NIMART rollout to primary healthcare facilities increases access to antiretrovirals in Johannesburg: An interrupted time series analysis

Introduction. South Africa has made remarkable progress in rolling out antiretroviral therapy (ART), with the largest number of people(more than 1.4 million) enrolled on antiretrovirals in the world. Decentralisation of services to primary health centres (PHCs) hasstrengthened retention of patients on ART and reduced the burden of managing uncomplicated cases at referral hospitals.Methods. This was a ten-step Nurse Initiatied Management of Antiretroviral Treatment (NIMART) rollout intervention in which nurses from 17 primary healthcare facilities of Region F, City of Johannesburg, South Africa, were trained and mentored in NIMART by the Wits Reproductive Health and HIV Research Institute (WRHI) to commence patients on ART in their PHCs. A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. To test the statistical significance of the impact of NIMART rollout on the referral hospital initiations and Region F monthly initiations, interrupted time series analysis was applied. Findings. Ten-step NIMART rollout was applied, with the first step being establishment of NIMART as a priority in order to obtain primary buy-in by the Department of Health (DoH) and City of Johannesburg (CoJ). Forty-five professional nurses were trained in NIMART by WRHI quality improvement mentors. By the end of September 2011, all 17 PHCs in Region F were initiating patients on ART. Totalinitiations significantly increased by 99 patients immediately after NIMART rollout (p=0.013) and continued to increase by an average of 9 every month (p=0.013), while referral facility initiations decreased by 12 (p=0.791) immediately after NIMART and then decreased by anaverage of 18 every month (p=0.01).Conclusion. In this study, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients. Engaging and having buy-in from DoH/CoJ partners in rolling out NIMART was crucial in increasing outputs as well as for sustainability of the NIMART programme

A comparative analysis of conventional Pap smear cytology, liquid based cytology and colposcopy clinical impression with colposcopy biopsy histology as gold standard in women undergoing colposcopy in Kenyatta National Hospital

Background: Cervical cancer is one of the most common female malignancies worldwide. Since the introduction of conventional Papanicolaou smear mortality from cervical cancer has reduced considerably. Despite its success, it has sensitivity of only 51% and false negative rate of 5-10%. Approved liquid based cytology (LBC) products by FDA claim a 65-percent increased detection rate of high grade squamous intraepithelial lesions (HGSIL) compared with conventional smears, as well as decreased unsatisfactory sample rates. Evidence shows that liquid based preparation is more sensitive and accurate for the detection of both squamous and glandular lesions of the cervix. Studies of the accuracy of liquid based preparations reports sensitivity of 61-66% and specificity of 82-91%. Objective of current study is to compare the performance of conventional Pap smear cytology, liquid based cytology and colposcopy clinical impression with colposcopic biopsy as the gold standard among women eligible for colposcopy in Kenyatta National Hospital, Kenya.Methods: This was a hospital-based comparative cross-sectional study. Convenient sampling over a period of 4 months was used to recruit clients referred to colposcopy clinic with abnormal Pap smear results.Results: A total of 73 patients referred with abnormal pap smears were recruited into the study. The mean age of the patients was 38 yrs (SD ±10). About 45% of the patients interviewed did not have knowledge of Pap smear testing. Both the results of referral Pap smear and repeat Pap smear were predominantly low grade squamous intraepithelial lesions (LGSIL) or HGSIL. With biopsy results being the gold standard, Liquid based cytology had a higher specificity of 75% when compared with conventional pap smears’ 11%.Conclusions: Even though colposcopy clinical impression has the highest agreement with colposcopy biopsy it’s a diagnostic and not a screening test, hence Liquid based cytology showed better performance as a screening test compared to conventional Pap smear. In general, there was good agreement for cytological results of repeat CPAP and LBC. We therefore recommend that for patients referred with abnormal pap smears requiring a repeat pap smear, liquid based cytology is used due to its higher specificity compared to conventional Pap smear

Evidence against rapid emergence of praziquantel resistance in Schistosoma haematobium, Kenya.

