Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa.

OBJECTIVES: We report on outcomes after 7 years of a community-based antiretroviral therapy (ART) programme in Khayelitsha, South Africa, with death registry linkages to correct for mortality under-ascertainment. DESIGN: This is an observational cohort study. METHODS: Since inception, patient-level clinical data have been prospectively captured on-site into an electronic patient information system. Patients with available civil identification numbers who were lost to follow-up were matched with the national death registry to ascertain their vital status. Corrected mortality estimates weighted these patients to represent all patients lost to follow-up. CD4 cell count outcomes were reported conditioned on continuous virological suppression. RESULTS: Seven thousand, three hundred and twenty-three treatment-naive adults (68% women) started ART between 2001 and 2007, with annual enrolment increasing from 80 in 2001 to 2087 in 2006. Of 9.8% of patients lost to follow-up for at least 6 months, 32.8% had died. Corrected mortality was 20.9% at 5 years (95% confidence interval 17.9-24.3). Mortality fell over time as patients accessed care earlier (median CD4 cell count at enrolment increased from 43 cells/microl in 2001 to 131 cells/microl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/microl per 6 months). By 5 years, 14.0% of patients had failed virologically and 12.2% had been switched to second-line therapy. CONCLUSION: At a time of considerable debate about future global funding of ART programmes in resource-poor settings, this study has demonstrated substantial and durable clinical benefits for those able to access ART throughout this period, in spite of increasing loss to follow-up

A Morbidity Survey of South African Primary Care

Publication of this article was funded by the Stellenbosch University Open Access Fund.The original publication is available at www.plosone.org/BibliographyBackground: Recent studies have described the burden of disease in South Africa. However these studies do not tell us which of these conditions commonly present to primary care providers, how these conditions may present and how providers make sense of them in terms of their diagnoses. Clinical nurse practitioners are the main primary care providers and need to be better prepared for this role. This study aimed to determine the range and prevalence of reasons for encounter and diagnoses found among ambulatory patients attending public sector primary care facilities in South Africa. Methodology/Principal Findings: The study was a multi-centre prospective cross-sectional survey of consultations in primary care in four provinces of South Africa: Western Cape, Limpopo, Northern Cape and North West. Consultations were coded prior to analysis by using the International Classification of Primary Care-Version 2 in terms of reasons for encounter (REF) and diagnoses. Altogether 18856 consultations were included in the survey and generated 31451 reasons for encounter (RFE) and 24561 diagnoses. Women accounted for 12526 (66.6%) and men 6288 (33.4%). Nurses saw 16238 (86.1%) and doctors 2612 (13.9%) of patients. The top 80 RFE and top 25 diagnoses are reported and ongoing care for hypertension was the commonest RFE and diagnosis. The 20 commonest RFE and diagnoses by age group are also reported. Conclusions/Significance: Ambulatory primary care is dominated by non-communicable chronic diseases. HIV/AIDS and TB are common, but not to the extent predicted by the burden of disease. Pneumonia and gastroenteritis are commonly seen especially in children. Women’s health issues such as family planning and pregnancy related visits are also common. Injuries are not as common as expected from the burden of disease. Primary care providers did not recognise mental health problems. The results should guide the future training and assessment of primary care providers.Stellenbosch University Open Access FundPublishers' Versio

Effectiveness of Patient Adherence Groups as a Model of Care for Stable Patients on Antiretroviral Therapy in Khayelitsha, Cape Town, South Africa

