RESUMEN

Objective: We evaluated growth metrics in HIV unexposed African breastfed infants in the first 18 months of life in association with in-utero exposure to Tenofovir Diphosphate Fumarate (TDF) containing pre-exposure prophylaxis (PrEP). Design: We conducted a secondary data analysis of a TDF-PrEP randomized control trial (CAP016 RCT). Pregnant women without HIV were randomized to initiating TDF-PrEP in pregnancy (Immediate-PrEP-IP) or deferred initiation of TDF-PrEP at cessation of breastfeeding (Deferred-PrEP-DP). Methods: Infant weight (W), length (L), and head circumference (HC) were measured at birth and 6, 26, 50, and 74 weeks of age. Stored dried blood spot samples from pregnant women randomized to the IP arm were used to measure tenofovir-diphosphate (TFV-DP) levels. Age-stratified mean weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), and head circumference-for-age (HCAZ) Z-scores were compared between infants exposed to varying TFV-DP concentrations and infants in the DP arm. Results: A total of 455 mother-infant pairs were included in the secondary analysis, 228 in the IP arm and 227 in the DP arm. WAZ, LAZ, WLZ, and HCAZ scores were comparable between infants in the Deferred-PrEP arm and Immediate-PrEP arm. In a mixed-effects linear regression model adjusting for maternal age, body mass index, socioeconomic and newborn characteristics, in-utero exposure to varying TFV-DP levels was not associated with WAZ (ß = -0.52), LAZ (ß = -0.46), WLZ (ß = -0.43) and HCAZ (ß = -0.11) scores over time. Conclusion: There was no evidence of an association between growth metrics in the first 18 months of life and in-utero exposure to TFV-DP among breastfed HIV unexposed infants.

RESUMEN

Background: Prevention of HIV vertical transmission programmes (VTPs) in South Africa has decreased paediatric HIV. These programmes require integration in referral hospitals. Objectives: To determine knowledge of and attitudes to the national VTP guidelines in staff from Obstetric and Paediatric disciplines at two referral hospitals. Method: Using a cross-sectional design, a questionnaire to assess knowledge of the guidelines and attitudes (awareness, ease-of-use and non-silo practice, measuring integrated practice) was developed and validated locally. Using standard statistical analyses, data from these questionnaires were used to draw comparisons and determine factors associated with knowledge and attitudes. Results: Of the 249 participants, 138 (55.4%) were in obstetrics, 125 (50.2%) were nurses, and 168 (67.5%) self-identified as junior staff. Knowledge scores were good, median score (Q1-Q3) was 91.7% (79.1-95.8), and higher in those who had discipline-specific training (P = 0.003). Junior staff (P = 0.002) had higher knowledge levels than senior staff. Most (80%) found the guidelines easy to use and had good awareness, which correlated with knowledge and training. Gaps included understanding of antenatal testing of HIV-negative women and timelines for neonatal HIV testing. Staff scored poorly on integrated practice; the median score (Q1-Q3) was 50% (33.3-58.3), which was inversely correlated with knowledge (r= -0.146, n = 249, P = 0.022). Conclusion: Staff in referral hospitals appear to be practising within silos when implementing VTPs, and this may result in failures to ensure integrated practice. Regularised interdisciplinary and interprofessional training may be important to ensure the integrated implementation of VTPs in referral hospitals.

RESUMEN

Asthma is the most common chronic respiratory disease among school-going adolescents worldwide. However, the burden of severe asthma is highest in Sub-Saharan Africa. This study aimed to explore teachers' perceptions of asthma care across six African countries. We conducted focus group discussions (FGDs) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. FGDs were conducted in Kumasi(Ghana), Blantyre (Malawi), Lagos (Nigeria), Durban (South Africa), Kampala (Uganda), and Harare (Zimbabwe) between 01 November 2020 and 30 June 2021. We identified two key themes related to asthma care; barriers to asthma care and suggestions to improve the care of adolescents with asthma. Barriers reported by teachers included a lack of knowledge and skills among themselves, adolescents, and caregivers. In addition, some traditional beliefs of teachers on asthma exacerbated challenges with asthma care in schools. Regarding suggestions, most teachers identified a need for all-inclusive asthma training programmes for teachers, adolescents and caregivers, focusing on acute episodes and mitigating triggers. Utilising teachers with personal experiences with asthma to advocate and support these initiatives was suggested. Further suggestions included the need for annual screening to enable early identification of adolescents with asthma and clarify restrictions on teachers administering asthma medications. Teachers across African schools identify multiple barriers to asthma care. Structured school education programs and annual asthma screening are key to addressing some barriers to care.