We examined the long-term efficacy of praziquantel against Schistosoma haematobium, the causative agent of urinary schistosomiasis, during a school-based treatment program in the Msambweni area of Coast Province, Kenya, where the disease is highly endemic. Our results, derived from treating 4,031 of 7,641 children from 1984 to 1993, indicate substantial year-to- year variation in drug efficacy. However, the pattern of this variation was not consistent with primary or progressive emergence of praziquantel resistance. Mathematical modeling indicated that, at current treatment rates, praziquantel resistance will likely take 10 or more years to emerge

Reconstruction of Complex Post-Traumatic Perineal/Pelvic Defects Using a Pedicled Anterolateral Thigh Flap in a Child

The complexity of the female pelvis and perineum becomes evident when traumatic or surgical defects need to be reconstructed; consideration should be given to the restoration or preservation of the most important  functions subserved by this anatomic region. We used a composite pedicled  fasciocutaneous anterolateral thigh flap with an innervated vastus lateralis muscle to reconstruct the pelvic ring, vagina, clitoris, labia and mons pubis. Unaided ambulation, urinary and anal continence were successfully restored. An appropriately designed pedicled ALT flap can be successfully used to achieve excellent pelvic/perineal reconstruction and functional restoration in complex pelvic/ perineal defects, even in children.Key Words: Trauma, Perineum, Pedicled ALT, Reconstructio

Factors associated with patient and health service delays in the management of TB in Central Equatoria State in 2008

Background: Tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis. Delays in diagnosis and treatment increase morbidity and mortality from tuberculosis, and the risk of transmission in the community.Methods: We conducted a cross-sectional survey at three TB treatment centres in Central Equatoria State, South Sudan. Smearpositive TB patients were enrolled in three study sites and interviewed within two days of beginning treatment using a structured questionnaire. This study was conducted to investigate factors that affect patient and health service delays in diagnosis and treatment of pulmonary tuberculosis (PTB) in Central Equatoria State.Results: 129 patients were enrolled in the study. The median patient’s, health provider’s and total pre-treatment periods are 4, 10 and 16 weeks respectively. The health care provider delay for patient diagnosis and start of treatment had the greatest contribution to overall total pre-treatment delayConclusions and recommendations: In Central Equatoria State, health care provider delay was the most frequent type of delay observed and was a major contributor to the overall total delay. This study indicated the need for strengthening the capacity of health workers for early detection and referral of TB patients. Further research is needed to identify reasons for health provider delay.Keywords: Mycobacterium tuberculosis, health service delays, South Suda

Cryotherapy Following Visual Inspection with Acetic Acid and Lugol's Iodine (Via/Vili) in Khwisero, Western Kenya: Lesson from the Field Affecting Policy and Practice

Background: Cervical cancer can be prevented and mortality/morbidity reduced by early detection and referral. Developing countries are likely to benefit from more cost effective methods of screening and treatment. Visual inspection with acetic acid and Lugol`s iodine (VIA/VILI) offers a see and treat solution thus an affordable and efficient way to identify pre-malignant lesions. Immediate treatment with cryotherapy can be offered if pre-malignant lesions are found on visual inspection. Cryotherapy is a simple procedure that is curative for dysplasia; it is likely to benefit cervical dysplasia cases picked early in resource poor settings, however there are several factors that hinder patients’ access to this noble technique.Objective: Determine hindrances to cryotherapy for patients following  positive results of VIA/VILI after referral.Design: Cross sectional StudySetting: Khwisero, Western Kenya.Subjects: Women attending a medical camp, willing to get screened for cervical cancer.Results: One hundred and nine patients were screened; seventy three (66.97%) were negative for VIA/VILI, twenty one (19.26%) were positive and referred for cryotherapy. Reasons for lack of follow up were financial constraints, lack of medical personnel at referral centres and poor access to the referral facilities.19.26% of women identified with positive lesions required intervention. No patient received cryotherapy following referral.Conclusion: There is urgent need for availability of cryotherapy machines and training of personnel who can perform cryotherapy at the primary care level. Regional studies on knowledge attitudes and practices about  VIA/VILI and cryotherapy are required to provide reasons for the poor uptake of this procedure

