HIV Infection and Ocular Disease in South Africa

The burden of ocular disease in sub-Saharan African countries is disproportionally high, especially among HIV-infected individuals. This thesis presents the results of studies that provide novel insight into the clinical field of ophthalmology in a high HIV prevalence setting in rural South Africa (Mopani District, Limpopo Province). This insight opens the door for further improvement of the clinical care for individuals affected by HIV-associated ocular diseases

High seroprevalence of human herpesviruses in HIV-infected individuals attending primary healthcare facilities in rural South Africa

Seroprevalence data of human herpesviruses (HHVs) are limited for sub-Saharan Africa. These are important to provide an indication of potential burden of HHV-related disease, in particular in human immunodeficiency virus (HIV)-infected individuals who are known to be at increased risk of these conditions in the Western world. In this cross-sectional study among 405 HIV-infected and antiretroviral therapy naïve individuals in rural South Africa the seroprevalence of HHVs was: herpes simplex virus type 1 (HSV-1) (98%), herpes simplex virus type 2 (HSV-2) (87%), varicella zoster virus (VZV) (89%), and 100% for both Epstein-Barr virus (EBV) and cytomegalovirus (CMV). Independent factors associated with VZV seropositivity were low educational status and having children. Lack of in-house access to drinking water was independently associated with positive HSV-1 serostatus, whereas Shangaan ethnicity was associated with HSV-2 seropositivity. Increasing age was associated with higher IgG titres to both EBV and CMV, whereas CD4 cell count was negatively associated with EBV and CMV IgG titres. Moreover, IgG titres of HSV-1 and 2, VZV and CMV, and CMV and EBV were positively correlated. The high HHV seroprevalence emphasises the importance of awareness of these viral infections in HIV-infected individuals in South Africa

Scatter plots of factors associated with human herpesvirus-specific serum IgG titres.

<p>Correlation between serum EBV and CMV IgG titres and the individual's (<b>A</b>) Age and (<b>B</b>) CD4 cell count. (<b>C</b>) Correlation between serum IgG titres of different human herpesviruses. Serum IgG titres, presented as binary logarithmic PEI/ml values, were calculated based on corresponding reference sera from the Paul-Ehrlich Institute (Erlangen, Germany). The Spearman correlation test was used for statistical analysis. HSV-1, herpes simplex virus 1; HSV-2, herpes simplex virus; VZV, varicella zoster virus; EBV, Epstein-Barr virus and CMV, cytomegalovirus.</p

Seroprevalence of human herpesviruses in HIV-infected individuals (n = 402).

<p>Data are presented as number (%). HSV  =  human simplex virus; VZV  =  varicella zoster virus; EBV  =  Epstein-Barr virus; CMV  =  cytomegalovirus.</p

Demographic characteristics of study participants (n = 405).

<p>Data are presented as number (%) unless otherwise indicated. SD  =  standard deviation; HIV  =  human immunodeficiency virus.</p>a<p>Clinical HIV-staging was done according to the WHO Clinical Staging of HIV/AIDS <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0099243#pone.0099243-World1" target="_blank">[11]</a>.</p

Crude risk factors associated with HSV-1, HSV-2, and VZV serostatus.

<p>Data are shown as numbers (%) or mean (sd). Crude odds ratios were calculated for demographic and clinical characteristics between positive and negative serological status. CI, Confidence interval; <i>p</i>-Value, Pearson Chi-square; na, not applicable; VZV, varicella zoster virus; HSV-1, herpes simplex virus 1; HSV-2, herpes simplex virus 2.</p

Strengthening primary eye care in South Africa: An assessment of services and prospective evaluation of a health systems support package

<div><p>Visual impairment is a significant public health concern, particularly in low- and middle-income countries where eye care is predominantly provided at the primary healthcare (PHC) level, known as primary eye care. This study aimed to perform an evaluation of primary eye care services in three districts of South Africa and to assess whether an ophthalmic health system strengthening (HSS) package could improve these services. Baseline surveys were conducted in Cape Winelands District, Johannesburg Health District and Mopani District at 14, 25 and 36 PHC facilities, respectively. Thereafter, the HSS package, comprising group training, individual mentoring, stakeholder engagement and resource provision, was implemented in 20 intervention sites in Mopani District, with the remaining 16 Mopani facilities serving as control sites. At baseline, less than half the facilities in Johannesburg and Mopani had dedicated eye care personnel or sufficient space to measure visual acuity. Although visual acuity charts were available in most facilities, <50% assessed patients at the correct distance. Median score for availability of nine essential drugs was <70%. Referral criteria knowledge was highest in Cape Winelands and Johannesburg, with poor clinical knowledge across all districts. Several HSS interventions produced successful outcomes: compared to control sites there was a significant increase in the proportion of intervention sites with eye care personnel and resources such as visual acuity charts (p = 0.02 and <0.01, respectively). However, engaging with district pharmacists did not improve availability of essential drugs (p = 0.47). Referral criteria knowledge improved significantly in intervention sites (p<0.01) but there was no improvement in clinical knowledge (p = 0.76). Primary eye care in South Africa faces multiple challenges with regard to organisation of care, resource availability and clinical competence. The HSS package successfully improved some aspects of this care, but further development is warranted together with debate regarding the positioning of eye services at PHC level.</p></div

Components of the ophthalmic health systems strengthening intervention.

<p>(PHC, Primary Health Care; VA, Visual Acuity).</p

Baseline and post-intervention surveys in Mopani District to assess the impact of a health system strengthening support package to improve primary eye care.

<p>Baseline and post-intervention surveys in Mopani District to assess the impact of a health system strengthening support package to improve primary eye care.</p

Baseline evaluation of primary eye care services in three district of South Africa.

<p>Baseline evaluation of primary eye care services in three district of South Africa.</p