Scielo RSS <![CDATA[Southern African Journal of HIV Medicine]]> vol. 18 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>The neuromyelitis optica presentation and the aquaporin-4 antibody in HIV-seropositive and seronegative patients in KwaZulu-Natal, South Africa</b>]]> BACKGROUND: The association of the anti-aquaporin-4 (AQP-4) water channel antibody with neuromyelitis optica (NMO) syndrome has been described from various parts of the world. There has been no large study describing this association from southern Africa, an HIV endemic area. HIV patients often present with visual disturbance or features of a myelopathy but seldom both either simultaneously or consecutively. We report our experience of NMO in the era of AQP-4 testing in HIV-positive and HIV-negative patients seen in KwaZulu-Natal, South Africa. METHODS: A retrospective chart review was undertaken of NMO cases seen from January 2005 to April 2016 in two neurology units serving a population of 7.1 million adults. The clinical, radiological and relevant laboratory data were extracted from the files and analysed. RESULTS: There were 12 HIV-positive patients (mean age 33 years), 9 (75%) were women and all 12 were black patients. Of the 17 HIV-negative patients (mean age 32 years), 15 (88%) were women and 10 (59%) were black people. The clinical features in the two groups ranged from isolated optic neuritis, isolated longitudinally extensive myelitis or combinations. Recurrent attacks were noted in six HIV-positive patients and six HIV-negative patients. The AQP-4 antibody was positive in 4/10 (40%) HIV-positive patients and 11/13 (85%) HIV-negative patients. The radiological changes ranged from longitudinal hyperintense spinal cord lesions and long segment enhancing lesions of the optic nerves. Three patients, all HIV-positive, had tumefactive lesions with incomplete ring enhancement. CONCLUSION: This study confirms the presence of AQP-4-positive NMO in southern Africa in both HIV-positive and HIV-negative patients. The simultaneous or consecutive occurrence of optic neuritis and myelitis in an HIV-positive patient should alert the clinician to test for the AQP-4 antibody. It is important to recognise this clinical syndrome as specific therapy is available. We further postulate that HIV itself may act as a trigger for an autoimmune process. <![CDATA[<b>Attitude shifts and knowledge gains: Evaluating men who have sex with men sensitisation training for healthcare workers in the Western Cape, South Africa</b>]]> BACKGROUND: Men who have sex with men (MSM) in South Africa experience discrimination from healthcare workers (HCWs), impeding health service access. OBJECTIVES: To evaluate the outcomes of an MSM sensitisation training programme for HCWs implemented in the Western Cape province (South Africa). METHODS: A training programme was developed to equip HCWs with the knowledge, awareness and skills required to provide non-discriminatory, non-judgemental and appropriate services to MSM. Overall, 592 HCWs were trained between February 2010 and May 2012. Trainees completed self-administered pre- and post-training questionnaires assessing changes in knowledge. Two-sample t-tests for proportion were used to assess changes in specific answers and the Wilcoxon rank-sum test for overall knowledge scores. Qualitative data came from anonymous post-training evaluation forms completed by all trainees, in combination with four focus group discussions (n = 28) conducted six months after their training. RESULTS: Fourteen per cent of trainees had received previous training to counsel clients around penile-anal intercourse, and 16% had previously received training around sexual health issues affecting MSM. There was a statistically significant improvement in overall knowledge scores (80% - 87%, p < 0.0001), specifically around penile-anal intercourse, substance use and depression after the training. Reductions in negative attitudes towards MSM and increased ability for HCWs to provide non-discriminatory care were reported as a result of the training. CONCLUSION: MSM sensitisation training for HCWs is an effective intervention to increase awareness on issues pertaining to MSM and how to engage around them, reduce discriminatory attitudes and enable the provision of non-judgemental and appropriate services by HCWs. <![CDATA[<b>Patients' recommendations for a patient-centred public antiretroviral therapy programme in eThekwini, KwaZulu-Natal</b>]]> BACKGROUND: The South African antiretroviral therapy (ART) programme, which is in its second decade of existence, includes many successes and challenges. This study provides patients' recommendations to address the challenges they currently experience at four antiretroviral (ARV) clinics based in urban public hospitals in order to provide a patient-centred service. OBJECTIVES: To use patients' recommendations to develop intervention strategies to improve patients' experiences of the public ART programme. METHOD: A three-stage, sequential, mixed-method study was implemented. Stage 1 recruited five