Are social support and HIV coping strategies associated with lower depression in adults on antiretroviral treatment? Evidence from rural KwaZulu-Natal,South Africa

We assess depression rates and investigate whether depression among HIV-infected adults receiving antiretroviral treatment (ART) is associated with social support and HIV coping strategies in rural South Africa (SA). The study took place in a decentralised public-sector ART programme in a poor, rural area of KwaZulu-Natal, SA, with high-HIV prevalence and high-ART coverage. The 12-item General Health Questionnaire (GHQ12), validated in this setting, was used to assess depression in 272 adults recently initiated on ART. Estimates of depression prevalence ranged from 33% to 38%, depending on the method used to score the GHQ12. Instrumental social support (providing tangible factors for support, such as financial assistance, material goods or services), but not emotional social support (expressing feelings, such as empathy, love, trust or acceptance, to support a person), was significantly associated with lower likelihood of depression [adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) 0.52–0.81, P < 0.001], when controlling for sex, age, marital status, education, household wealth and CD4 cell count. In addition, using “avoidance of people” as a strategy to cope with HIV was associated with an almost three times higher odds of depression (aOR = 2.79, CI: 1.34–5.82, P = 0.006), whereas none of the other five coping strategies we assessed was significantly associated with depression. In addition to antidepressant drug treatment, interventions enhancing instrumental social support and behavioural therapy replacing withdrawal behaviours with active HIV coping strategies may be effective in reducing the burden of depression among patients on ART.     

Antiretroviral therapy initiation and adherence in rural South Africa: community health workers’ perspectives on barriers and facilitators

South Africa has the largest global HIV/AIDS epidemic, but barriers along the HIV care continuum prevent patients from initiating and adhering to antiretroviral therapy (ART). To qualitatively explore reasons for poor ART initiation and adherence rates from the unique perspective of community health workers (CHWs), we conducted focus groups during May–August 2014 with 21 CHWs in rural Msinga, KwaZulu-Natal. Interviews were audio-recorded, transcribed, and translated from Zulu into English. Hybrid deductive and inductive analytical methods were applied to identify emergent themes. Multiple psychosocial, socioeconomic, and socio-medical barriers acted at the level of the individual, social network, broader community, and healthcare environment to simultaneously hinder initiation of and adherence to ART. Key themes included insufficient patient education and social support, patient dissatisfaction with healthcare services, socioeconomic factors, and tension between ART and alternative medicine. Fear of lifelong therapy thwarted initiation whereas substance abuse principally impeded adherence. In conclusion, HIV/AIDS management requires patient counselling and support extending beyond initial diagnosis. Treating HIV/AIDS as a chronic rather than acute infectious disease is key to improving ART initiation and long-term adherence. Public health strategies include expanding CHWs' roles to strengthen healthcare services, provide longitudinal patient support, and foster collaboration with alternative medicine providers.     

How far should life-style be corrected in the elderly?

To ensure a healthy elderly population, correction of life-style is one of the most important approaches. Smoking cessation, regulation of alcohol intake, prevention of obesity, improvement of nutrition, promotion of physical activity are key factors for prevention of bed-ridden and extension of healthy life span. Although corrections of life-style are essential in childhood, adolescence, and the middle-aged and elderly periods, the methods and purpose are different in each life stage. The risks of emaciation and malnutrition are more important rather than that of obesity in the elderly aged 75 years or over. As for the influence of smoking in cardiovascular and respiratory diseases, smoking can be a trigger for arrhythmia, peripheral vascular constriction, and irritation of the respiratory tract in the elderly. Smoking cessation is necessary even among elderly people. It is also necessary to decrease the amount of alcohol intake, because the ability of metabolize alcohol is limited in the elderly. Physical activity in the elderly people is fundamental not only to maintain the ability of daily living, but also to improve metabolic function and to prevent depression. Vigorous intervention to increase physical activity such as exercise class is recommended, especially in the elderly.     