Asunto(s)

RESUMEN

OBJECTIVES: This study identifies barriers and provides recommendations to improve asthma care in children across sub-Saharan Africa, where qualitative data is lacking despite high rates. DESIGN: One of the aims of our National Institute for Health Research global health research group 'Achieving Control of Asthma in Children in Africa' was to use qualitative thematic analysis of transcribed audio recordings from focus group discussions (FGDs) to describe barriers to achieving good asthma control. SETTING: Schools in Blantyre (Malawi), Lagos (Nigeria), Durban (South Africa), Kampala (Uganda) and Harare (Zimbabwe). PARTICIPANTS: Children (n=136), 12-14 years with either asthma symptoms or a diagnosis and their caregivers participated in 39 FGDs. All were recruited using asthma control questions from the Global Asthma Network survey. RESULTS: There were four key themes identified: (1) Poor understanding, (2) difficulties experienced with being diagnosed, (3) challenges with caring for children experiencing an acute asthma episode and (4) suboptimal uptake and use of prescribed medicines. An inadequate understanding of environmental triggers, a hesitancy in using metred dose inhalers and a preference for oral and alternate medications were identified as barriers. In addition, limited access to healthcare with delays in diagnosis and an inability to cope with expected lifestyle changes was reported. Based on these findings, we recommend tailored education to promote access to and acceptance of metred dose inhalers, including advocating for access to a single therapeutic, preventative and treatment option. Furthermore, healthcare systems should have simpler diagnostic pathways and easier emergency access for asthma. CONCLUSIONS: In a continent with rapidly increasing levels of poorly controlled asthma, we identified multiple barriers to achieving good asthma control along the trajectory of care. Exploration of these barriers reveals several generalisable recommendations that should modify asthma care plans and potentially transform asthma care in Africa. TRIAL REGISTRATION NUMBER: 269211.

Asunto(s)

RESUMEN

BACKGROUND: The safety of tenofovir disoproxil fumarate and emtricitabine as pre-exposure prophylaxis (PrEP) in pregnant women not living with HIV is uncertain. We aimed to compare pregnancy and neonatal outcomes in women exposed and not exposed to PrEP during pregnancy. METHODS: In this single-site, open-label, randomised, non-inferiority trial in Durban, South Africa, we evaluated pregnancy and neonatal outcomes in pregnant women aged 18 years or older, not living with HIV, and at 14-28 weeks' gestation at the time of enrolment. Eligible participants were randomly assigned (1:1) using a computer-generated permuted block (block size of ten) randomisation list to immediate initiation or deferred initiation of PrEP until breastfeeding cessation. Participants in the immediate PrEP group received a monthly supply of once daily oral tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg. Participants in the deferred PrEP group received standard of care for HIV prevention. The primary outcomes were the occurrence of preterm live birth (<37 weeks gestational age) and very preterm birth (<34 weeks gestational age) determined by menstrual dating, low birthweight (<2500 g), very low birthweight (<1500 g), stillbirth (≥20 weeks gestational age), and small for gestational age (birthweight less than the tenth percentile). Post-natal safety outcomes will be reported elsewhere. We used binomial regression models to estimate risk differences and two-sided 90% CIs. Immediate PrEP was non-inferior to deferred PrEP if the upper bound of the 90% CI of the risk difference was less than the upper predefined non-inferiority margin for preterm birth (7·5%), very preterm birth (2·6%), low birthweight (5·5%), very low birthweight (1·2%), stillbirth (1·0%), and small for gestational age (3·7%). All outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT3227731. FINDINGS: Between Sept 25, 2017, and Dec 6, 2019, we screened 693 women, of whom 540 were randomly assigned to immediate PrEP (n=271) or deferred PrEP (n=269). The median gestational age was 19 weeks (IQR 15-23 for immediate PrEP and 16-23 for deferred PrEP). The risk difference between the immediate PrEP group and the deferred PrEP group for preterm birth was -4·7% (90% CI -10·7 to 1·2; immediate PrEP was non-inferior), for very preterm birth was 0·6% (-3·4 to 4·6; upper limit exceeded the non-inferiority margin), for low birthweight was 2·5% (-1·6 to 6·6; upper limit exceeded the non-inferiority margin), for very low birthweight was 0% (-1·4 to 1·4; upper limit exceeded the non-inferiority margin), for stillbirth was 1·2% (-1·5 to 3·8; upper limit exceeded the non-inferiority margin), and for small for gestational age was 0·9% (-1·2 to 2·9; immediate PrEP was non-inferior). INTERPRETATION: In our study, PrEP was not associated with preterm birth or small for gestational age infants. Our data support the use of tenofovir disoproxil fumarate and emtricitabine in pregnancy and our reassuring findings can be used to allay safety concerns among pregnant women. FUNDING: South African Medical Research Council and Gilead Sciences.

