Maternal intravenous immunoglobulin: a non-invasive treatment option for Rhesus D-sensitised women with previous adverse pregnancy outcomes

Background. Maternal intravenous immunoglobulin (IVIG) may delay the onset and severity of fetal anaemia in Rhesus D (RhD)- sensitised pregnancies, thereby minimising the need for intrauterine transfusion and its associated complications. Objective. To compare the pregnancy outcomes of RhD-sensitised women who received antenatal IVIG with those who did not receive antenatal IVIG. Methods. This was a retrospective cross-sectional analysis of RhD-sensitised women who attended the Wits Fetal Medicine Centre (Johannesburg) from 1 January 2008 to 31 May 2018. Criteria for maternal IVIG administration were: (i) previous adverse pregnancy outcome (early neonatal death, intrauterine fetal death or miscarriage related to RhD sensitisation), (ii) women with high antibody titre levels (≥1:64) in the absence of fetal anaemia; and (iii) rising antibody titre levels. Maternal antibody titre levels, pregnancy and neonatal outcomes were compared in women who received IVIG v. those who did not receive IVIG. Results. Of the 42 RhD-sensitised women, 14 received IVIG. A greater proportion of women experienced a decrease in antibody titres in the IVIG v. no-IVIG group (43% v. 11%, respectively; p=0.04). Nine of the 10 women in the IVIG group with a previous adverse pregnancy outcome had a successful pregnancy outcome following IVIG treatment. Conclusion. Maternal IVIG may provide a successful pregnancy outcome in RhD-sensitised women with previous adverse pregnancy outcomes related to Rh disease, or women with raised or increasing maternal antibody titre levels who present in the first or early second trimester

Surgical infections at a regional hospital in Gauteng: reasons for delay to care and profile of pathology

Background: Present on arrival infection is a common indication for admission of surgical patients initially managed at primary care level. We aimed to describe the demographic and disease profile of patients presenting with infection requiring surgical management, describe determinants of patients' health-seeking behaviour, and identify barriers to care.Methods: A prospective descriptive questionnaire-based study was conducted at Edenvale General Hospital between February 2014 and October 2016. Minors were excluded. Results: Eighty-nine patients participated. Abscesses (26%), diabetic foot (22%), and cellulitis (16%) were the commonest categories of infection necessitating admission. The majority of patients were South African (88%), Black African (82%), males (58%), without medical aid (99%), who were not formally employed (58%), were from poor households (74%), inhabited some form of formal housing (90%), were in charge of decisions regarding personal health (80%), and first sought help at the primary care level (71%). Delay to presentation was noted in 69% of patients, and delay to referral in 46%. Age, race, history of diabetes, and main source of monthly income were significant variables in delayed presentation (p<0.05), and age and level of care on first contact in delayed referral (p<0.05) in the study sample. The most common reason for delay to presentation (84%) and referral (61%) was patients' belief that their problem would resolve spontaneously. Conclusions: Patients' socio-economic status, past medical history, demographics, level of first contact with the health care system, and perceptions of their own health contributed to delays in seeking and receiving care in the study sample. These delays may be addressed by interventions that target the availability, accessibility, acceptability and affordability of health care services

Focus Group Discussion with Private Sector Doctors in the eThekwini Metro of KwaZulu-Natal on the Management of HIV/AIDS Patients

Background: Highly active antiretroviral treatment (HAART) is essential in the treatment of HIV/AIDS; however; a holistic approach to HIV/AIDS management is important. This study was done to confirm the findings of two studies done previously in the eThekwini Metro of KwaZulu-Natal on private sector doctors' management of HIV-infected patients and to obtain more in-depth information about their nonpharmacological management of HIV-infected patients. Methods: Two focus group discussions were conducted amongst private sector doctors in the eThekwini Metro; after obtaining their consent. The focus group sessions were scripted; audio-taped and transcribed verbatim. Prevalent themes were identified and reported. Results: Eight doctors participated. Of the total patient population seen annually by the majority of the doctors; an average of 43.8was HIV infected. Doctors in this study managed their patients both pharmacologically and nonpharmacologically. Seventy-five per cent of doctors indicated that the taste of medicine played an important role in nonadherence to treatment; but all agreed that cultural beliefs also influenced the patient's adherence to medication. Theft of medicines and the outof- stock situation prevented antiretroviral drug access; which impacted negatively on adherence. Five doctors mentioned that depressed patients abused alcohol; resulting in nonadherence. One doctor reported that he used the biopsychosocial approach to improve adherence in his patients. Doctors indicated that the disability grant given by the South African Government caused patients not to adhere to treatment in order to maintain a CD4 count of 200 or less so as to qualify for the grant.Conclusions: The study confirmed the previous study findings in that it showed that private sector doctors manage their HIV-infected patients both pharmacologically and nonpharmacologically. It further provided new and interesting information with regard to the nonpharmacological methods employed in HIV/AIDS management; that is the incorporation of cultural beliefs in the management of HIV-infected patients to improve adherence to treatment; and the role of the disability grant and pharmaceutical formulations in contributing to nonadherence by HIV-infected patients

