27 research outputs found
Poverty and inequality – but of what - as social determinants of health in Africa?
Background: Many African economies have achieved substantial economic growth over the past recent years, yet several of the Millennium Development Goals (MDGs) including those concerned with health, remain considerably behind target. This paper examines whether progress towards these goals is being hampered by existing levels of poverty and income inequality. It also considers whether the inequality hypothesis of Wilkinson and Pickett1 applies to population health outcomes in African states.Methods: Correlation analysis and scatter plots were used to assess graphically the link between variations in health outcomes, level of poverty and income inequality in different countries. Health status outcomes were measured by using four indicators: infant and under-five (child) mortality rates; maternal mortality ratios; and life expectancy at birth. In each of the 52 African nations, the proportion of the population living below the poverty line is used as an indicator of the level of poverty and Gini coefficient as a measure of income inequality. The study used a comprehensive review of secondary and relevant literature that are pertinent in the subject area. The data datasets obtained online from UNICEF2 and UNDP3 (2009) used to test the research questions. World Health Organization the three broad dimensions to consider when moving towards better population health outcome through Universal Health Coverage and the Social Determinants of Health framework reviewed to establish the poverty and income inequality link in African countries population health outcomes.Results: The study shows that poverty is strongly associated with all health outcome differences in Africa (IMR, cc = 0.63; U5MR, cc = 0.64; MMR, cc = 0.49; life expectancy at birth, cc = -0.67); income inequality with only one of the four indicators (IMR, cc = 0.14; U5MR, cc = 0.07; MMR, cc = 0.22; life expectancy at birth, cc = -0.49), whereas income inequality is associated with one of the four indicators.Conclusion: The study shows that tackling poverty should be the immediate concern in Africaas a means of promoting better health for all. There is a question mark over whether the findings of Wilkinson and Pickett1 on the relationship between income inequality and health apply to Africa. The reasons for this question mark are discussed. More research is needed to investigate whether the inequality results found in this study are replicated in other studies of African health.Keywords: Health inequalities, poverty, income inequality, MDGs, social determinants of health, Afric
Association between viral suppression during the third trimester of pregnancy and unintended pregnancy among women on antiretroviral therapy : results from the 2019 antenatal HIV Sentinel Survey, South Africa
OBJECTIVES :
About half of the pregnancies among women living with HIV (WLWH) receiving antiretroviral
therapy (ART) in sub-Saharan African countries are reported to be unintended. Unintended
pregnancy is associated with late initiation of antenatal care (ANC), and may delay provision
of viral load monitoring services, antenatal adherence counselling and support, and other
services that promote sustained viral suppression throughout pregnancy. This study examines the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy.
METHODS :
This was an analysis of data from a national antenatal survey conducted at 1 589 public
health facilities in South Africa between 1 October and 15 November 2019. Consenting
pregnant women aged 15–49 years attending ANC during the survey period were enrolled.
Demographic and clinical data were collected through interview and medical record review.
Pregnancy intention was assessed using two questions from the London Measure of
Unplanned Pregnancy, and responses were categorized as “unintended,” “undecided,” and
“intended.” Blood specimens were collected from all women and tested for HIV; and if positive, a viral load test was performed. A survey domain-based poisson regression model
examined the association between unsuppressed viral load during the third trimester of
pregnancy and unintended pregnancy among women who initiated ART before pregnancy.
Viral suppression was defined as viral load <50 copies/mL.
RESULTS :
Of 10 901 WLWH with viral load data available, 63.3% (95% confidence interval (CI):
62.4%-64.1%) were virally suppressed. Among the 2 681 women (representing 24.1% of all
WLWH with viral load data) who initiated ART before pregnancy and were in their third trimester at the time of enrolment, 74.4% (95% CI: 73.0%-75.8%) were virally suppressed. In
the same population, the proportion virally suppressed was lower among women whose current pregnancies were unintended (72.1%, 95% CI: 70.1%-74.1%) compared to women
whose pregnancies were intended (78.3%, 95% CI: 75.9%-80.5%). In multivariable analyses adjusted for age, gravity, marital status, education, location of facility and syphilis status,
unintended pregnancy was associated with unsuppressed viral load during the third trimester (adjusted relative risk: 1.3, 95% CI: 1.1–1.4) among women who initiated ART before
pregnancy.
