved in public policy processes are accountable for CoI, including experts, scientists, professionals, industry and government officials. The liquor industry in South Africa is presented as a case study. Generic principles of how to identify, manage and address CoI are discussed. We propose that health professionals and policy makers should avoid partnering with industries that are harmful to health. Regarding institutional CoI, we recommend that there should be effective policies, procedures and processes for governing public-private joint ventures with such industries. These include arms-length funding, maintaining the balance between contesting vested interests, and full disclosure of the identity and affiliations of all participants in structures and reports pertaining to public policy-making

South African health care providers’ recognition of the links between alcohol and HIV in their daily practice: a pilot study.

This pilot study assessed the extent to which health care providers in HIV care and treatment, substance abuse intervention and employee assistance programmes (EAPs) consider and inform their clients about the role of alcohol use/abuse in HIV transmission, HIV disease progression and adherence to antiretroviral therapy (ART). A web- and telephone-based survey was conducted among 84 of the aforementioned programmes. Albeit not routinely, respondents from most organisations reported addressing the issues of alcohol in HIV transmission, disease progression and ART adherence among their clients. Contrary to expectations, many programmes do consider the links between alcohol and HIV and AIDS in their operations, but seem to lack adequate resources, information and skills to intervene in a comprehensive way. Key Words: Alcohol, HIV/AIDS, South Africa, health care providers, antiretroviral therapy, adherenc

A comparative analysis of pharmacists' perspectives on codeine use and misuse - a three country survey

Background: The misuse of codeine is of increasing concern in a number of countries, particularly as this relates to over -the-counter pain and cough relief medication, and is also supplied as a prescription medicine. The study aimed to obtain and analyse the opinions and experience of pharmacy staff with regard to codeine misuse. Methods: A cross-sectional web-based survey of pharmacy staff’s perspectives on this issue was administered through professional or regulatory bodies and completed by samples drawn in South Africa (n = 124), Ireland (n = 464) and the United Kingdom (n = 129). Results: The majority of participants reported combination codeine-containing products as most popular, but significantly more pharmacy staff in South Africa reported codeine-containing cough syrups as most commonly popular (X2 = 122.7(2), p < 0.001). Codeine use was also seen significantly more of a public health problem in South Africa than in the other two countries (X2 = 7.6(2), p = 0.02). There was no difference across countries in the level of codeine misuse reported by pharmacy staff. Further findings indicate that professional training and education is desired, with unequivocal findings for the need for greater codeine control (X2 = 12.0(2), p = 0.002). Conclusion: In conclusion, there were some inter-country differences, but overall the findings seem to suggest that pharmacists across all three countries view codeine misuse as a problem among their customers. Recommendations centre on risk management, surveillance and staff training

Comparison of baseline drinking practices, knowledge, and attitudes of adult s residing in communities taking part in the FAS prevention study in South Africa

Foetal Alcohol Syndrome (FAS) has been identified as among the most serious consequences associated with hazardous and harmful drinking in the Western Cape province, South Africa. Community surveys were conducted in two wine growing regions in this province to assess drinking behaviour, guide interventions and serve as a baseline for assessing the impact of population-level interventions. As part of a cross-sectional comparative study interviews were conducted with 384 and 209 randomly selected adults in the prevention (PC) and comparison communities (CC) respectively. Over 80% of respondents resided in urban areas, except inthe CC, where 61% of males resided on farms. Symptoms of hazardous or harmful drinking were reported by 16.0% of females and 32.5% of males in the PC, while 19.3% of females and 56.2% of males in the CC reported such drinking. Over two-thirds of respondents indicated that it was equally harmful for a woman to drink during any of the trimesters of pregnancy, but more than 30% of the women interviewed had never had a health worker speak to them about the effects of drinking during pregnancy. Over 10% had never heard of fetal alcohol syndrome. The findings reinforce the need for interventions to address hazardous/harmful use of alcohol inboth communities and also to address gaps in knowledge regarding the effects of drinking during pregnancy.Key Words: Alcohol, epidemiology, pregnancy, South Afric

Monitoring the prevalence of methamphetamine-related presentations at psychiatric hospitals in Cape Town, South Africa

Objective: This study aimed to determine a demographic profile of methamphetamine (MA)-related admissions to major psychiatric services in Cape Town, obtain a substance use profile from admitted patients, a profile of common MA-related symptoms encountered during the assessment of the patients presenting with MA-related problems, and a brief profile of the psychiatric diagnoses made.Method: Staff in six psychiatric hospitals or wards in Cape Town collected data on methamphetamine related admissions between July and December 2008 using a one-page record review form. The data collection form consisted of the patient’s demographic details, presenting symptoms, previous admission details, current MA and other substance use information, and DSM-IV diagnosis. Results: A total of 235 forms were completed. Most patients were male (69%) and the mean age was 25 years. The most common presenting symptoms were aggressive behaviour (74%), followed by delusions (59%) and hallucinations (57%). Males were two times more likely to present with aggression as compared to females, while females were significantly more likely to present with depressed mood or euphoric/elevated mood. The majority of patients had substanceinduced psychotic disorder (41%), followed by schizophrenia (31%). Twelve percent (12%) had bipolar mood disorder.Conclusion: MA-related psychiatric admissions pose serious challenges to all health services dealing with these patients. Further training and treatment protocol development and distribution is indicated.Keywords: Methamphetamine; Admissions; Psychosis; South Afric

Inequitable access to substance abuse treatment services in Cape Town, South Africa

BACKGROUND:Despite high levels of substance use disorders in Cape Town, substance abuse treatment utilization is low among people from disadvantaged communities in Cape Town, South Africa. To improve substance abuse treatment utilization, it is important to identify any potential barriers to treatment initiation so that interventions to reduce these barriers can be implemented. To date, substance abuse research has not examined the factors associated with substance abuse treatment utilization within developing countries. Using the Behavioural Model of Health Services Utilization as an analytic framework, this study aimed to redress this gap by examining whether access to substance abuse treatment is equitable and the profile of variables associated with treatment utilization for people from poor communities in Cape Town, South Africa. METHODS: This study used a case-control design to compare 434 individuals with substance use disorders from disadvantaged communities who had accessed treatment with 555 controls who had not accessed treatment on a range of predisposing, treatment need and enabling/restricting variables thought to be associated with treatment utilization. A hierarchical logistic regression was conducted to assess the unique contribution that the need for treatment, predisposing and enabling/restricting variable blocks made on substance abuse treatment utilization. RESULTS: Findings revealed that non-need enabling/restricting variables accounted for almost equal proportions of the variance in service utilization as the need for treatment variables. These enabling/restricting variables also attenuated the influence of the treatment need and predisposing variables domains on chances of treatment utilization. Several enabling/restricting variables emerged as powerful partial predictors of utilization including competing financial priorities, geographic access barriers and awareness of treatment services. Perceived severity of drug use, a need for treatment variable) was also a partial predictor of utilization. CONCLUSIONS: Findings point to inequitable access to substance abuse treatment services among people from poor South African communities, with non-need factors being significant determinants of treatment utilization. In these communities, treatment utilization can be enhanced by (i) expanding the existing repertoire of services to include low threshold services that target individuals with less severe problems; (ii) providing food and transport vouchers as part of contingency management efforts, thereby reducing some of the financial and geographic access barriers; (iii) introducing community-based mobile outpatient treatment services that are geographically accessible; and (iv) employing community-based outreach workers that focus on improving awareness of where, when and how to access existing treatment services