Despite the Zambian Government’s effort to expand services to district level, this study reports that it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages. The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital. The study found that mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases ‘lost to follow-up’. This might be due to the closer involvement of the community and the better support offered by these services to rural clients. These services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.
Equitable health services
The South African Mental Health Care Act (the Act) No. 17 of 2002 stipulated that regional and district hospitals be designated to admit, observe and treat mental health care users (MHCUs) for 72 hours before they are transferred to a psychiatric hospital. This study surveyed medical managers in 49 ‘designated’ hospitals in KwaZulu-Natal (KZN) on infrastructure, staffing, administrative requirements and mental health care user case load pertaining to the Act for the month of July 2009. Thirty-six (73.4%) hospitals responded to the survey: 83.3% stated that the Act improved mental health care for MHCUs through the protection of their rights, provision of least restrictive care, and reduction of discrimination; 27.8% had a psychiatric unit and, of the remaining 26 hospitals, 30.6% had general ward beds dedicated for psychiatric admissions; 44.4% had some form of seclusion facility; and 66.7% provided an outpatient psychiatric service. Seventy-six per cent of admissions were involuntary or assisted. Thirteen of the 32 state psychiatrists in KZN were employed at eight of these hospitals. Designated hospitals expressed dissatisfaction with the substantial administrative load required by the Act. The Review Board had not visited 29 (80.6 %) hospitals in the preceding 6 months. Although ‘designated’ hospitals admit and treat assisted and involuntary MHCUs, they do so against a backdrop of inadequate infrastructure and staff, a high administrative load, and a low level of contact with Review Boards.
As a signatory to the UN Convention on the Rights of Persons with Disabilities, South Africa has committed itself to transformation aimed at ending the inequities that characterise mental health service provision and ‘closing the gap’. To measure South Africa’s progress, this study compared budget allocations over a five-year period to six psychiatric and six general hospitals in KwaZulu-Natal (KZN) and contrasted current numbers of psychiatric beds and psychiatric personnel in that province with the numbers required to comply with national norms. It found that the mean increase in budget allocations to public psychiatric hospitals was 3.8% per annum, while that to general hospitals over the same period was 10.2% per annum. The median cumulative budget increase for psychiatric hospitals was significantly lower than that of general hospitals. No psychiatric hospitals received specific funding for tertiary services development. KZN has 25% of the acute psychiatric beds and 25% of the psychiatrists required to comply with national norms, with the most serious shortages experienced in northern KZN. There are 0.38 psychiatrists per 100 000 population in KZN. In conclusion, the author argues that inequitable funding, inadequate facilities and significant shortages of mental health professionals pervade the mental health and psychiatric services in KZN; and that there is little evidence of government abiding by its public commitments to redress the inequities that characterise mental health services.
This presentation investigates the barriers to access that couples face when deciding to use family planning. It identifies a number of key barriers in Africa, including limited method choice, prohibitive financial costs, psychosocial factors relating to the status of women, medical and legal restrictions, provider bias and misinformation. The author of the presentation has two recommendations. Firstly, Governments should prioritise family planning and have line items in their budgets for family planning training and services, and for commodities. Secondly, they should make available the fullest possible range of contraceptive choices, including voluntary sterilisation, through the widest range of distribution channels, backed up by access to safe abortion.
This research asks whether a cervical cancer prevention programme in South Africa that includes an HPV vaccine is more cost-effective than the current strategy of screening alone. It found that, while a combination of vaccination and screening at the current vaccine price is more costly than screening alone, it is a cost-effective strategy for preventing cervical cancer. The main cost driver is the vaccine cost. If the vaccine price is reduced, vaccination followed by screening might be a very affordable policy option. The vaccine has the potential to reduce the incidence of HPV-related diseases, and to reduce the cost of treating cervical cancer. This requires a well-functioning screening programme aimed at secondary prevention of cervical cancer as the HPV vaccine does not eliminate, but rather reduces the risk of cervical cancer. In South Africa, screening coverage is very low (well below 50%) and adherence to treatment of pre-cancerous and cancerous lesions is also less than 100%, thus having another preventative measure could be desirable. Approaches for reducing the cost of introducing the vaccine (which should be publicly funded) include accessing international funding mechanisms, such as the United Nations Children’s Fund (UNICEF), using public-private partnerships and getting commitment from pharmaceutical companies to reduce prices.