Identification of Sources from which Doctors in the Private Sector Obtain Information on HIV and AIDS

Background: Doctors need to constantly update their knowledge and obtain information in order to practise high-quality medicine. Antiretroviral drugs have been available only since around 1996; therefore many of the doctors who were trained prior to 1996 would not have received any formal training in the management of HIV and AIDS patients. Where doctors source their general medical knowledge has been established; but little is known about where doctors source information on HIV/AIDS. This study investigated where private sector doctors from the eThekwini Metro obtain information on HIV and AIDS for patient management. Methods: A descriptive cross-sectional study among 133 private general practitioners (GPs) and 33 specialist doctors in the eThekwini Metro of KwaZulu-Natal; South Africa; was conducted with the use of questionnaires. The questionnaires were analysed using SPSS version 15. A p value of 0.05 was considered statistically significant. Results: The majority of the doctors (92.4) obtained information on HIV and AIDS from journals. Continuing Medical Education (CME); textbooks; pharmaceutical representatives; workshops; colleagues and conferences were identified as other sources of information; while only 35.7of doctors were found to use the internet for information. GPs and specialists differed significantly with regard to their reliance on colleagues (52.9versus 72.7; p 0.05) and conferences (48.6versus 78.8; p 0.05) as sources of HIV information. More than 90of doctors reported that CME courses contributed to better management of HIV and AIDS patients.) obtained information on HIV and AIDS from journals. Continuing Medical Education (CME); textbooks; pharmaceutical representatives; workshops; colleagues and conferences were identified as other sources of information; while only 35.7of doctors were found to use the internet for information. GPs and specialists differed significantly with regard to their reliance on colleagues (52.9versus 72.7; p 0.05) and conferences (48.6versus 78.8; p 0.05) as sources of HIV information. More than 90of doctors reported that CME courses contributed to better management of HIV and AIDS patients. Conclusion: Private sector doctors in the eThekwini Metro obtain information on HIV from reliable sources in order to have up-to-date knowledge on the management of HIV-infected patients

Evaluation of the Clinical Management of HIV-Infected Patients by Private Sector Doctors in the eThekwini Metro; KwaZulu-Natal

Background: Although private sector doctors are the backbone of treatment service in many countries; caring for patients with HIV entails a whole new set of challenges and difficulties. The few studies done on the quality of care of HIV patients; in the private sector in developing countries; have highlighted some problems with management. In South Africa; two-thirds of doctors work in the private sector. Though many studies on HIV/AIDS have been undertaken; few have been done in the private sector in terms of the management of this disease. Therefore; a study was undertaken to evaluate the clinical management of HIV-infected patients by private sector doctors. Methods: A descriptive cross-sectional study was undertaken in the eThekwini Metro in KwaZulu-Natal; South Africa; with 190 private sector doctors who; in the first phase of the study; indicated that they manage HIV and AIDS patients and would be willing to participate in the second phase of the study. The HIV guidelines of the Department of Health and Human Services and the South African National Department of Health were used to compare the treatment of HIV patients by these doctors. Results: Eighty-five doctors (54.5) always measured the CD4 count and viral load levels at diagnosis. Both CD4 counts and viral load were always used by 76 doctors (61.8) to initiate therapy. Of the doctors; 134 (78.5) initiated therapy at CD4 count 200 cells/mm3. The majority of doctors prescribed triple therapy regimens using the 2 NRTI + 1 NNRTI combination. Doctors who utilised CD4 counts tended to also use viral load (VL) to assess effectiveness and change therapy (p 0.001). At initiation of treatment; 68.5of the doctors saw their patients monthly and 64.3saw them every three to six months; when stable. Conclusion: The majority of private sector doctors were compliant with current guidelines for HIV management; hence maintaining an acceptable quality of clinical healthcare

Adherence-Monitoring Practices by Private Healthcare Sector Doctors Managing HIV and AIDS Patients in the eThekwini Metro of KwaZulu-Natal