Abstract: Background: Innovative models of care are required to cope with the ever-increasing number of patients on antiretroviral therapy in the most affected countries. This study, in Khayelitsha, South Africa, evaluates the effectiveness of a group-based model of care run predominantly by non-clinical staff in retaining patients in care and maintaining adherence. Methods and Findings: Participation in ‘‘adherence clubs’’ was offered to adults who had been on ART for at least 18 months, had a current CD4 count .200 cells/ml and were virologically suppressed. Embedded in an ongoing cohort study, we compared loss to care and virologic rebound in patients receiving the intervention with patients attending routine nurse-led care from November 2007 to February 2011. We used inverse probability weighting to estimate the intention-totreat effect of adherence club participation, adjusted for measured baseline and time-varying confounders. The principal outcome was the combination of death or loss to follow-up. The secondary outcome was virologic rebound in patients who were virologically suppressed at study entry. Of 2829 patients on ART for .18 months with a CD4 count above 200 cells/ml, 502 accepted club participation. At the end of the study, 97% of club patients remained in care compared with 85% of other patients. In adjusted analyses club participation reduced loss-to-care by 57% (hazard ratio [HR] 0.43, 95% CI = 0.21–0.91) and virologic rebound in patients who were initially suppressed by 67% (HR 0.33, 95% CI = 0.16–0.67). Discussion: Patient adherence groups were found to be an effective model for improving retention and documented virologic suppression for stable patients in long term ART care. Out-of-clinic group-based models facilitated by non-clinical staff are a promising approach to assist in the long-term management of people on ART in high burden low or middleincome settings

Correcting for Mortality Among Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A Cohort Analysis

Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system

Reasons for encounter and diagnoses of patients attending primary care clinics in the Saldanha Bay and Swartland rural sub districts, Western Cape Province : a prospective cross-sectional survey

Thesis (MMed)--Stellenbosch University, 2012.ENGLISH SUMMARY : Background: The public health sector is the principal provider of healthcare to the majority of South Africans. The primary health care (PHC) system was designed to provide equitable and accessible healthcare to all, but the system remains plagued by many challenges. Key to overcoming these challenges is to have a better understanding of the reasons why patients access the service in the first instance and also of the case mix of diseases affecting the population. Studies outlining the reasons for patients’ encounter and the diagnoses offered are scant. Objectives: The aim of the study was to assess the main reasons for encounter (RFE) and the diagnoses made by the healthcare provider of patients attending primary health care clinics in the two rural sub districts of Saldanha Bay and Swartland in the Western Cape. Methods: The prospective cross-sectional study involved 13 healthcare providers (mainly clinical nurse practitioners) working at 10 randomly selected primary healthcare facilities in the two sub districts. The participants were asked to record the RFE’s and diagnoses of all the patients they consulted on a data collection sheet. Data was collected on six days over a 12 month period from August 2009 to June 2010. The International Classification of Primary Care, second edition (ICPC-2) system was used to code the RFE’s and problems defined during all patient encounters. Results: During 1277 patient encounters, 2091 RFE’s were recorded and 1706 diagnoses were offered. The majority of complaints were respiratory (19.9%), digestive (11.2%), musculoskeletal (9.6%), cardiovascular (9.3%), skin (8.8%) and general and unspecified (7.6%). The majority of diagnoses offered by the providers were respiratory (21.4%), cardiovascular (14.2%), skin (9.1%) and digestive (8.6%). Hypertension (10.8%) was the commonest condition managed. Infectious diseases, TB and HIV, occurred at low prevalence (2.9% and 1.5% respectively) Gender did not influence the number of RFE’s and diagnoses. There was a significant difference in the mean numbers of RFE’s and diagnoses between the different age groups(p values 0.0237 and 0.0000 respectively). The majority of patients seen during all encounters were children under the age of 4 (17.3%), who presented mainly with symptoms of, and were diagnosed with respiratory disorders. Conclusion: During the study we were able to ascertain the main reasons for encounters and the diagnoses made by the health care providers of patients attending public primary care facilities in the rural sub districts of Saldanha Bay and Swartland. The study has demonstrated that the concept of the RFE is useful to describe the content of primary care practice in this setting. It can also be concluded that the ICPC-2 as a coding system, is an excellent tool for the description of the RFE’s, and can provide us with morbidity patterns in any setting.AFRIKAANSE OPSOMMING : Geen opsomming beskikbaar

RFE associated with chronic care (N = 31451).

<p>RFE associated with chronic care (N = 31451).</p

Distribution of number of consultations by age groups.

<p>Distribution of number of consultations by age groups.</p

Patterns of selected reasons for encounter by age.

<p>Patterns of selected reasons for encounter by age.</p