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1.  A novel HIV treatment model using private practitioners in South Africa 
Sexually transmitted infections  2012;88(2):136-140.
The extent of the HIV epidemic in South Africa may render the public sector capacity inadequate to manage all patients requiring antiretroviral therapy (ART). Private practitioners are an underutilised resource that could be utilized to ease this challenge.
We developed a model of care using 72 private practitioners in five provinces in urban and rural areas of South Africa with centralised clinical support, training, pharmacy control and data management. We describe the programme, its quality control measures and patient outcomes using a cohort analysis.
Between January 2005 and December 2008, 9,102 individuals were started on ART, 63% female, mean age 35 years, median viral load 50,655 copies/ml and median baseline CD4 count 123 cells/μl. Retention (alive and in care) in those who started on ART after 12 months was 63% (5,743/9,102) in the 2005 cohort and did not change by calendar year. After 36 months, retention was 50% and 59%, for those enrolled in 2005 and 2006 respectively. The percentage virally suppressed remained similar over the cohorts at 6 months, 82% vs. 84%, 84% and 85% from 2005 - 2008, p=0.66; but improved slightly at 12 months, 78% vs. 83%, 83% and 84% from 2005 - 2008, p=0.05.
The results show that a well-managed private practitioner-based model can achieve comparable results to public service programmes, although long-term retention needs further evaluation. This model of ART delivery can be used to expand access to ART in areas where the public sector is unable to meet the demand.
PMCID: PMC3724420  PMID: 22345028
2.  Valacyclovir in the treatment of acute retinal necrosis 
BMC Ophthalmology  2012;12:48.
To report the outcome of oral valacyclovir as the sole antiviral therapy for patients with acute retinal necrosis (ARN).
This study reports a retrospective, interventional case series of nine consecutive patients with ten eyes with newly diagnosed ARN treated with oral valacyclovir as the sole antiviral agent. Eight patients received oral valacyclovir 2 g tid (Valtrex, GlaxoSmithKline) and one patient with impaired renal function received oral 1 g tid. The main outcome measures were response to treatment, time to initial response to treatment, time to complete resolution of retinitis, best corrected visual acuity (BCVA) at final follow-up, retinal detachment and development of recurrent or second eye disease.
Retinitis resolved in ten of ten (100%) affected eyes. The median time to initial detectable response was seven days and the median time to complete resolution was 21 days. A final BCVA of 20/40 or better was achieved in 6/10 (60%) of eyes. 3/10 eyes (30%) developed a retinal detachment. No patients developed either disease reactivation or second eye involvement over the course of the study (mean follow up 31 weeks, range 7 to 104 weeks).
Treatment with oral valacyclovir as the sole antiviral therapy resulted in complete resolution of retinitis. Final BCVA and retinal detachment rate were comparable with previously reported outcomes for intravenous acyclovir.
PMCID: PMC3487766  PMID: 22947428
Acute retinal necrosis; Herpetic retinitis; Acyclovir; Valacyclovir
3.  Contrasting Reasons for Discontinuation of Antiretroviral Therapy in Workplace and Public-Sector HIV Programs in South Africa 
AIDS Patient Care and STDs  2011;25(1):53-59.
We investigated reasons for clinical follow-up and treatment discontinuation among HIV-infected individuals receiving antiretroviral therapy (ART) in a public-sector clinic and in a workplace clinic in South Africa. Participants in a larger cohort study who had discontinued clinical care by the seventh month of treatment were traced using previously provided locator information. Those located were administered a semistructured questionnaire regarding reasons for discontinuing clinical follow-up. Participants who had discontinued antiretroviral therapy were invited to participate in further in-depth qualitative interviews. Fifty-one of 144 (35.4%) in the workplace cohort had discontinued clinical follow-up by the seventh month of treatment. The median age of those who discontinued follow-up was 46 years and median educational level was five years. By contrast, only 16.5% (44/267) of the public-sector cohort had discontinued follow-up. Among them the median age was 37.5 years and median education was 11 years. Qualitative interviews were conducted with 17 workplace participants and 10 public-sector participants. The main reasons for attrition in the workplace were uncertainty about own HIV status and above the value of ART, poor patient–provider relationships and workplace discrimination. In the public sector, these were moving away and having no money for clinic transport. In the workplace, efforts to minimize the time between testing and treatment initiation should be balanced with the need to provide adequate baseline counseling taking into account existing concepts about HIV and ART. In the public sector, earlier diagnosis and ART initiation may help to reduce early mortality, while links to government grants may reduce attrition.