patients from the four sites to formulate and test a structured questionnaire prior to data collection. Stage 2 recruited a stratified random sample of 400 patients (100 from each hospital) to complete the administered structured questionnaire. Stage 3 purposively selected 12 patients (three from each of the four sites) to participate in in-depth audio-recorded interviews using an interview schedule. RESULTS: The 412 patients prioritised six recommendations, which are as follows: waiting areas should be enclosed to protect patients from the elements (rain, sun, lightening, wind and cold); patients should not have to return their files to the main hospital or ARV clinic themselves; stable patients should collect their ARV drugs every three months; pharmacy opening and closing times should be revised to suit patients' needs; HIV-positive patient representatives should be elected at each ARV clinic to address patients' concerns and/or challenges to ensure that the programme could be more patient-centred and ARV clinic operating times should be extended to open later during weekdays and over weekends. CONCLUSION: Patients living with HIV have a valuable contribution to make in assessing service delivery and making recommendations to create a patient-centred healthcare environment, which will feasibly increase their adherence to ART. <![CDATA[<b>Delays in switching patients onto second-line antiretroviral treatment at a public hospital in eThekwini, KwaZulu-Natal</b>]]> BACKGROUND: South Africa has one of the largest antiretroviral treatment (ART) programmes globally. In addition to increasing access to ART, it is important that the health system also focuses on the appropriate management of patients who fail first-line ART. Delays in switching patients onto second-line ART can adversely affect patient outcomes.AIM: To identify the patient-related and programmatic factors that delay switching patients onto second-line ART, and to assess whether these delays contribute to subsequent virological failure.METHODS: Clinical records of adult patients switched onto second-line ART between 2011 and 2014 at a public antiretroviral clinic were used to collect demographic, clinical, laboratory and programmatic data (availability of viral load results, inadequate patient follow-up, insufficient notes for effective follow-up). Data were analysed using univariate and multivariate logistic regression.RESULTS: The median duration from the date of first and confirmatory documented high viral load (VL > 1000 copies/mL) to being switched to second-line ART was 13.2 months [interquartile range (IQR) 1.1-52.7 months] and 6.4 months (IQR 0-43.3 months), respectively. Inadequate prescriber notes for appropriate follow-up (p = 0.01) and unavailability of patients' viral load results (p = 0.02) were significantly associated with delays in switching to second-line ART. There was no significant association between the time taken to switch to second-line ART and subsequent virological failure.CONCLUSION: We observed lengthy delays in switching patients to second-line ART. Modifiable programmatic factors were found to be significantly associated with delays in switching to second-line ART. <![CDATA[<b>Actions of female sex workers who experience male condom failure during penetrative sexual encounters with clients in Cape Town: Implications for HIV prevention strategies</b>]]> BACKGROUND: Condom failure has always been found to coexist with condom usage, especially among sex workers. OBJECTIVE: To describe the actions of female sex workers when they are faced with situations of condom failure. METHODS: Using the survey design, the participants were selected through the snowball sampling method. Their responses were obtained using a structured questionnaire. A total of 100 questionnaires were analysed. RESULTS: With respect to the immediate actions of sex workers after condom failure, 36% of the respondents continued with the sexual encounter after noticing that the condom was broken. Another 36% stopped immediately when they noticed that the condom had failed, but replaced the condom; 13% of the participants stopped the sexual encounter completely; 3% applied vaginal spermicidal foam; and 5% of the respondents stopped immediately and took a douche when they had the chance. For the actions within the next 24 hours of experiencing condom failure with a client, 53% of the participants did nothing; 4% sought counsel from a professional; 3% of the respondents took alcohol or drugs to forget the incident, 25% went to the clinic for assistance and 8% offered other responses. CONCLUSION: While continuing the sexual encounter without replacing the condom, taking alcohol and drugs or doing nothing could increase the risk of contracting HIV; however, actions like stopping the sexual encounter completely and visiting a clinic or a professional could make a difference between staying HIV negative or seroconverting. There is a need for targeted intervention to address issues of inappropriate behaviours after experiencing condom failure.