Asunto(s)

RESUMEN

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been infrequently described in Africa. OBJECTIVE: To describe the clinical characteristics, outcomes and associations of severe disease in children hospitalized with MIS-C in KwaZulu-Natal. METHODS: Retrospective multicenter study of children (0-13 years) who met the Centers for Disease Control and Prevention criteria for MIS-C. Children with shock were compared with children without shock to determine the characteristics of severe MIS-C. RESULTS: Twenty-nine children with MIS-C were identified, the mean age was 55 (SD ±45) months, 25 (86%) were Black-African, and 8 (28%) had pre-existing comorbidities. The predominant presenting symptoms included fever 29 (100%), gastrointestinal symptoms 25 (83%), skin rash 19 (65%), and shock 17 (59%). Children with shock had significantly increased CRP (P = 0.01), ferritin (P < 0.001), troponin-T (P = 0.02), B-type natriuretic peptide (BNP) (P = 0.01), and lower platelets (P = 0.01). Acute kidney injury (P = 0.01), cardiac involvement (P = 0.02), and altered levels of consciousness (P = 0.03) were more common in children with shock. The median length of hospital stay was 11 (IQR 7-19) days, with a mortality of 20.6%. Children who did not survive had significantly higher ferritin levels 1593 (IQR 1069-1650) ng/mL versus 540 (IQR 181-1156) ng/mL; P = 0.03) and significantly more required mechanical ventilation (OR 18; confidence interval 1.7-191.5; P = 0.005). CONCLUSIONS: Hospitalized children with MIS-C in KwaZulu-Natal had more aggressive disease and higher mortality than children in better-resourced settings. Markedly elevated biomarkers and critical organ involvement were associated with severe disease. Risk factors for poor outcomes include higher ferritin levels and the need for mechanical ventilation.

Asunto(s)

RESUMEN

Background: The coronavirus disease 2019 (COVID-19) pandemic poses challenges to paediatric and adolescent HIV treatment programme. Modelling exercises raised concerns over potential impact of disruptions. Objectives: To describe the impact of the COVID-19 pandemic on viral load (VL) testing among infants, children and adolescents on antiretroviral treatment (ART) in Durban, South Africa. Method: Routinely collected, aggregated data of monthly VL counts done on all those less than 19 years old from January 2018 to January 2022 was analysed. An interrupted time series analysis using a Prais-Winsten linear regression model, including terms for lockdowns and excess mortality determined VL trends. Results: The unadjusted mean VL was 2166 (confidence interval [CI]: 252.2) and 2016 (CI: 241.9), P = 0.039, and percentage VL suppression rates (72.9%, CI: 2.4% vs 73.6%, CI: 1.8%) across COVID and pre-COVID periods, showing no significant difference, P = 0.262. In the interrupted time series analysis, modelled monthly VL counts did not differ significantly by lockdown level (e.g., level 5 lockdown: -210.5 VLs, 95% CI: -483.0 to +62.1, P = 0.138) or excess mortality (-0.1, 95% CI: -6.3 to 6.1, P = 0.969). A significant downward trend in VL testing over time, including during the pre-COVID-19 period (-6.6 VL per month, 95% CI: -10.4 to -2.7, P = 0.002), was identified. Conclusion: Viral load suppression for children and adolescents were not negatively affected by COVID-19. A trend of decrease in VL testing predated COVID-19. What this study adds: Evidence presented that HIV VL testing and suppression rates in children and adolescents in a high burden setting were sustained through the COVID pandemic.