Intestical polyparasitism in a rural Kenyan community

Background: Polyparasitism seems to be a common feature in human populations in sub-Saharan Africa. However, very little is known about its epidemiological significance, its long term impact on human health or the types of interactions that occur between the different parasite species involved.Objectives: To determine the prevalence and co-occurrence of intestinal parasites in a rural community in the Kibwezi, Makueni district, Kenya.Design: A cross sectional study.Setting: Kiteng’ei village, Kibwezi, Makueni district, between May and September 2006.Subjects: One thousand and forty five who comprised of 263 adult males, 271 adult females> 15 years of age and 232 boys, and 279 girls < 15 years of age.Interventions: All infected members of the community were offered Praziquantel (at dosages of 40 mg/ kg body weight) for Schistosomiasis and Albendazole (600 mg) for soil transmitted helminths.Results: A total of ten intestinal parasite species (five protozoan and five helminth parasite species) were present in this community and polyparasitsm was common in individuals 5- 24 years of age with no gendar related differences. Most of the infections were mild. The protozoan parasites of public health significance present were Entamoeba histolytica and Giardia lamblia with prevalence of 12.6% and 4.2%, respectively. The helminth parasites of public health significance in the locality were Schistosoma mansoni with a prevalence of 28%, and hookworms prevalence of 10%. About 53% of the study population harboured intestinal parasite infections, with 31 % of the infected population carrying single parasite species infections, and 22% harbouring two or more intestinal parasite species per individual. Significant positive associations (p value

Long term study on the effect of mollusciciding with niclosamide in streamhabitats on the transmission of schistosomiasis mansoni after community-basedchemotherapy in Makueni District, Kenya

Background: Schistosoma mansoni infection is a persistent public health problem in many Kenyan communities. Although praziquantel is available, re-infection after chemotherapy treatment is inevitable, especially among children. Chemotherapy followed by intermittent mollusciciding of habitats of Biomphalaria pfeifferi, the intermediate host snail, may have longer term benefits, especially if timed to coincide with natural fluctuations in snail populations. Methods: In this cohort study, the Kambu River (Intervention area) was molluscicided intermittently for 4 years, after mass chemotherapy with praziquantel in the adjacent community of Darajani in January 1997. The nearby Thange River was selected as a control (Non-intervention area), and its adjacent community of Ulilinzi was treated with praziquantel in December 1996. Snail numbers were recorded monthly at 9–10 sites along each river, while rainfall data were collected monthly, and annual parasitological surveys were undertaken in each village. The mollusciciding protocol was adapted to local conditions, and simplified to improve prospects for widespread application. Results: After the initial reduction in prevalence attributable to chemotherapy, there was a gradual increase in the prevalence and intensity of infection in the non-intervention area, and significantly lower levels of re-infection amongst inhabitants of the intervention area. Incidence ratio between areas adjusted for age and gender at the first follow-up survey, 5 weeks after treatment in the non-intervention area and 4 months after treatment in the intervention area was not significant (few people turned positive), while during the following 4 annual surveys these ratios were 0.58 (0.39-0.85), 0.33 (0.18-0.60), 0.14 (0.09-0.21) and 0.45 (0.26-0.75), respectively. Snail numbers were consistently low in the intervention area as a result of the mollusciciding. Following termination of the mollusciciding at the end of 2000, snail populations and infections in snails increased again in the intervention area. Conclusion: The results of this study demonstrate that in the Kenyan setting a combination of chemotherapy followed by intermittent mollusciciding can have longer term benefits than chemotherapy alone

Comparison of pap smear, visual inspection with acetic acid, human papillomavirus DNA-PCR testing and cervicography

Objective: To assess the test qualities of four screening methods to detect cervical intra-epithelial neoplasia in an urban African setting. Method: Six hundred fiftythree women, attending a family planning clinic in Nairobi (Kenya), underwent four concurrent screening methods: pap smear, visual inspection with acetic acid (VIA), PCR for high risk human papillomavirus (HR HPV) and cervicography. The presence of cervical intra-epithelial neoplasia (CIN) was verified by colposcopy or biopsy. Result: Sensitivity (for CIN2 or higher) and specificity (to exclude any CIN or cancer) were 83.3% (95% CI [73.6, 93.0]) and 94.6% (95% CI [92.6, 96.5]), respectively, for pap smear; 73.3% (95% CI [61.8, 84.9]) and 80.0% (95% CI [76.6, 83.4]) for VIA; 94.4% (95% CI [84.6, 98.8]) and 73.9% (95% CI [69.7, 78.2]) for HR HPV; and 72.3% (95% CI [59.1, 85.6]) and 93.2% (95% CI [90.8, 95.7]) for cervicography. Conclusion: The pap smear had the highest specificity (94.6%) and HPV testing the highest sensitivity (94.4%). The visual methods, VIA and cervicography, were similar and showed an accuracy in between the former two tests