CONCLUSION :
The identified association between unsuppressed viral load and unintended pregnancy
among pregnant women who initiated ART before pregnancy highlights the need to
strengthen routine assessment of fertility preferences and provision of contraceptive services to reproductive age WLWH receiving ART.The President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreement 5 NU2GGH001631, https:// www.cdc.gov/; World Health organization (WHO), South African Medical Research Council (SAMRC), National Department of Health (NDoH), and NICD.http://www.plosone.orgdm2022Statistic
Progress towards the UNAIDS 95-95-95 targets among pregnant women in South Africa : results from the 2017 and 2019 national Antenatal HIV Sentinel Surveys
OJECTIVES :
The UNAIDS 95-95-95 global targets for epidemic control aim to ensure by 2030 that 95% of
HIV-positive people know their HIV status, 95% of people diagnosed with HIV receive sustained antiretroviral therapy (ART), and 95% of people on ART have viral suppression. While
data on the first and second 95 targets are routinely reported nationally, data on the third 95
target are not available for pregnant women in South Africa. The lack of data on the third 95
target limits the inclusion of low viral suppression as one of the contributing factors in MTCT
root cause analyses. This study assessed progress towards the 95-95-95 targets among pregnant women between the ages of 15–49 years attending public health facilities in South Africa.
METHOD :
Data were obtained from two consecutive national cross-sectional antenatal HIV sentinel surveys conducted between 1 October and 15 November in both 2017 and 2019. In each survey,
data on age, knowledge of HIV status, ART initiation, and geographical location (province)
were extracted from medical records. A blood specimen was collected from each woman and
tested for HIV. Viral load tests were performed on HIV-positive specimens. Descriptive and
multiple logistic regression analyses were performed to examine association between province and viral suppression (defined as viral load <50 copies/mL) using the combined dataset
(i.e., both 2017 and 2019 data combined). All analyses considered the survey design.
RESULTS :
Of 10 065 and 11 321 HIV-positive women included in the 2017 and 2019 surveys, respectively, 96.0% (95% confidence interval (CI): 95.6–96.4%) and 97.6% (95% CI: 97.3–97.8%) knew their HIV-positive status; 86.6% (95% CI: 85.9–87.3%) and 96.0% (95% CI: 95.6–
96.4%) of those who knew their HIV status were receiving ART; while 64.2% (95% CI: 63.2–
65.2%) and 66.0% (95% CI: 65.1–66.8%) of those receiving ART were virally suppressed.
Achievement of the third 95 target significantly varied by province ranging from 33.9–72.6%
in 2017 and 43.4–77.3% in 2019. Knowledge of HIV-positive status, ART initiation, and viral
suppression increased in both 15–24 and 25–49 year age groups between 2017 and 2019.
In a multivariable analysis adjusting for survey year, gravidity, and education, the odds of
viral suppression significantly varied by province (except KwaZulu-Natal and Western
Cape, other provinces were less likely to attain viral suppression compared to Gauteng),
age (adjusted odds ratio (AOR) for 15–24 years vs 25–49 years: 0.7, 95% CI: 0.6–0.8), and
timing of ART initiation (AOR for ART initiation during pregnancy vs before pregnancy: 0.4,
95% CI: 0.5–0.6).
CONCLUSION :
Although in 2019 the first and second 95 targets were achieved among pregnant women,
meeting the third 95 target remains a challenge. This study highlighted the importance of
promoting early ART initiation and the need to target young women in efforts to improve
progress towards the third 95 target. Additionally, the provincial variation in viral suppression
could be further investigated in future studies to identify and address the root causes underlying these differences.DATA AVAILABILITY STATEMENT : Access to primary
data is subject to restrictions owing to privacy and
ethics policies set by the South African
Government. Requests for access to the data can
be made to the National Health Laboratory Services
directly (http://www.nhls.ac.za/) and require a full
protocol submission. Inquiries can be made to
Academic Affairs and Research at NHLS at
[email protected] received funding from: the
President’s Emergency Plan for AIDS Relief
(PEPFAR) through the Centers for Disease Control
and Prevention (CDC) under the terms of
cooperative agreement 5 NU2GGH001631, https://
www.cdc.gov/. In addition, World Health
organization (WHO), South African Medical
Research Council (SAMRC), National Department
of Health (NDoH), and NICD funded the data
collection for the survey. Disclaimer: The findings
and conclusions in this manuscript are those of the
authors and do not necessarily represent the
official position of the funding agencies. The
funders had no role in study design, data collection
and analysis, decision to publish, or preparation of
the manuscripthttp://www.plosone.orgdm2022Statistic
First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa
BACKGROUND : There is a paucity of data on the national
population-level effectiveness of preventing mother-tochild
transmission (PMTCT) programmes in high-HIVprevalence,
resource-limited settings. We assessed
national PMTCT impact in South Africa (SA), 2010.