RESUMEN

BACKGROUND: Neglected sexual side effects (NSSE) are a group of less common sexual side effects that may present after Prostate Cancer (PCa) treatment. There is currently no valid and reliable tool to identify these side effects. A modified Delphi study is an effective way of developing the content of such a screening tool. METHODS: A modified Delphi study was used to obtain consensus from a multi-disciplinary group of experts over 3 rounds during a 12 week period. Ten statements were presented containing 8 closed-ended statements on individual NSSEs, and 2 open-ended statements on psychosocial impact related to NSSE. Consensus was defined as a 75% strongly agree achievement on each statement, or the final statement evolution at the end of 3 rounds. Statement support in each round was determined by mean, standard deviation and range, after a numerical value was allocated to each statement during specific rounds. All three rounds were structured and suggestions and additions were incorporated in the statement evolution of the three rounds. RESULTS: Thirty-five participants were invited, and 27 completed Round 1 (RD 1), 23 participants completed RD2, and 20 participants completed RD3. All 3 rounds were completed in 12 weeks. Statement 1 (sexual arousal incontinence), statement 2 (climacturia) and statement 3 (orgasm intensity) reached consensus after RD2, and statement 9 (sexual dysfunction impact) and statement 10 (experiences) were removed after RD3. Statement 4 (orgasmic pain), statement 5 (anejaculation), statement 6 (sensory disturbances), statement 7 (penile length shortening) and statement 8 (penile curvature) were finalised after the conclusion of RD3. Statements 1-3 were the most stable statements with the most support and least amount of disagreement. Statements 4-8 were less stable, but support for them improved over the 3 rounds. Statements 9-10 both had good stability, but the support indicated that they needed to be removed from the set of statements. Statement 5 had the poorest range due to an outlier opinion. CONCLUSIONS: Consensus was reached on the items making up the NSSE screening tool. Health care practitioners will be able to use this tool to identify the evidence of NSSE after PCa treatment. Further testing will be undertaken to confirm the reliability and validly of the tool.

Asunto(s)

RESUMEN

BACKGROUND: Newly qualified medical practitioners in South Africa (SA) are part of the frontline health care workers who face Africa's most severe coronavirus disease 2019 (COVID-19) pandemic. The experiences of interns during the pandemic reflect SA's preparedness to respond in a crisis and inform strategies that could be adopted to balance training and service in resource-challenged contexts. AIM: To explore the strengths, weaknesses, opportunities and threats posed during the first wave of the COVID-19 pandemic as reflected on by interns within the clinical training platforms in SA. SETTING: Public hospitals in KwaZulu-Natal. METHODS: An online questionnaire consisting of eight open-ended questions based on the SWOT framework related to personal and professional perspectives to clinical training during the COVID-19 pandemic was developed using SurveyMonkey. All data were collected remotely via social media platforms. Data were thematically analysed. RESULTS: Forty-six interns reflected on personal and systemic challenges as the major threats and weaknesses in intern training during the COVID-19 pandemic. Extrapolating on strengths and opportunities, there were three overarching learnings interns reflected on. These related to being a medical professional, communities of practice and the development and enhancement of clinical and non-clinical competencies. Existing challenges in the environment exacerbated the threats posed by COVID-19 and innovative strategies related to improving support, feedback, broadening the intern curriculum and online training. CONCLUSION: Although the clinical environment where interns learn and work is often stressful and overpowered by high service burdens, there are unique opportunities to enhance self-directed learning and graduate competencies, even in the midst of the COVID-19 pandemic.