Acceptability of HIV self-testing among men and women in KwaZulu-Natal,South Africa

Successful implementation of Universal Test and Treat as a strategy to achieve the 90-90-90 target requires higher HIV testing rates. Currently, uptake of HIV testing is not optimal which has directed research initiatives towards identification of additional HIV testing methods. HIV self-testing (HIVST) has received growing attention as a complementary testing approach as it overcomes barriers that are commonly associated with current HIV testing methods. In sub-Saharan Africa, acceptability rates showed a gendered pattern of men benefitting more than women, with limited evidence to explain this difference. This study assessed whether men or women in KwaZulu-Natal displayed a higher acceptance of HIVST and also explored factors that influenced and motivated their acceptability. Participants were recruited through purposive sampling at two clinical research sites to participate and underwent qualitative assessments. The outcomes from focus group discussions coupled with findings from a scoping review informed the design and data collection instruments for in-depth interviews. A randomised cross-over study design exposed participants to HIV counselling and testing and HIVST, accompanied by before (baseline) and after in-depth interviews. HIVST was acceptable among most participants with acceptability higher in women. Men preferred HIVST due to convenience and efficiency, whilst women favoured HIVST due to its potential to provide autonomy and empowerment. Also, lack of HIV counselling and managing a positive HIV result as well as linkage to care were raised as deterrents of HIVST. As HIVST was acceptable by most participants, future research efforts should be directed towards evaluating the feasibility of its introduction into the public health sector.     

Attitudes to HIV voluntary counselling and testing among mineworkers in South Africa: will availability of antiretroviral therapy encourage testing?

We conducted a study to identify attitudes that influence uptake of HIV voluntary counselling and testing (VCT) amongst gold mine workers in South Africa; 105 healthy men were interviewed. The level of basic knowledge of HIV was high, but reported awareness of the extent of HIV infection in the workforce and perceived personal risk of HIV infection was low. Health issues were considered the most important indication for HIV testing and one-third had been tested. Fear of testing positive for HIV and the potential consequences, particularly stigmatization, disease and death, were the major identified barriers to VCT. Half of the participants felt workplace education programmes needed to be improved to promote VCT access. Twenty-six per cent became more favourably inclined towards HIV testing in response to information on improvements that have been made to the confidentiality and convenience of the company's VCT service. Only 14% then indicated that they would be more likely to access VCT if antiretroviral therapy became available. A vigorous community education programme is essential if the introduction of ART is to be effective in promoting uptake of VCT.     

Scaling up access to antiretroviral treatment in southern Africa: who will do the job?

Malawi, Mozambique, Swaziland, and South Africa have some of the highest HIV/AIDS burdens in the world. All four countries have ambitious plans for scaling-up antiretroviral treatment for the millions of HIV-positive people in the region. In January 2004, we visited these countries with the intention of directly observing the effect of AIDS, especially on health systems, to talk with policy makers and field workers about their concerns and perspectives regarding the epidemic, and to investigate the main issues related to scaling up antiretroviral treatment. We found that financial resources are not regarded as the main immediate constraint anymore, but that the lack of human resources for health is deplored as the single most serious obstacle for implementing the national treatment plans. Yet, none of the countries has developed an urgently required comprehensive human resource strategy. This may also need increased donor attention and resources.     

Who fails to complete tuberculosis treatment? Temporal trends and risk factors for treatment interruption in a community-based directly observed therapy programme in a rural district of South Africa.

SETTING: Hlabisa Tuberculosis Programme, Hlabisa, South Africa. OBJECTIVE: To determine trends in and risk factors for interruption of tuberculosis treatment. METHODS: Data were extracted from the control programme database starting in 1991. Temporal trends in treatment interruption are described; independent risk factors for treatment interruption were determined with a multiple logistic regression model, and Kaplan-Meier survival curves for treatment interruption were constructed for patients treated in 1994-1995. RESULTS: Overall 629 of 3,610 surviving patients (17%) failed to complete treatment; this proportion increased from 11% (n = 79) in 1991/1992 to 22% (n = 201) in 1996. Independent risk factors for treatment interruption were diagnosis between 1994-1996 compared with 1991-1993 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.6-2.4); human immunodeficiency virus (HIV) positivity compared with HIV negativity (OR 1.8, 95%CI 1.4-2.4); supervised by village clinic compared with community health worker (OR 1.9, 95%CI 1.4-2.6); and male versus female sex (OR 1.3, 95%CI 1.1-1.6). Few patients interrupted treatment during the first 2 weeks, and the treatment interruption rate thereafter was constant at 1% per 14 days. CONCLUSIONS: Frequency of treatment interruption from this programme has increased recently. The strongest risk factor was year of diagnosis, perhaps reflecting the impact of an increased caseload on programme performance. Ensuring adherence to therapy in communities with a high level of migration remains a challenge even within community-based directly observed therapy programmes.     