METHODS : A facility-based survey was conducted using
a stratified multistage, cluster sampling design. A
nationally representative sample of 10 178 infants aged
4–8 weeks was recruited from 565 clinics. Data
collection included caregiver interviews, record reviews
and infant dried blood spots to identify HIV-exposed
infants (HEI) and HIV-infected infants. During analysis,
self-reported antiretroviral (ARV) use was categorised:
1a: triple ARV treatment; 1b: azidothymidine
>10 weeks; 2a: azidothymidine ≤10 weeks; 2b:
incomplete ARV prophylaxis; 3a: no antenatal ARV and
3b: missing ARV information. Findings were adjusted for
non-response, survey design and weighted for live-birth
distributions.
RESULTS : Nationally, 32% of live infants were HEI; early
mother-to-child transmission (MTCT) was 3.5% (95% CI
2.9% to 4.1%). In total 29.4% HEI were born to
mothers on triple ARV treatment (category 1a) 55.6%
on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal
ARV (3a) and 5.5% had missing ARV information (3b).
Controlling for other factors groups, 1b and 2a had
similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b,
0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT
was higher in group 2b (AOR 3.68, 1.69 to 7.97).
Within group 3a, early MTCT was highest among
breastfeeding mothers 11.50% (4.67% to 18.33%) for
exclusive breast feeding, 11.90% (7.45% to 16.35%)
for mixed breast feeding, and 3.45% (0.53% to 6.35%)
for no breast feeding). Antiretroviral therapy or
>10 weeks prophylaxis negated this difference (MTCT
3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60%
and 2.11%, 1.28% to 2.95%, respectively).
CONCLUSIONS : SA, a high-HIV-prevalence middle income
country achieved <5% MTCT by 4–8 weeks post
partum. The long-term impact on PMTCT on HIV-free
survival needs urgent assessment.South African National Research Foundationhttp://jech.bmj.comhb201
Investigating the quality of HIV rapid testing practices in public antenatal health care facilities, South Africa
Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient
epidemic tracking, programme planning and resource allocation. HIV sentinel surveillance
usually employs unlinked anonymous HIV testing which raises ethical, epidemiological and
public health challenges in the current era of universal test and treat. The World Health
Organization (WHO) recommends that countries should consider using routine prevention
of mother-to-child transmission of HIV (PMTCT) data for surveillance. We audited antenatal
care clinics to assess the quality of HIV rapid testing practices as the first step to assess
whether South Africa is ready to utilize PMTCT programme data for antenatal HIV surveillance. In 2017, we conducted a cross-sectional survey in 360 randomly sampled antenatal
care clinics using the adapted WHO Stepwise-Process-for-Improving-the-Quality-of-HIVRapid-Testing (SPI-RT) checklist. We calculated median percentage scores within a
domain (domain-specific median score), and across all domains (overall median percentage
scores). The latter was used to classify sites according to five implementation levels; (from
0:<40% to 4: 90% or higher). Of 346 (96.1%) facilities assessed, an overall median percentage score of 62.1% (inter-quartile range (IQR): 50.8–71.9%) was obtained. The lowest
domain-specific median percentage scores were obtained under training/certification (35%
IQR: 10.0–50.0%) and external quality assurance (12.5% IQR: 0.0–50.0%), respectively.
The majority (89%) of sites had an overall median score at level 2 or below; of these, 37%
required improvement in specific areas and 6.4% in all areas. Facilities in districts implementing the HIV Rapid Test Quality Improvement Initiative and supported by the President’s
Emergency Plan for AIDS Relief (PEPFAR) had significantly higher median overall scores (65.6% IQR: 53.9–74.2%) (P-value from rank sum test: <0.001) compared with non–PEPFAR–supported facilities (56.6% IQR:47.7–66.0%). We found sub-optimal implementation
of HIV rapid testing practices. We recommend the expansion of the PEPFAR-funded Rapid
Test Continuous Quality Improvement (RTCQI) support to all antenatal care testing sites.DATA AVAILABILITY STATEMENT : All data files are
available from the Figshare data repository: DOI 10.6084/m9.figshare.20257362.The United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention (CDC).http://www.plosone.orgdm2022Paediatrics and Child Healt
Poverty and inequality \u2013 but of what - as social determinants of health in Africa?