Asunto(s)

RESUMEN

PURPOSE: Self-directed learning (SDL) has been advocated for effective training of final-year health professions students. COVID-19 challenges conventional teaching, learning, and assessment in the clinical environment. This study aimed to identify and explore enablers and barriers to SDL among final-year health professions students training during the COVID-19 pandemic. METHODS: Adopting the SWOT (strengths, weaknesses, opportunities and threats) framework, this study explored the clinical learning and training experiences of final-year health professions students during the pandemic. A survey was conducted via online platforms. Data from 155 respondents were thematically analyzed. RESULTS: Personal attributes such as reflection, self-determination, motivation, resilience, and positive learning behaviors and skills were identified as SDL enablers. Collaborative learning networks and online learning platforms facilitate learning needs and goals. Fear and anxiety, untrusted learning sites, uncertainty about graduation, financial issues and challenges in the learning environments were the major themes related to barriers to SDL. CONCLUSION: The importance of SDL as a skill for uncertain times warrants further investigation in the training of future healthcare professionals. Inclusive planning and engagement with final-year health professions students to address identified stressors, as well as the creation of shared platforms where students are part of the decision-making processes for clinical learning and training are recommended. Responsive curricula that optimize unpredictable disruptions in clinical training are needed to equip students to diagnose their own learning needs and implement appropriate learning strategies.

RESUMEN

Background: Health provision in South Africa requires a focus on primary health care within the public health system. Medical practitioners continue to migrate from the public health service. Given the need for human resources in primary health care, this study was conducted to explore the perceptions and experiences of newly-qualified medical practitioners (interns) about pursuing a career in primary health care in the public health sector. Methods: This exploratory, qualitative study specifically explored the factors related to interns' perceptions about careers in primary health and child health care in the public health service in five hospitals in KwaZulu-Natal (KZN). Data was collected through focus group discussions with a purposive sample of intern participants, who were chosen for having had the necessary experience to decide on long-term careers. The data were coded, categorised and themed using a combination of manual and computer-assisted methods. (NVivo 11 software). Results: Themes both external and specific to the intern-supervisor relationship were identified that influences intern career intentions. A high disease burden in resource-constrained institutions that are perceived to be poorly managed and sub-optimal intern-supervisor relationships lead to inadequate participation within 'communities of practice' during internship. Interns viewed careers related to primary health care negatively, preferring to specialise in other fields. Discussion: Multiple challenges are identified when participating in caring for adults and children in KZN's public health service. This coupled with a perceived inadequate supervisor support favour interns to see medical specialisation as a more feasible career option rather than primary health care. Experiences during internship possibly influence future career intentions that are discordant with SA's national health priorities. Improving the intern working environment may be a way forward to stimulate interns' interests in careers congruent with SA's health needs, specifically careers in primary health care.

Asunto(s)

RESUMEN

Background: Newly qualified medical practitioners in South Africa (SA) are part of the frontline health care workers who face Africa's most severe coronavirus disease 2019 (COVID-19) pandemic. The experiences of interns during the pandemic reflect SA's preparedness to respond in a crisis and inform strategies that could be adopted to balance training and service in resource-challenged contexts. Aim: To explore the strengths, weaknesses, opportunities and threats posed during the first wave of the COVID-19 pandemic as reflected on by interns within the clinical training platforms in SA. Setting: Public hospitals in KwaZulu-Natal. Methods: An online questionnaire consisting of eight open-ended questions based on the SWOT framework related to personal and professional perspectives to clinical training during the COVID-19 pandemic was developed using SurveyMonkey. All data were collected remotely via social media platforms. Data were thematically analyzed. Results: Forty-six interns reflected on personal and systemic challenges as the major threats and weaknesses in intern training during the COVID-19 pandemic. Extrapolating on strengths and opportunities, there were three overarching learnings interns reflected on. These related to being a medical professional, communities of practice and the development and enhancement of clinical and non-clinical competencies. Existing challenges in the environment exacerbated the threats posed by COVID-19 and innovative strategies related to improving support, feedback, broadening the intern curriculum and online training. Conclusion: Although the clinical environment where interns learn and work is often stressful and overpowered by high service burdens, there are unique opportunities to enhance self-directed learning and graduate competencies, even in the midst of the COVID-19 pandemic.

