A reflection on the South African Medical Association – past, present and future

The South African Medical Association (SAMA) recently adopted changes to its Memorandum of Incorporation and Rules that effectively realigned the organisation's governance structure into a fully-fledged member-based organisation. At its core is the ongoing obligation of SAMA to transform, with 50% of all elected SAMA structures needing to be occupied by historically disadvantaged South Africans. SAMA was formed in 1997 and effected in 1998 through the amalgamation of the then Medical Association of South Africa (MASA) and a number of Partner Organisations. It is now almost 2 decades old and has seen many challenges, both from within and without. Despite this, it has remained the only broad-based doctor-only representative body in South Africa. Its structure is dominated by two membership committees, the public sector having now formalised itself into a trade union for employed doctors, with both general practitioners and specialists catered for by the private practice membership department. Many challenges remain, and SAMA has positioned itself to deal effectively with issues affecting doctors in a manner that ensures the profession remains united in the interests of delivering the best healthcare we can to our patients

A clinicopathological cohort study of liver pathology in 301 patients with HIV/AIDS

Includes abstract. Includes bibliographical references

HIV/AIDS influences blood and blood product use at Groote Schuur Hospital, Cape Town

Background. Use of blood and blood products in the medical wards at Groote Schuur Hospital, Cape Town, has increased substantially and significantly increased expenditure. It was suspected that the increased burden of HIV/AIDS could be a contributing factor. Methods. Doctors voluntarily completed a structured questionnaire when blood or blood products were utilised over a 3-month period in 2009. Statistical analysis was performed using Microsoft Excel, SPSS and STATISTICA. Results. Of 67 patients analysed, 46 (68.6%) were female, mean age 36.7 (standard deviation (SD) 8.7) years; 21 (31.3%) were male, mean age 39.3 (SD 13.5) years; and 41 (61.2%) were HIV positive, of whom 17 (41.5%) were on antiretroviral therapy (ART). HIV-infected patients were on average 10 years younger than HIV-uninfected patients (p=0.012). Anaemia was the cytopenia necessitating transfusion in 68.7% of cases, but its causes differed between HIV-infected and uninfected patients. The median CD4 count was 203 cells/μl (range 24 - 540) for HIV-infected patients on ART and 74 cells/μl (range 2 - 276) for those not on ART (p=0.012). The mean numbers of packed red cell and fresh-frozen plasma units transfused in the HIV-infected not on ART, HIV-infected on ART and HIV-uninfected groups were 3.3, 2.0 and 1.5 (p=0.013) and 13.5, 2.7 and 1.0 (p<0.001), respectively. ART in HIV-positive patients markedly decreased transfusion requirements (p<0.001). There was one minor transfusion reaction. Conclusion. HIV/AIDS is a significant factor contributing to the increased use of blood and blood products in the medical wards at Groote Schuur Hospital. Being on ART appeared to reduce the requirement for blood and blood products

Diagnosing multiple opportunistic infections: the value of a liver biopsy

Liver function test abnormalities are prevalent in patients with HIV, and in particular advanced HIV.1 Opportunistic infections, drug hepatotoxicity and viral hepatitis co-infections are frequently encountered.2-4 We present a patient with advanced HIV and abnormal liver function tests in whom the definitive diagnosis of multiple opportunistic infections was made by liver biopsy. This case illustrates the diagnostic value of liver biopsy in our local patient population, where diagnostic uncertainty is common and empiric therapy is often the standard of care. Southern African Journal of HIV Medicine Vol. 9 (4) 2008: pp. 51-5

Thieves of the state and the South African Medical Association (SAMA)

No Abstract

Identifying the Effects of the COVID-19 Pandemic on Individuals with Dual Diagnoses (Mental Health and Substance Use) at CenterPointe Residential Treatment Center

Background: Social distancing measures associated with the COVID-19 pandemic began on March 28th, 2020in the United States. With these implemented measures, the mental health of the population was worsening due to isolation, closures, and fear. Rates of anxiety, depression, and co-occurring substance abuse increased as well. CenterPointe is a behavioral health organization that has a residential treatment facility in Omaha, Nebraska for patients with mental health and substance use disorder dual diagnoses. They utilize the DLA-20 tool with their patients at intake, every 90 days, and at discharge. The DLA-20 is a standardized tool that assesses an individual’s functioning in daily life. Objectives: The purpose of this study was to identify the effect of COVID on daily functioning by analyzing the DLA-20 scores, identify treatment completion and goals met, determine prominent demographic data, and to analyze changes in mental health or substance use disorder diagnoses. Method: This was a retrospective cohort study analyzing a deidentified data set with two groups. The groups were pre-COVID (March 29th, 2018- March 29th, 2020) and post-COVID (March 30th, 2020-March 23th, 2022) and consisted of individuals in CenterPointe’s residential treatment program. Results: Individuals admitted during COVID had higher DLA scores on admission than individuals admitted pre-COVID. Fewer individuals had completed treatment as well as met their goals with COVID compared to pre-COVID. The results also revealed a decrease in the homeless population and an increase in unemployed individuals post-COVID. Nicotine use decreased by 5% and cocaine use increased by 4% post-COVID. Conclusions: The DLA-20 results revealed that people in the post-COVID category entered the treatment program with a higher DLA score indicating a higher level of functioning than individuals admitted during the height of the pandemic. This indicates that the COVID-19 pandemic may not have caused an increase in symptoms and impairment of functioning among the individuals being treated at CenterPointe’s residential treatment center as originally assumed. The study also highlighted the usefulness of the DLA-20 tool to assess functioning in individuals with a mental health and substance use disorder diagnosis amidst the COVID-19 pandemic