Microbicides Development Programme 301 was a phase 3, randomised, double-blind, parallel-group trial, undertaken at thirteen clinics in South Africa, Tanzania, Uganda, and Zambia. The study enrolled 9,385 of the initial 15,818 women who were screened. Mean reported gel use at last sex act was 89%. HIV-1 incidence was much the same between groups at study end, for placebo, for hazard ratio 1.05, and at discontinuation. Incidence of the primary safety endpoint at study end was 4.6 per 100 woman-years in the 0.5% PRO2000 group and 3.9 in the placebo group; and was 4.5 in the 2% PRO2000 group at discontinuation. The study concludes that, although they are safe, 0.5% PRO2000 and 2% PRO2000 gels are not efficacious against vaginal HIV-1 transmission and are not indicated for this use.
An estimated 55,000 people die of rabies in Africa and Asia every year, a viral disease passed from an infected animal to a human through biting or scratching. In both humans and animals it is deemed fatal once it enters the central nervous system, with only a handful of survivors. Already nine human cases that resulted in death have been confirmed in South Africa this year; three in the Eastern Cape, two in Kwa Zulu-Natal, one in Mpumalanga and three in Limpopo. Experts in the medical fraternity have described this as worrying, saying people need to be aware of rabies. Professor Lucille Blumberg of the National Institute for Communicable Diseases, says her institution deals with up to 20 cases of human rabies per year. She says that if a person is bitten by a stray animal, they should immediately wash the wound very well, to physically remove the virus, then visit a clinic immediately to get an injection to prevent infection and to go on a course of injections to develop antibodies to the disease.
The Global Plan to Stop TB 2011-2015 is a new roadmap for curbing the global epidemic of tuberculosis, and it aims to save five million lives between 2011 and 2015 and eliminate TB as a public health problem by 2050 but comes with a price tag of US$47 billion, nearly half of which must still be found. The Plan builds on progress towards goals laid out in 2006 to halve TB prevalence and death rates by 2015 and scale up TB diagnosis, treatment and care, but adds essential research targets including the development of faster methods to test and treat TB and to prevent it through an effective vaccine. Specifically, the plan provides countries with guidance on how to improve TB control through scaling up existing interventions for its diagnosis and treatment and by making use of new diagnostic tests and drugs that will become available over the next five years. A new test that uses molecular line probe assays to detect multi-drug resistant (MDR) TB in a few days instead of the weeks needed using older testing methods has already been introduced in some countries. Other tests that will soon be available can detect TB in a matter of hours. The pipeline of new TB drugs promises shorter treatment times. Meanwhile, nine TB vaccine candidates are in clinical trials and a new generation of TB vaccines is expected to be available by 2020. Other major elements of the plan focus on efforts to combat drug-resistant TB and TB in people living with HIV. It calls for a scale-up in access to tests that can detect resistance to first- and second-line TB drugs, identifying limited laboratory capacity as the main reason why only 5% of the estimated 440,000 people who had MDR-TB in 2008 were diagnosed. It also recommends testing all TB patients for HIV and providing antiretroviral treatment to all those who test positive.
The study’s aim was to estimate rates of completion of CD4+ lymphocyte testing (CD4 testing) within 12 weeks of testing positive for human immunodeficiency virus (HIV) at a large HIV/AIDS clinic in South Africa, and to identify clinical and demographic predictors for completion. In the study, CD4 testing was considered complete once a patient had retrieved the test results. To determine the rate of CD4 testing completion, researchers reviewed the records of all clinic patients who tested positive for HIV between January 2008 and February 2009 to identify predictors for completion through multivariate logistic regression. Of the 416 patients who tested positive for HIV, 84.6% initiated CD4 testing within the study timeframe. Of these patients, 54.3% were immediately eligible for antiretroviral therapy (ART) because of a CD4 cell count ≤ 200/µl, but only 51.3% of the patients in this category completed CD4 testing within 12 weeks of HIV testing. Among those not immediately eligible for ART, only 14.9% completed CD4 testing within 12 weeks. Overall, of HIV+ patients who initiated CD4 testing, 65% did not complete it within 12 weeks of diagnosis. The higher the baseline CD4 cell count, the lower the odds of completing CD4 testing within 12 weeks. The study concluded that patient losses between HIV testing, baseline CD4 cell count and the start of care and ART are high. As a result, many patients receive ART too late. It recommends health information systems that link testing programmes with care and treatment programmes.
This report presents the global treatment outcomes from all sites providing complete data for new and previously treated multi-drug-resistant TB (MDR-TB) patients. Ten of the 27 high MDR-TB burden countries reported treatment outcomes. A total of 71 countries and territories provided complete data for treatment outcomes for 4,500 MDR-TB patients. In 48 sites documenting outcomes, patient management and drug quality were found to conform to international standards. Treatment success was documented in 60% of patients overall. The report found that treatment success in MDR-TB patients remains low, even in well-resourced settings because of a high frequency of death, treatment failure and default, as well as many cases reported without definitive outcomes. New findings presented in this report give reason to be cautiously optimistic that MDR-TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDR-TB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated M/XDR-TB cases – is to be reached.