How are surgical theatres in rural Africa utilized? A review of five years of services at a district hospital in Ghana

Although the extent of the unmet need for surgeries is well-known, little is known about the surgery performed in district hospitals in sub-Saharan Africa. We review five years of utilization of theatre services at the Kintampo Hospital in rural Ghana. The source of data was the theatre logbook and other hospital records for the period 2005-2009. During this time, 1391 surgeries were performed in the theatre. This approximates a rate of 250/100,000 population. Fifty-two percent were performed in patients aged 18-35 years. The most frequently performed surgeries were: caesarean sections (46%); hernia repair (41%); and other laparotomies (10%). The major indications were cephalopelvic disproportion, right inguinal hernia and typhoid perforation, respectively. Typhoid perforation was the main indication for surgery in children aged less than 10 years. The potential for an expansion of the scope of services should be explored in order to improve access to essential surgery for this population.     

Do self‐assessments of health predict future mortality in rural South Africa? The case of KwaZulu‐Natal in the era of antiretroviral treatment

Objectives While self‐assessments of health (SAH) are widely employed in epidemiological studies, most of the evidence on the power of SAH to predict future mortality originates in the developed world. With the HIV pandemic affecting largely prime age individuals, the strong association between SAH and mortality derived from previous work might not be relevant for the younger at‐risk groups in countries with high HIV prevalence in the era of antiretroviral treatment. We investigate the power of SAH to predict mortality in a community with high HIV prevalence and antiretroviral treatment (ART) coverage using linked data from three sources: a longitudinal demographic surveillance, one of Africa’s largest, longitudinal, population‐based HIV surveillances, and a decentralised rural HIV treatment and care programme. Methods We used a Cox proportional hazards specification to examine whether SAH significantly predicts mortality hazard in a sample composed of 9217 adults aged 15–54, who were followed up for mortality for 8 years. Results Self‐assessments of health strongly predicted mortality (within 4 years of follow‐up), with a clear gradient of the adjusted hazard ratios (aHRs), relative to the baseline of ‘excellent’ self‐assessed health status and controlling for age, gender, marital status, the socio‐economic status (SES), variables education, employment, household expenditures and household assets, and HIV status and ART uptake: 1.40 (95% CI 0.99–1.96) for ‘very good’ self‐assessed health status (SAHS); 2.10 (95% CI 1.52–2.90) for ‘good’ SAHS; 3.12 (95% CI 2.18–4.45) for ‘fair’ SAHS; and 4.64 (95% CI 2.93–7.35) for ‘poor’ SAHS. While a similar association remained in the unadjusted analysis of long‐term mortality (within 4–8 years of follow‐up) the hazard ratios capturing SAH are jointly insignificant in predicting of mortality once HIV status, ART uptake and gender, age, marital status and SES were controlled for. HIV status and ART programme participation were large and highly significant predictors of long‐term mortality. Conclusions Our findings validate SAH as a variable that significantly predicts short‐term mortality in a community in sub‐Saharan Africa with high HIV prevalence, morbidity and mortality. When predicting long‐term mortality, however, it is much more important to know a person's HIV status and ART programme participation than SAH.     

Understanding women and men’s acceptability of current and new HIV prevention technologies in KwaZulu-Natal,South Africa

Despite significant advances to the HIV epidemic, prevention remains a challenge globally. Adolescent girls and young women in southern and Eastern Africa are still at high risk of acquiring HIV infection with limited prevention options. The expanding product pipeline of novel drugs and delivery approaches has highlighted the importance of acceptability and uptake of these anti-retroviral based products to realize their full prevention potential. Community engagement is now imperative to inform both product development and uptake; with research directed to understand what potential users are willing to use given the broader cultural-gender context in which HIV prevention product choices are made/negotiated.

We conducted ten gender specific discussion groups with 112 participants in three of the eight highest HIV prevalence districts in urban, peri-urban, and rural KwaZulu-Natal. The participants where purposively selected according to age, location and sex. The data was analysed thematically in terms of the key enablers and barriers of accepting three key HIV dosing strategies; the oral pill, the vaginal ring and the injectable among men and women.

The study found that women are willing to consider HIV prevention options that align with their current sexual and reproductive health routines, offers the longest duration of protection, and requires minimal/no partner involvement, in contrast most men were not supportive of their partners using of any form of PrEP, irrespective of dosing strategies and formulations as it raised questions of infidelity and side effects on men. The findings is indicative of the complexities of women’s product choices, which are often embedded in a system of personal preference on an intrapersonal level, but also of male dominance, gender norms and cultural contexts at an interpersonal level.

Understanding this intrapersonal-interpersonal interplay can enhance PrEP messaging and promotion; further highlighting the need to expand biomedical innovations for women initiated technologies.     

Hydroxychloroquine and chloroquine in COVID-19: should they be used as standard therapy?

Clinical Rheumatology - The pandemic of the new coronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has urged the nations to an unprecedented world-wide reaction,...     