A decade of hepatitis C at the University of Cape Town/Groote Schuur Hospital Liver Clinic, South Africa, in the pre-direct-acting antivirals era

Background. Hepatitis C virus (HCV) in South Africa (SA) is incompletely characterised and understood. Epidemiological and clinical data will better inform our understanding and assist national policy decision-making. Against the background of more than two decades of clinical challenges in HCV management, the advent of direct-acting antivirals (DAAs) now makes HCV elimination plausible.Objectives. To better understand the base from which we come, we elected to review and characterise our HCV experience at Groote Schuur Hospital (GSH), Cape Town, SA, in the pegylated interferon (Peg-IFN) and ribavirin (RBV) management era.Methods. Patients with chronic HCV infection attending the GSH Liver Clinic from 2002 to 2014 were included in the analysis. Relevant data were extracted from a registry and existing clinical records were accessed. Two brands of Peg-IFN were available, and patients treated with the first-generation add-on protease inhibitor telaprevir were included.Results. A total of 238 patients were included in the analysis (median (interquartile range) 47 (37 - 58) years, 60.5% males). Males were significantly younger than females (43.5 (35 - 52) years v. 55 (42 - 64) years, respectively) (p<0.0001). The majority were white (55.9%) or of mixed ancestry (21.8%), 16.4% were HIV co-infected, 3.7% were hepatitis B virus (HBV) co-infected, and 1 patient (0.4%) was triple-infected with HCV, HBV and HIV. The most likely mode of HCV acquisition was blood or blood product exposure prior to 1992 (32.8%) and injecting drug use (17.6%), while 30.3% of patients had no clear risk factor identifiable. Genotypes (GTs) 1 - 5 were observed, with GT-1 (34.9%) predominating. Of patients who were biopsied (n=90), 30.0% had ≥F3 fibrosis, with 15.6% cirrhotic. With IL28B polymorphisms, the heterozygous CT (23.9%) and CC (15.5%) genotypes were most frequent. Of the patients, 32.6% accessed Peg-IFN/RBV-based therapy, 6.5% (n=5) with add-on telaprevir. GT-1 (35.1%) was most prevalent in the treatment group, followed by GT-3 (26.0%) and GT-5 (18.2%); 10.0% were HIV co-infected. The overall sustained virological response (SVR) rate was 75.3%, with 37.0% of GT-1 patients not achieving SVR. Of the patients treated, 49.4% experienced adverse events, including cytopenias (32.5%) and depression (15.6%), and 23.4% required cell support in the form of erythropoietin and/or granulocyte-macrophage colony-stimulating factor.Conclusions. HCV patients in the Peg-IFN/RBV management era typified the epidemiology of HCV. GT distribution was pangenotypic, and treatment outcomes were encouraging despite treatment challenges. Patient selection, IL28B and sensible support of cytopenias probably accounted for these favourable outcomes. However, numbers treated were limited, and the DAA era of therapy allows for rapid expansion of therapy with now growing numbers of patients and a changing local epidemiology.

Hepatitis C prevalence in HIV-infected heterosexual men and men who have sex with men

Background. Globally 1% of individuals are infected with hepatitis C virus (HCV). In South Africa (SA) the prevalence ranges between 0.3% and 1%, with few prospective screening data available. Similarly, local data on transmission modes of HCV are limited, but probably include parenteral routes and pre-1992 blood or blood products. The risk of heterosexual transmission of HCV is low but is increased in men who have sex with men (MSM), with co-transmission risk of both HIV and HCV. Objectives. Given few local data, we sought to better understand HCV characteristics and prevalence in two groups of HIV-infected men. Methods. HIV-positive men in the greater Cape Town metropolitan area were recruited. Sexual orientation was self-identified and demographic and other personal data were obtained via a confidential questionnaire. Participants were screened for HCV after a blood draw. Those with positive HCV tests had further HCV RNA confirmation. Risk factors associated with HCV seropositivity were determined. Results. Five hundred HIV-positive men were recruited, 285 (57.0%) MSM and 215 (43.0%) non-MSM, median age 36 years (interquartile range (IQR) 20 - 64) and 37 years (IQR 21 - 56), respectively (p=NS). Overall, 3.4% (n=17) screened HCV-positive, 5.6% MSM (n=16) and 0.5% non-MSM (n=1); 82.4% were viraemic for HCV RNA. In respect of genotype distribution, 50.0% were infected with genotype 1a, 14.3% with genotype 4 and 35.7% with genotype 2. In terms of risk, MSM were more likely to have used drugs (54.4% v. 30.2%; p<0.001) and to have used all five modes of drug administration (13.0% MSM v. 0.5% non-MSM for injected drugs, 36.1% v. 2.3% for inhaled, 10.0% v. 0% for rectal, 48.1% v. 28.8% for smoked and 27.4% v. 2.3% for oral). More MSM than non-MSM (46.3% v. 16.7%) reported having sex while using recreational drugs, and similarly more MSM (21.4% v. 14%) reported having sex with a sex worker (SW). Risk factors for HCV seropositivity included drug use history (odds ratio (OR) 6.28, 95% confidence interval (CI) 1.78 - 22.12; p=0.004) and in MSM, sex with an SW (OR 5.5, 95% CI 2.06 - 14.68; p=0.001) or use of recreational drugs with sex (OR 6.88, 95% CI 2.21 - 21.44; p=0.001). Conclusions. HCV prevalence in HIV-positive MSM is higher than previously appreciated or documented in SA. Risk factors include injection drug use, use of recreational drugs with sex, and sex with SWs. Targeted interventions are required to address this emerging challenge to achieve the viral hepatitis elimination ideal by 2030.S Afr Med J 2018;108(7):568-57