The protection of prisoners’ rights to health care services in South African law: Is it adequate?

A recent newspaper article depicted a dismal picture of the situation behind the walls of the largest prison in the Southern hemisphere. It was revealed that at least four prisoners die of HIV/AIDS at Westville Prison every month because the Department of Correctional Services does not have the resources to provide treatment. In terms of Section 35(2)(e) of the South African Constitution prisoners are entitled to medical treatment at state expense, dependant of course on the availability of resources. The issue of the availability of resources has seen a barrage of case law being brought to the fore challenging section 35(2) (e). This article examines some of these cases and also attempts to shed light on the plight of prisoners in accessing their rights to health care services

Factors associated with repeat genital symptoms among sexually transmitted infection service attendees in South Africa, 2015 - 2016

Background. South African guidelines recommend a syndromic approach for the management of sexually transmitted infections (STIs), based on the presence of genital symptoms. However, the guidelines do not prescribe specific indications for microbiology testing for patients presenting with or without repeat genital symptoms.Objectives. To describe the prevalence of and factors associated with repeat genital symptoms among STI service attendees at primary care facilities.Methods. This was a cross-sectional study at 7 STI primary care facilities participating in the aetiological surveillance of STIs between January 2015 and December 2016. Demographic and clinical information and appropriate genital specimens were collected from participants presenting with vaginal discharge syndrome (VDS), male urethral syndrome (MUS) and/or genital ulcer syndrome (GUS). Repeat genital symptoms were defined as self-reported history of the same STI-related genital symptoms in the preceding 12 months. Multivariable logistic regression identified factors associated with repeat genital symptoms.Results. Of 1 822 eligible participants, 480 (30%) had repeat genital symptoms (25% and 75% in the preceding 3 months and 12 months, respectively). Of those with repeat genital symptoms, the median age was 28 (interquartile range (IQR) 24 - 32) years, and 54% were females. The most common aetiological agents among participants with VDS, MUS and GUS were bacterial vaginosis (n=132; 55%), Neisseria gonorrhoeae (n=172; 81%) and ulcers (n=67; 63%), respectively. One hundred and seven (20%) participants had no detectable common STI aetiology. In the multivariable analysis, repeat genital symptoms were associated with HIV co-infection (adjusted odds ratio (aOR) 1.43; 95% confidence interval (CI) 1.14 - 1.78), VDS diagnosis (aOR 1.39; 95% CI 1.10 - 1.76), self-reported condom use (aOR 1.56; 95% CI 1.20 - 2.03) and age 25 - 34 years (aOR 1.33; 95% CI 1.03 - 1.71).Conclusions. Our study found a high prevalence of repeat genital symptoms ‒ a significant proportion without STI aetiology. Identified factors of repeat genital symptoms highlight the need for improved integration of HIV and STI prevention and management. Further research is needed to determine the aetiology of repeat genital symptoms and the contribution of non-STI causes

The demographic and clinical profiles of women presenting with vaginal discharge syndrome at primary care facilities in South Africa: Associations with age and implications for management

Background. Current South African guidelines for the management of vaginal discharge syndrome (VDS) do not recommend treatment for sexually transmitted infection (STI) pathogens for women aged ≥35 years whose partners do not have male urethritis syndrome. The guideline assumes that older women are unlikely to have an STI and that their partners do not have asymptomatic infections.Objectives. To describe the demographic, behavioural and clinical characteristics of women with VDS, comparing older women (≥35 years) with younger women, and to determine the performance of age alone as a criterion for predicting the presence of STI.Methods. This was a cross-sectional study at seven primary healthcare centres taking part in the aetiological surveillance of STIs between January 2015 and December 2016. Eligible women presenting with VDS were enrolled and completed a nurse-administered questionnaire. Genital swabs and blood specimens were collected for laboratory testing. Data were entered into surveillance-specific databases and exported into Stata 14 for analysis. Descriptive statistics were used to compare demographic and clinical profiles of older with younger women. A receiver operator curve (ROC) was used to determine the age cut-off that would best differentiate between women who had infection with STI pathogens and those without.Results. Of 757 women enrolled, 157 (20.7%) were aged ≥35 years. HIV positivity was 46.6%, and higher in older than younger women (54.9% v. 44.5%; p=0.02). Of those enrolled, 283 (37.4%) had bacterial vaginosis (BV) and/or Candida infection only, 232 (30.7%) had BV or Candida with STI pathogens detected, 98 (13%) were infected with STI pathogens only, and 144 (19.0%) did not have any detectable STI or non-STI causes. Although older women were less likely than younger women to have Neisseria gonorrhoeae, Chlamydia trachomatis or Mycoplasma genitalium infection (23.6% v. 38.2%; p<0.01), the burden in older women was not negligible. The area under the ROC for age was 57.5% (95% confidence interval 53.2 - 61.8%), which implies suboptimal performance.Conclusions. Although older women with VDS were less likely than younger women to have STIs, a significant proportion of them did have an infection with STI pathogens. Age alone was not a good criterion for discriminating between women with and without infection with STI pathogens. Other ways of improving the VDS algorithm performance are needed, as is better integration of HIV and STI prevention and treatment.Â

Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in Gauteng Province, South Africa

Background. Patients with community-acquired urinary tract infections (UTIs) frequently present to healthcare facilities in South Africa (SA).Aim. To provide information on UTI aetiology and antimicrobial susceptibility of pathogens.Methods. We recruited women with UTI-related symptoms, who tested positive for .2 urine dipstick criteria (proteinuria, blood, leucocytes or nitrites) at 1 public and 5 private primary healthcare facilities in 2011. Demographic and clinical data were recorded and mid-stream urine (MSU) specimens were cultured. UTI pathogens were Gram-stained and identified to species level. Etest-based antimicrobial susceptibility testing was performed for amoxicillin/clavulanic acid, cefixime, cefuroxime,  ciprofloxacin, fosfomycin, levofloxacin, nitrofurantoin, norfloxacin and trimethoprim/sulphamethoxazole.Results. Of the 460 women recruited, 425 MSU samples were processed and 204 UTI pathogens were identified in 201 samples. Most pathogens were Gram-negative bacilli (GNB) (182; 89.2%) and 22 (10.8%) were Gram-positive cocci (GPC). Escherichia coli was the most frequent GNB (160; 79.6%), while Enterococcus faecalis was the predominant GPC (8; 4.0%). The UTI pathogens had similar susceptibility profiles for fosfomycin (95.5%; 95% confidence interval (CI) 92.6 - 98.4), the 3 fluoroquinolones (94.1%; 95% CI 90.8 - 97.4), nitrofurantoin (91.7%; 95% CI 87.8 - 95.6), cefuroxime (90.1%; 95% CI 86.0 - 94.3) and cefixime (88.2%; 95% CI 83.7 - 92.6). UTI pathogens were less susceptible to amoxicillin/clavulanic acid (82.8%; 95% CI 77.5 - 88.0) when compared with fluoroquinolones and fosfomycin. Trimethoprim/ sulphamethoxazole was the least efficacious antimicrobial agent (44.3% susceptible; 95% CI 37.4 - 51.2).Conclusion. This study provides relevant data for the empirical treatment of community-acquired UTIs in SA

Factors associated with repeat genital symptoms among sexually transmitted infection service attendees in South Africa, 2015-2016

BACKGROUND. South African guidelines recommend a syndromic approach for the management of sexually transmitted infections (STIs), based on the presence of genital symptoms. However, the guidelines do not prescribe specific indications for microbiology testing for patients presenting with or without repeat genital symptoms. OBJECTIVES. To describe the prevalence of and factors associated with repeat genital symptoms among STI service attendees at primary care facilities. METHODS. This was a cross-sectional study at 7 STI primary care facilities participating in the aetiological surveillance of STIs between January 2015 and December 2016. Demographic and clinical information and appropriate genital specimens were collected from participants presenting with vaginal discharge syndrome (VDS), male urethral syndrome (MUS) and/or genital ulcer syndrome (GUS). Repeat genital symptoms were defined as self-reported history of the same STI-related genital symptoms in the preceding 12 months. Multivariable logistic regression identified factors associated with repeat genital symptoms. RESULTS. Of 1 822 eligible participants, 480 (30%) had repeat genital symptoms (25% and 75% in the preceding 3 months and 12 months, respectively). Of those with repeat genital symptoms, the median age was 28 (interquartile range (IQR) 24 - 32) years, and 54% were females. The most common aetiological agents among participants with VDS, MUS and GUS were bacterial vaginosis (n=132; 55%), Neisseria gonorrhoeae (n=172; 81%) and ulcers (n=67; 63%), respectively. One hundred and seven (20%) participants had no detectable common STI aetiology. In the multivariable analysis, repeat genital symptoms were associated with HIV co-infection (adjusted odds ratio (aOR) 1.43; 95% confidence interval (CI) 1.14 - 1.78), VDS diagnosis (aOR 1.39; 95% CI 1.10 - 1.76), self-reported condom use (aOR 1.56; 95% CI 1.20 - 2.03) and age 25 - 34 years (aOR 1.33; 95% CI 1.03 - 1.71). CONCLUSIONS. Our study found a high prevalence of repeat genital symptoms ‒ a significant proportion without STI aetiology. Identified factors of repeat genital symptoms highlight the need for improved integration of HIV and STI prevention and management. Further research is needed to determine the aetiology of repeat genital symptoms and the contribution of non-STI causes.The SA National Department of Health through a core surveillance funding grant to the National Institute for Communicable Diseases (NICD).http://www.samj.org.zaam2021School of Health Systems and Public Health (SHSPH

The relationship between intimate partner violence and probable depression among adolescent girls and young women in Lilongwe, Malawi