PMCID: PMC3030909  PMID: 21214378
4.  A study of patient attitudes towards decentralisation of HIV care in an urban clinic in South Africa 
In South Africa, limited human resources are a major constraint to achieving universal antiretroviral therapy (ART) coverage. Many of the public-sector HIV clinics operating within tertiary facilities, that were the first to provide ART in the country, have reached maximum patient capacity. Decentralization or "down-referral" (wherein ART patients deemed stable on therapy are referred to their closest Primary Health Clinics (PHCs) for treatment follow-up) is being used as a possible alternative of ART delivery care. This cross-sectional qualitative study investigates attitudes towards down-referral of ART delivery care among patients currently receiving care in a centralized tertiary HIV clinic.
Ten focus group discussions (FGDs) with 76 participants were conducted in early 2008 amongst ART patients initiated and receiving care for more than 3 months in the tertiary HIV clinic study site. Eligible individuals were invited to participate in FGDs involving 6-9 participants, and lasting approximately 1-2 hours. A trained moderator used a discussion topic guide to investigate the main issues of interest including: advantages and disadvantages of down-referral, potential motivating factors and challenges of down-referral, assistance needs from the transferring clinic as well as from PHCs.
Advantages include closeness to patients' homes, transport and time savings. However, patients favour a centralized service for the following reasons: less stigma, patients established relationship with the centralized clinic, and availability of ancillary services. Most FGDs felt that for down-referral to occur there needed to be training of nurses in patient-provider communication.
Despite acknowledging the down-referral advantages of close proximity and lower transport costs, many participants expressed concerns about lack of trained HIV clinical staff, negative patient interactions with nurses, limited confidentiality and stigma. There was consensus that training of nurses and improved health systems at the local clinics were needed if successful down-referral was to take place.
PMCID: PMC3167749  PMID: 21871068
decentralization; down-referral; South Africa; ART; level of care
5.  Complete Resolution of a Giant Pigment Epithelial Detachment Secondary to Exudative Age-Related Macular Degeneration after a Single Intravitreal Ranibizumab (Lucentis) Injection: Results Documented by Optical Coherence Tomography 
Case Reports in Ophthalmology  2010;1(2):110-113.
To describe a patient with a giant pigment epithelial detachment (PED) secondary to exudative age-related macular degeneration (ARMD) successfully treated with a single intravitreal ranibizumab (Lucentis) injection (0.5 mg/0.05 ml).
An 89-year-old woman presented with a six-day history of reduced vision and distortion in the left eye. Best-corrected visual acuity in that eye was 6/15. Fundoscopy revealed a giant PED and exudates temporally to the fovea. Optical coherence tomography showed a PED associated with subretinal and intraretinal fluid. Fluorescein angiography confirmed the diagnosis of an occult choroidal neovascularization. Treatment with intravitreal injections of ranibizumab (Lucentis) was recommended, although the increased risk of retinal pigment epithelium (RPE) rip was mentioned.
Four weeks after the first intravitreal Lucentis injection, the visual acuity in the left eye improved to 6/7.5, with a significant improvement of the distortion and a complete anatomical resolution of the PED confirmed by optical coherence tomography.
Giant PED secondary to exudative ARMD can be successfully treated with intravitreal ranibizumab, despite the increased risk of RPE rip. To our knowledge, this is the first case presenting with complete resolution of PED after a single ranibizumab injection.