Asunto(s)

RESUMEN

BACKGROUND: Exclusive breastfeeding for 6 months and breastfeeding with complementary feeds until 12 months for HIV exposed and uninfected (HEU) infants or 24 months for HIV unexposed (HU) infants is the current World Health Organisation (WHO) recommendation for low and middle income countries (LMICs) to improve clinical outcomes and growth trajectories in infants. In a post-hoc evaluation of HEU and HU cohorts, we examine growth patterns and clinical outcomes in the first 9 months of infancy in association with breastfeeding duration. METHODS: Two cohorts of infants, HEU and HU from a low-socioeconomic township in South Africa, were evaluated from birth until 9 months of age. Clinical, anthropometric and infant feeding data were analysed. Standard descriptive statistics and regression analysis were performed to determine the effect of HIV exposure and breastfeeding duration on growth and clinical outcomes. RESULTS: Included in this secondary analysis were 123 HEU and 157 HU infants breastfed for a median of 26 and 14 weeks respectively. Median WLZ score was significantly (p < 0.001) lower in HEU than HU infants at 3, 6 and 9 months (- 0.19 vs 2.09; - 0.81 vs 0.28; 0.05 vs 0.97 respectively). The median LAZ score was significantly lower among HU infants at 3 and 6 months (- 1.63 vs 0.91, p < 0.001; - 0.37 vs 0.51, p < 0.01) and a significantly higher proportion of HU was classified as stunted (LAZ < -2SD) at 3 and 6 months (3.9% vs 44.9%, p < 0.001; 4.8% vs 20.9%, p < 0.001 respectively) independent of breastfeeding duration. A higher proportion of HEU infants experienced one or more episodes of skin rash (44.5% vs 12.8%) and upper respiratory tract infection (URTI) (30.1% vs 10.9%) (p < 0.0001). In a multivariable analysis, the odds of occurrence of wasting, skin rash, URTI or any clinical adverse event in HEU infants were 2.86, 7.06, 3.01 and 8.89 times higher than HU infants after adjusting for breastfeeding duration. CONCLUSION: Our study has generated additional evidence that HEU infants are at substantial risk of infectious morbidity and decreased growth trajectories however we have further demonstrated that these adverse outcomes were independent of breastfeeding duration.

Asunto(s)