This analysis estimates prevalence of intimate partner violence (IPV) and its association with probable depression among adolescent girls and young women (AGYW) in Lilongwe, Malawi, and whether partner’s controlling behaviour modifies this relationship. Baseline data was utilised from the Girl Power-Malawi study of 1000 15–24-year-old AGYW in Lilongwe. Emotional, physical, and sexual IPV experiences with a current or recent partner were measured using the modified Conflict Tactics Scale. Probable depression was measured by scoring ≥10 on the Centre for Epidemiologic Studies-Short Depression Scale (CES-D-10). Generalised linear models with log-link and binomial distribution estimated prevalence ratios (PR) and 95% confidence intervals (CI) for the association between IPV types and probable depression. Partner’s controlling behaviour was examined as an effect modifier. Participants’ mean age was 19.2 years, with 70% never-married. IPV prevalence varied for emotional (59%), physical (36%), sexual (46%), and all forms (20%). Prevalence of probable depression was 47%. AGYW who experienced each IPV type had a higher prevalence of probable depression: physical (PR:1.54, CI:1.28–1.86), sexual (1.46, CI:1.21–1.75), emotional (1.37, CI:1.14–1.64), all forms (1.72, CI:1.41–2.09). IPV and probable depression were prevalent and strongly associated, especially among AGYW reporting controlling behaviour. Interventions addressing IPV and controlling behaviour may positively impact depression among AGYW

Perceptions of and interest in HIV pre-exposure prophylaxis use among adolescent girls and young women in Lilongwe, Malawi

Background Oral Pre-Exposure Prophylaxis (PrEP) is an effective HIV prevention strategy for adherent users. Adolescent girls and young women (AGYW) in sub-Saharan Africa may particularly benefit from PrEP because of the disproportionate burden of HIV in this group. Understanding potential users’ perceptions of and interest in using PrEP is critical to promote the utilization of PrEP by individuals at risk of HIV. Methods This qualitative investigation of AGYW’s knowledge of and interest in PrEP use was conducted in the context of Girl Power, a quasi-experimental cohort study comparing four models of service delivery at four health centers in Lilongwe, Malawi. We conducted individual in-depth interviews (IDIs) with 40 HIV-negative AGYW ages 15–24 years old six months after enrolment in the parent study. An explanation of PrEP was provided to participants. Interview topics included participants’ prior knowledge of, interest in, concerns about, and delivery preferences for PrEP. Analysis consisted of structural coding of interview transcripts corresponding to interview topics, summary of responses within these topics, and identification and description of emerging themes within each topic. Results None of the AGYW had knowledge of PrEP prior to the IDIs, but once explained, a majority expressed an interest in using it due to inconsistencies in condom use, condom use errors, their own or their partners’ concurrent sexual partnerships, and rape. Most AGYW hoped that PrEP would be available in youth-friendly sections of health centers for easy access and youth-friendly counselling. They suggested that discrete packaging of PrEP would be needed to ensure user privacy. Concerns about relationship destabilization and accusations of promiscuity were raised as potential barriers to use. Conclusion General interest in PrEP among AGYW was high. Discrete packaging and access to youth-friendly PrEP delivery modalities may facilitate the utilization of PrEP as a prevention strategy among sexually active AGYW. Attention to potential negative reactions from partners and community members to PrEP use will be needed when introducing PrEP to this population

Predictors of HIV, HIV Risk Perception, and HIV Worry Among Adolescent Girls and Young Women in Lilongwe, Malawi

BACKGROUND: Adolescent girls and young women (AGYW) in sub-Saharan Africa have high HIV prevalence and incidence. We sought to understand which HIV risk factors individually and in combination contribute to risk, and whether these factors are associated with HIV worry and risk perception. SETTING: This study is ongoing at 4 public health centers in Lilongwe, Malawi (2016-2017).METHODS: AGYW of 15-24 years old were recruited to participate in a study assessing 4 models of service delivery. At each health center, participants completed a baseline survey assessing socioeconomic, behavioral, biomedical, and partnership characteristics; self-reported HIV status; and, if HIV-uninfected, HIV risk perception (high versus low or none) and HIV worry (any versus none). We analyzed associations between baseline characteristics and HIV prevalence, risk perception, and worry. RESULTS: Among 1000 AGYW, median age was 19 years (IQR: 17-21). Thirty-three participants reported being HIV-infected. Fifteen characteristics were associated with HIV infection. Having more risk factors was associated with higher HIV prevalence (≤4 factors, 0.5%; 5-8 factors, 6%; >8 factors, 21%). Having more risk factors was also associated with higher risk perception (P < 0.001) and higher worry (P < 0.001). However, among those with ≥8 risk factors, 52% did not consider themselves to be at high risk and 21% did not report any HIV worry. CONCLUSIONS: Most AGYW perceive little risk of HIV acquisition, even those at highest risk. As a critical gap in the HIV prevention cascade, accurate risk perception is needed to tailor effective and sustained combination prevention strategies for this vulnerable population