How best to approach endocrine evaluation in patients with HIV in the era of combined antiretroviral therapy?

Endocrine and metabolic dysfunction has been documented throughout the history of clinical experience with HIV and AIDS. Opportunistic infections such as CMV and TB adrenalitis, tumours affecting endocrine organs, and cachexia and wasting can still be seen, particulary in severely immunocompromised individuals who may be noncompliant with, resistant to, or without access to effective antiretroviral therapy (ART). However, in those with good control of their HIV infection, the profile of endocrinopathy in HIV has largely changed with the advent of highly effective combination ART. The problems that we now more frequently see in people living for many years with low viral loads and good CD4 counts relate to side effects or interactions of therapy. These included adverse metabolic effects of antiretrovirals, most notably dyslipidaemia and lipodystrophy with protease inhibitors, drug–drug interactions, including marked CYP3A4 inhibition with protease inhibitors and autoimmune endocrinopathy as part of an immune reconstitution syndrome after initiation of antiretrovirals. In addition, chronic endocrine and metabolic disorders, including hypogonadism and osteoporosis, occur at higher levels than in the background population, associated with chronic illness, lower body weight and use of both prescribed and nonprescribed drugs.     

Delayed-type hypersensitivity skin test reactivity and survival in HIV-infected patients in Uganda: should anergy be a criterion to start antiretroviral therapy in low-income countries?

Access to antiretroviral (ARV) drugs is improving in sub-Saharan Africa but still constrained by several clinical and logistical obstacles. There is a need to develop affordable markers to guide initiation of treatment. We present a prospective cohort study of 779 patients participating in a TB prophylaxis trial. We performed separate analyses for anergic and nonanergic subjects. Prognostic factors for anergic and nonanergic subjects differed between groups. Individuals with anergy and constitutional symptoms were at the highest risk of death. Incident tuberculosis and CD4 < 200 cells/muL at enrollment were the strongest risk factors for death. HIV disease is associated with substantial morbidity and mortality in this population. The burden caused by tuberculosis is particularly high. Anergy is a strong and independent predictor of death. World Health Organization criteria to start ARV may be strengthened with the addition of DTH testing, an inexpensive and readily available tool in sub-Saharan Africa.     

VEGF and angiopoietins in diabetic glomerulopathy: How far for a new treatment?

Diabetic nephropathy (DN) is the major cause of end-stage renal disease in Western countries and its prevalence continues to increase (United States Renal Data System 2010, http://www.usrds.org/). Treatments currently utilised for DN provide only partial renoprotection, hence the need to identify new targets for therapeutic intervention. Metabolic and haemodynamic abnormalities have been implicated in the pathogenesis of DN, triggering the activation of intracellular signaling molecules that lead to the dysregulation of vascular growth factors and cytokines, such as vascular endothelial growth factor (VEGF) and angiopoietins, important players in the functional and structural regulation of the glomerular filtration barrier. This review focuses on the importance of VEGF-A and angiopoietins in kidney physiology and in the diabetic kidney, exploring their potential therapeutic role in the prevention and delay of diabetic glomerulopathy.     

Is there a rural/urban gap in the quality of HIV care for treatment-naïve HIV-positive individuals initiating antiretroviral therapy in British Columbia?

Rurally located people living with HIV (PLWH) face unique challenges associated with remoteness that may negatively affect their HIV care outcomes. The Programmatic Compliance Score (PCS) has been used previously as a quality of care metric, and is predictive of mortality for treatment-naïve individuals initiating combination antiretroviral therapy (cART). This study looked at whether the rurality of PLWH impacted their PCS. PCS was calculated for PLWH (≥19 years old) initiating cART in British Columbia between 2000 and 2013. Rurality was determined at the time of cART initiation using two methodologies: (1) a categorical postal code method; and (2) the General Practice Rurality Index (GPRI), a score representing an individual’s degree of rurality. Ordinal logistic regression modeling was used to assess the relationship between rurality and PCS. Among 4616 PLWH with an evaluable PCS, 176 were classified as rural and 3512 as urban (928 had an unknown postal code). After adjusting for age, sex, hepatitis C status, Indigenous ancestry, and year of cART initiation, categorical rurality was not associated with a worse PCS (adjusted odds ratio (AOR) 1.04; 95% CI: 0.77–1.39). However, an increasing degree of rurality was associated with a worse PCS (AOR (per 10 increase in GPRI) 1.13; 95% CI: 1.06–1.20). Given that a poor PCS has been shown to be predictive of all-cause mortality for individuals initiating cART, strategies to improve access to HIV care for rural individuals should be evaluated.