RESUMEN

BACKGROUND: With increasing intention to treat HIV as early as possible, evidence to confirm the safety and therapeutic drug concentrations of a nevirapine-based antiretroviral regimen in the early neonatal period is needed. This study aims to establish dosing of nevirapine for very early treatment of HIV-exposed neonates at high risk of HIV acquisition. METHODS: IMPAACT P1115 is a multinational phase 1/2 proof-of-concept study in which presumptive treatment for in-utero HIV infection is initiated within 48 h of birth in HIV-exposed neonates at high risk of HIV acquisition. Participants were neonates who were at least 34 weeks gestational age at birth and enrolled within 48 h of birth, born to women with presumed or confirmed HIV infection who had not received antiretrovirals during this pregnancy. The regimen consisted of two nucleoside reverse transcriptase inhibitors plus nevirapine dosed at 6 mg/kg twice daily for term neonates (≥37 weeks gestational age) or 4 mg/kg twice daily for 1 week and 6 mg/kg twice daily thereafter for preterm neonates (34 to <37 weeks gestational age). Here, we report the secondary outcomes of the study: nevirapine exposures in study weeks 1 and 2 and treatment-associated grade 3 or 4 adverse events at least possibly related to study treatment up to study week 4. A population pharmacokinetic model to assess nevirapine exposure was developed from dried blood spot and plasma nevirapine concentrations at study weeks 1 and 2. Nevirapine exposure was assessed in all patients with available blood samples and safety was assessed in all participants. This trial is registered at ClinicalTrials.gov (NCT02140255). FINDINGS: Between Jan 23, 2015, and Sept 4, 2017, 438 neonates were enrolled and included in analyses; 36 had in-utero HIV infection and 389 (89%) were born at term. Neonates without confirmed in-utero HIV infection received nevirapine for a median of 13 days (IQR 7-14). Measured dried blood spot nevirapine concentrations were higher than the minimum HIV treatment target (3 µg/mL) in 314 (90%, 95% CI 86-93) of 349 neonates at week 1 and 174 (87%, 81-91) of 201 at week 2. In Monte-Carlo simulations, week 1 nevirapine concentrations exceeded 3 µg/mL in 80% of term neonates and 82% of preterm neonates. DAIDS grade 3 or 4 adverse events at least possibly related to antiretrovirals occurred in 30 (7%, 95% CI 5-10) of 438 infants but did not lead to nevirapine cessation in any neonates; neutropenia (25 [6%] neonates) and anaemia (six [1%]) were most common. INTERPRETATION: Nevirapine at the dose studied was confirmed to be safe and provides therapeutic exposure concentrations. These data support nevirapine as a component of presumptive HIV treatment in high-risk neonates. FUNDING: National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.

Asunto(s)

RESUMEN

BACKGROUND: South African (SA) paediatric interns (recently qualified medical graduates) work in a high disease burdened and resource deficient environment for two years, prior to independent practice. Perceptions of this learning environment (LE) influences their approaches to training as well as the outcomes of this period of development. Obstacles to creating a supportive LE and supervisor interaction affects the quality of this training. Measuring perceptions of the LE with validated instruments can help inform improvements in learning during this crucial period of medical education. METHODS: The aims of this study was to determine the psychometric qualities of the Postgraduate Hospital Educational Environment Measure (PHEEM) amongst paediatric interns across four hospital complexes in South Africa and to measure the LE as perceived by both interns and their supervisors. Construct validity was tested using factor analysis and internal consistency was measured with Cronbach's alpha. RESULTS: A total of 209 interns and 60 supervisors (69% intern response rate) responded to the questionnaire. The PHEEM was found to be very reliable with an overall Cronbach's alpha of 0.943 and 0.874 for intern and supervisors respectively. Factor analysis using a 3-factor solution accounted for 42% of the variance with the teaching subscale having the best fit compared with the other sub-scales of the original tool. Most interns perceived the learning environment as being more positive than negative however, their perceptions differed significantly from that of their supervisors. Poor infrastructural support from institutions, excessive workloads and inadequate supervision were factors preventing optimal training of paediatric interns. CONCLUSIONS: The SA version of the PHEEM tool used was found to be a reliable and valid instrument for use in interns amongst high disease burdened contexts. Various obstacles to creating an ideal learning environment for paediatric interns were identified to be in need of urgent review. Key differences in perceptions of an ideal learning environment between interns and their supervisors need to be fully explored as these may result in sub-optimal supervision and mentoring.

Asunto(s)

RESUMEN

BACKGROUND: While the impact of HAART on growth in children is well established, the influence of prior nutritional status on the response to HAART is not well known. METHODS: A retrospective study was conducted on 120 children in South Africa. Patients were divided into 3 groups (normal, moderately underweight, and severely underweight) based on weight-for-age z-scores (WAZ). Age, weight, height, CD4 cell percentage, and viral load were recorded at initiation of HAART and after 24 months of therapy. Data were analyzed using t-tests, chi tests, and one-way ANOVA. RESULTS: At baseline, 58% of children were normal weight, 18% moderately underweight, and 23% severely underweight. After 24 months of HAART, WAZ improved significantly in moderately and severely underweight patient groups compared with the normal group. Height-for-age z-scores (HAZ) increased in all 3 groups with severely underweight children gaining more height than normal weight counterparts. Weight-for-height z-scores (WHZ) normalized in the severely underweight group. Mean CD4 cell percentages increased significantly in all 3 groups while viral loads decreased significantly in all groups with no differences among the groups at the end of 24 months of therapy. Of the entire cohort, 75% achieved undetectable HIV RNA viral loads. CONCLUSIONS: Underlying malnutrition does not adversely affect growth, immunologic or virologic response to HAART in HIV-infected children. Underweight children exhibit an equally robust response to treatment as their well-nourished peers.