PMCID: PMC3047744  PMID: 21373383
Age-related macular degeneration; Anti-VEGF; Pigment epithelial detachment; Ranibizumab (Lucentis); Retinal pigment epithelium rip
6.  Contrasting predictors of poor antiretroviral therapy outcomes in two South African HIV programmes: a cohort study 
BMC Public Health  2010;10:430.
Many national antiretroviral therapy (ART) programmes encourage providers to identify and address baseline factors associated with poor treatment outcomes, including modifiable adherence-related behaviours, before initiating ART. However, evidence on such predictors is scarce, and providers judgement may often be inaccurate. To help address this evidence gap, this observational cohort study examined baseline factors potentially predictive of poor treatment outcomes in two ART programmes in South Africa, with a particular focus on determinants of adherence.
Treatment-naïve patients starting ART were enrolled from a community and a workplace ART programme. Potential baseline predictors associated with poor treatment outcomes (defined as viral load > 400 copies/ml or having discontinued treatment by six months) were assessed using logistic regression. Exposure variables were organised for regression analysis using a hierarchical framework.
38/227 (17%) of participants in the community had poor treatment outcomes compared to 47/117 (40%) in the workplace. In the community, predictors of worse outcomes included: drinking more than 20 units of alcohol per week, having no prior experience of chronic medications, and consulting a traditional healer in the past year (adjusted odds ratio [aOR] 15.36, 95% CI 3.22-73.27; aOR 2.30, 95%CI 1.00-5.30; aOR 2.27, 95% CI 1.00-5.19 respectively). Being male and knowing someone on ART were associated with better outcomes (aOR 0.25, 95%CI 0.09-0.74; aOR 0.44, 95%CI 0.19-1.01 respectively). In the workplace, predictors of poor treatment outcomes included being uncertain about the health effects of ART and a traditional healer's ability to treat HIV (aOR 7.53, 95%CI 2.02-27.98; aOR 4.40, 95%CI 1.41-13.75 respectively). Longer pre-ART waiting time (2-12 weeks compared to <2 weeks) predicted better treatment outcomes (aOR 0.13, 95% CI 0.03-0.56).
Baseline predictors of poor treatment outcomes were largely unique to each programme, likely reflecting different populations and pathways to HIV care. In the workplace, active promotion of HIV testing may have extended ART to individuals who, without provider initiation, would not have spontaneously sought care. As provider-initiated testing makes ART available to individuals less motivated to seek care, patients may need additional adherence support, especially addressing uncertainty about the health benefits of ART.
PMCID: PMC2920888  PMID: 20649946
7.  "That is why I stopped the ART": Patients' & providers' perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme 
BMC Public Health  2008;8:63.
As ART programmes in African settings expand beyond the pilot stages, adherence to treatment may become an increasing challenge. This qualitative study examines potential barriers to, and facilitators of, adherence to ART in a workplace programme in South Africa.
We conducted key informant interviews with 12 participants: six ART patients, five health service providers (HSPs) and one human resources manager.
The main reported barriers were denial of existence of HIV or of one's own positive status, use of traditional medicines, speaking a different language from the HSP, alcohol use, being away from home, perceived severity of side-effects, feeling better on treatment and long waiting times at the clinic. The key facilitators were social support, belief in the value of treatment, belief in the importance of one's own life to the survival of one's family, and the ability to fit ART into daily life schedules.
Given the reported uncertainty about the existence of HIV disease and the use of traditional medicines while on ART, despite a programme emphasising ART counselling, there is a need to find effective ways to support adherence to ART even if the individual does not accept biomedical concepts of HIV disease or decides to use traditional medicines. Additionally, providers should identify ways to minimize barriers in communication with patients with whom they have no common language. Finally, dissatisfaction with clinical services, due to long waiting times, should be addressed.
PMCID: PMC2276211  PMID: 18282286

Results 1-7 (7)