Background: Many African economies have achieved substantial economic
growth over the past recent years, yet several of the Millennium
Development Goals (MDGs) including those concerned with health, remain
considerably behind target. This paper examines whether progress
towards these goals is being hampered by existing levels of poverty and
income inequality. It also considers whether the inequality hypothesis
of Wilkinson and Pickett1 applies to population health outcomes in
African states. Methods: Correlation analysis and scatter plots were
used to assess graphically the link between variations in health
outcomes, level of poverty and income inequality in different
countries. Health status outcomes were measured by using four
indicators: infant and under-five (child) mortality rates; maternal
mortality ratios; and life expectancy at birth. In each of the 52
African nations, the proportion of the population living below the
poverty line is used as an indicator of the level of poverty and Gini
coefficient as a measure of income inequality. The study used a
comprehensive review of secondary and relevant literature that are
pertinent in the subject area. The data datasets obtained online from
UNICEF2 and UNDP3 (2009) used to test the research questions. World
Health Organization the three broad dimensions to consider when moving
towards better population health outcome through Universal Health
Coverage and the Social Determinants of Health framework reviewed to
establish the poverty and income inequality link in African countries
population health outcomes. Results: The study shows that poverty is
strongly associated with all health outcome differences in Africa (IMR,
cc = 0.63; U5MR, cc = 0.64; MMR, cc = 0.49; life expectancy at birth,
cc = -0.67); income inequality with only one of the four indicators
(IMR, cc = 0.14; U5MR, cc = 0.07; MMR, cc = 0.22; life expectancy at
birth, cc = -0.49), whereas income inequality is associated with one of
the four indicators. Conclusion: The study shows that tackling poverty
should be the immediate concern in Africaas a means of promoting better
health for all. There is a question mark over whether the findings of
Wilkinson and Pickett1 on the relationship between income inequality
and health apply to Africa. The reasons for this question mark are
discussed. More research is needed to investigate whether the
inequality results found in this study are replicated in other studies
of African health
Coverage of maternal viral load monitoring during pregnancy in South Africa : results from the 2019 national Antenatal HIV Sentinel Survey
OBJECTIVES : South Africa has made remarkable progress in increasing the coverage
of antiretroviral therapy (ART) among pregnant women; however, viral suppression
among pregnant women receiving ART is reported to be low. Access to routine viral
load testing is crucial to identify women with unsuppressed viral load early in pregnancy
and to provide timely intervention to improve viral suppression. This study
aimed to determine the coverage of maternal viral load monitoring nationally, focusing
on viral load testing, documentation of viral load test results, and viral suppression
(viral load < 50 copies/mL). At the time of this study, the first-line
regimen for
women initiating ART during pregnancy was non-nucleoside
reverse transcriptase
(NNRTI)-based
regimen.
METHODS : Between 1 October and 15 November 2019, a cross-sectional
survey was
conducted among 15-to
49-year-
old
pregnant women attending antenatal care in
1589 nationally representative public health facilities. Data on ART status, viral load
testing and viral load test results were extracted from medical records. Logistic regression
was used to examine factors associated with coverage of viral load testing.
RESULTS : Of 8112 participants eligible for viral load testing, 81.7% received viral
load testing, and 94.1% of the viral load test results were documented in the medical
records. Of those who had viral load test results documented, 74.1% were virally
suppressed. Women initiated on ART during pregnancy and who received ART
for three months had lower coverage of viral load testing (73%) and viral suppression
(56.8%) compared with women initiated on ART before pregnancy (82.8% and
76.1%, respectively). Initiating ART during pregnancy rather than before pregnancy was associated with a lower likelihood of receiving a viral load test during pregnancy
(adjusted odds ratio = 1.6, 95% confidence interval: 1.4–1.8).