Asunto(s)

RESUMEN

It is estimated that almost 300,000 children in South Africa have human immunodeficiency virus (HIV) infection. The disease is responsible for reversing decreases in child mortality. Few data exist evaluating the outcomes of the prevention of mother-to-child transmission of HIV (PMTCT) program, although PMTCT coverage appears to be low. Hospitals are still witnessing large numbers of admissions of HIV-infected children. Postnatal transmission of HIV is high, reflecting poor education of and support for women in their infant feeding choices. Too few infants and children are entering care through early diagnosis, which should be widely available. Cotrimoxazole prophylaxis coverage is inadequate, contributing to high morbidity and mortality in infants. The number of children receiving antiretroviral therapy (ART) is increasing steadily. However, significant inequalities in access to ART exist between and within provinces. Challenges for pediatric ART include a lack of sufficiently trained health care personnel and inadequate facilities, as well as the complexity of drug regimens and formulations. The compartmentalization of the ART rollout program hinders PMTCT and makes it difficult for children to be identified and referred into appropriate services. This article delineates the challenges to pediatric HIV care in South Africa and provides some practical recommendations to improve it.

Asunto(s)

RESUMEN

BACKGROUND: Zinc deficiency is associated with impaired immune function and an increased risk of infection. Supplementation can decrease the incidence of diarrhoea and pneumonia in children in resource-poor countries. However, in children with HIV-1 infection, the safety of zinc supplementation is uncertain. We aimed to assess the role of zinc in HIV-1 replication before mass zinc supplementation is recommended in regions of high HIV-1 prevalence. METHODS: We did a randomised double-blind placebo-controlled equivalence trial of zinc supplementation at Grey's Hospital in Pietermaritzburg, South Africa. 96 children with HIV-1 infection were randomly assigned to receive 10 mg of elemental zinc as sulphate or placebo daily for 6 months. Baseline measurements of plasma HIV-1 viral load and the percentage of CD4+ T lymphocytes were established at two study visits before randomisation, and measurements were repeated 3, 6, and 9 months after the start of supplementation. The primary outcome measure was plasma HIV-1 viral load. Analysis was per protocol. FINDINGS: The mean log(10) HIV-1 viral load was 5.4 (SD 0.61) for the placebo group and 5.4 (SD 0.66) for the zinc-supplemented group 6 months after supplementation began (difference 0.0002, 95% CI -0.27 to 0.27). 3 months after supplementation ended, the corresponding values were 5.5 (SD 0.77) and 5.4 (SD 0.61), a difference of 0.05 (-0.24 to 0.35). The mean percentage of CD4+ T lymphocytes and median haemoglobin concentrations were also similar between the two groups after zinc supplementation. Two deaths occurred in the zinc supplementation group and seven in the placebo group (p=0.1). Children given zinc supplementation were less likely to get watery diarrhoea than those given placebo. Watery diarrhoea was diagnosed at 30 (7.4%) of 407 clinic visits in the zinc-supplemented group versus 65 (14.5%) of 447 visits in the placebo group (p=0.001). INTERPRETATION: Zinc supplementation of HIV-1-infected children does not result in an increase in plasma HIV-1 viral load and could reduce morbidity caused by diarrhoea. RELEVANCE TO PRACTICE: Programmes to enhance zinc intake in deficient populations with a high prevalence of HIV-1 infection can be implemented without concern for adverse effects on HIV-1 replication. In view of the reductions in diarrhoea and pneumonia morbidity, zinc supplementation should be used as adjunct therapy for children with HIV-1 infection.

Asunto(s)