CONCLUSIONS : Viral load result documentation was high; viral load testing could be improved
especially among women initiating ART during pregnancy. The low viral suppression
among women who initiated ART during pregnancy despite receiving ART for three months highlights the importance of enhanced adherence counselling during
pregnancy. Our finding supports the WHO recommendation that a Dolutegravir-containing
regimen be the preferred regimen for women who are newly initiating
ART during pregnancy for more rapid viral suppression.The World Health Organization (WHO), the National Department of Health (NDoH), and the National Institute for Communicable Diseases (NICD).http://www.wileyonlinelibrary.com/journal/hivam2022Statistic
Mixed Biopolymer Systems Based on Bovine and Caprine Caseins, Yeast β-Glucan, and Maltodextrin for Microencapsulating Lutein Dispersed in Emulsified Lipid Carriers
Lutein is an important antioxidant that quenches free radicals. The stability of lutein and hence compatibility for food fortification is a big challenge to the food industry. Encapsulation can be designed to protect lutein from the adverse environment (air, heat, light, pH). In this study, we determined the impact of mixed biopolymer systems based on bovine and caprine caseins, yeast β-glucan, and maltodextrin as wall systems for microencapsulating lutein dispersed in emulsified lipid carriers by spray drying. The performance of these wall systems at oil/water interfaces is a key factor affecting the encapsulation of lutein. The highest encapsulation efficiency (97.7%) was achieved from the lutein microcapsules prepared with the mixed biopolymer system of caprine αs1-II casein, yeast β-glucan, and maltodextrin. Casein type and storage time affected the stability of lutein. The stability of lutein was the highest (64.57%) in lutein microcapsules prepared with the mixed biopolymer system of caprine αs1-II casein, yeast β-glucan, and maltodextrin, whereas lutein microcapsules prepared with the biopolymer system of bovine casein, yeast β-glucan, and maltodextrin had the lowest (56.01%). The stability of lutein in the lutein microcapsules dramatically decreased during storage time. The antioxidant activity of lutein in the lutein microcapsules was closely associated with the lutein concentration
Mixed Biopolymer Systems Based on Bovine and Caprine Caseins, Yeast β-Glucan, and Maltodextrin for Microencapsulating Lutein Dispersed in Emulsified Lipid Carriers
Lutein is an important antioxidant that quenches free radicals. The stability of lutein and hence compatibility for food fortification is a big challenge to the food industry. Encapsulation can be designed to protect lutein from the adverse environment (air, heat, light, pH). In this study, we determined the impact of mixed biopolymer systems based on bovine and caprine caseins, yeast β-glucan, and maltodextrin as wall systems for microencapsulating lutein dispersed in emulsified lipid carriers by spray drying. The performance of these wall systems at oil/water interfaces is a key factor affecting the encapsulation of lutein. The highest encapsulation efficiency (97.7%) was achieved from the lutein microcapsules prepared with the mixed biopolymer system of caprine αs1-II casein, yeast β-glucan, and maltodextrin. Casein type and storage time affected the stability of lutein. The stability of lutein was the highest (64.57%) in lutein microcapsules prepared with the mixed biopolymer system of caprine αs1-II casein, yeast β-glucan, and maltodextrin, whereas lutein microcapsules prepared with the biopolymer system of bovine casein, yeast β-glucan, and maltodextrin had the lowest (56.01%). The stability of lutein in the lutein microcapsules dramatically decreased during storage time. The antioxidant activity of lutein in the lutein microcapsules was closely associated with the lutein concentration
Impact of Staging Concordance and Downstaging After Neoadjuvant Therapy on Survival Following Resection of Intrahepatic Cholangiocarcinoma: A Bayesian Analysis
Introduction: Concordance between clinical and pathological staging, as well as the overall survival (OS) benefit associated with neoadjuvant therapy (NAT) remain ill-defined. We sought to determine the impact of staging accuracy and NAT downstaging on OS among patients with intrahepatic cholangiocarcinoma (ICC). Methods: Patients treated for ICC between 2010 and 2018 were identified using the National Cancer Database. A Bayesian approach was applied to estimate NAT downstaging. OS was assessed relative to staging concordant/overstaged disease treated with upfront surgery, understaged disease treated with upfront surgery, no downstaging, and downstaging after NAT. Results: Among 3384 patients, 2904 (85.8%) underwent upfront surgery, whereas 480 (14.2%) received NAT and 85/480 (18.4%) were downstaged. Patients with cT3 (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.34–3.34), cN1 (OR 2.47, 95% CI 1.71–3.58) disease, and patients treated at high-volume facilities (OR 1.63, 95% CI 1.13–2.36) were more likely to receive NAT (all p \u3c 0.05). Median OS was 40.1 months (95% CI 38.6–43.4). Patients with cT1-2N1 (NAT: 31.5 months vs. upfront surgery: 22.4 months; p = 0.04) and cT3-4N1 (NAT: 27.8 months vs. upfront surgery: 14.4 months; p = 0.01) disease benefited most from NAT. NAT downstaging decreased the risk of death among patients with cT3-4N1 disease (hazard ratio [HR] 0.35, 95% CI 0.15–0.82). In contrast, understaged patients with cT1-2N0/X (HR 2.15, 95% CI 1.83–2.53) and cT3-4N0/X (HR 1.71, 95% CI 1.06–2.74) disease treated with upfront surgery had increased risk of death. Conclusions: Patients with N1 ICC treated with NAT demonstrated improved OS compared with upfront surgery. Downstaging secondary to NAT conferred survival benefits among patients with cT3-4N1 versus upfront surgery. NAT should be considered in ICC patients with advanced T disease and/or nodal metastases