Background: The danger of poor adherence to treatment by patients with HIV infection is that poor adherence correlates with clinical and virological failure. Understanding how private-sector doctors monitor adherence by their HIV-infected patients could assist in developing interventions to improve adherence by these patients. Information about such practices amongst private-sector doctors in the province of KwaZulu-Natal; however; is limited. This study was; therefore; undertaken to assess the private-sector doctor adherence-monitoring practices of HIV-infected patients in the eThekwini metro of KwaZulu-Natal. Methods: A descriptive cross-sectional study was undertaken amongst private general practitioners (GPs) and specialists managing HIV/AIDS patients in the eThekwini metro. Anonymous semi-structured questionnaires were used to investigate adherence-monitoring practices by these doctors and their strategies to improve adherence. Results: A total of 171 doctors responded; with over 75in practice for over 11 years and 78.9indicating that they monitored adherence. A comparison between the GPs and the specialists found that 82.6of the GPs monitored adherence compared with 63.6of the specialists (p = 0.016). The doctors used several approaches; with 60.6reporting the use of patient self-reports and 18.3reporting the use of pill counts. A total of 68.7of the doctors indicated that their adherence monitoring was reliable; whilst 19.7indicated that they did not test the reliability of their monitoring tools .The most common strategy used to improve adherence by their patients was through counselling. Other strategies included alarm clocks; SMSs; telephone calls to the patients; the encouragement of family support and the use of medical aid programmes. Conclusions: Private-sector doctors managing HIV/AIDS patients in the eThekwini metro of KwaZulu-Natal do monitor adherence and employ strategies to improve adherence

Nuchal Translucency as a Method of First-Trimester Screening for Aneuploidy

Objective. To determine the effectiveness of nuchal translucency (NT) screening in predicting aneuploidy and structural abnormalities in a South African population. Study design. Descriptive study. Setting. Chris Hani Baragwanath Hospital fetal medicine unit. Outcome measures. An adjusted risk was derived from the combination of maternal age-related risk and the risk derived from NT screening. A positive screen was denoted by an adjusted risk of more than 1/300 and a negative screen by an adjusted risk of less than 1/300. In order to determine the number of undiagnosed abnormalities in the group; all babies were examined by a paediatrician at birth to detect and describe dysmorphic features. Results. A total of 428 patients underwent first-trimester screening between July 2003 and July 2005. Three per cent were lost to follow-up. Of the 415 patients analysed; 59 screened positive and 356 screened negative. The mean age for both groups of patients was 30.1 years. Of the 57 patients who screened positive; 24 elected to have chorionic villus sampling (CVS). This resulted in the detection of 6 chromosomal abnormalities and 2 structural abnormalities. Among the remaining 356 patients; who had screened negative; 2 had an increase in the adjusted risk when the risk was compared with the background risk; and 1 chromosomal abnormality was detected in this group; 8 elected to have CVS because of a previous history of a chromosomal abnormality; and there were no abnormalities among them. Conclusions. The use of these screening methods has enabled prenatal karyotyping to become cost effective; and allows concentration on pregnancies at highest risk for chromosomal abnormalities; regardless of age

Nuchal Translucency (NT) as a Method of First Trimester Screening for Aneuploidy

Objective : To determine the effectiveness of nuchal translucency screening in predicting aneuploidy and structural abnormalities in a South African population Study design Descriptive Study Setting Chris Hani Baragwanath Hospital Fetal Medicine Unit Outcome measures An adjusted risk was derived from the combination of maternal age-related risk and the risk derived from nuchal translucency screening. A positive screen was denoted by an adjusted risk of more than 1/300 and a negative screen by an adjusted risk of less than 1/300. In order to determine the number of undiagnosed abnormalities in the group; all babies were examined by a paediatrician at birth to detect and describe dysmorphic features. Results : A total of 428 patients underwent first trimester screening between July 2003 and July 2005. Three percent were lost to follow up. Of the 415 cases analyzed; 57 patients screened positive and 356 patients screened negative. The mean age for both groups of patients was 30.1 years. Of the 57 patients that screened positive 24 elected to have chorionic villus sampling (CVS). This resulted in the detection of 6 chromosomal abnormalities and 2 structural abnormalities. Among the remaining 356 patients; who had screened negative; 2 had an increase in the adjusted risk when the risk was compared to the background risk; and one chromosomal abnormality was detected in this group; 8 elected to have CVS because of a previous history of a chromosomal abnormality and there were no abnormalities among them. Conclusions : The use of these screening methods has enabled prenatal karyotyping to become cost effective; and to allow concentration on pregnancies at highest risk for chromosomal abnormalities; regardless of age

Barriers to HIV Care and Treatment by Doctors: A review of the literature

This paper provides a review of the reported barriers that prevent doctors from managing HIV infected patients. The four most commonly reported barriers were: fear of contagion; fear of losing patients; unwillingness to care; and inadequate knowledge /training about treating HIV patients. Barriers to treating HIV infected patients is frequently reported in many countries and it is important for developing countries such as South Africa to learn from these experiences by identifying local problems so that constructive interventions and strategies can be developed to address these barriers; thereby improving the quality of patient care. Further research in respect of the local situation is required. Introduction Over the last two decades acquired immunodeficiency syndrome (AIDS) has emerged as one of the most serious public health problems in the world; and by the end of 2003 it was estimated that 5.3 million South Africans were human immunodeficiency virus (HIV) positive; which corresponds to 21.5

Barriers to HIV Care and Treatment by Doctors : a Review of the Literature

This paper provides a review of the reported barriers that prevent doctors from managing HIV infected patients. The four most commonly reported barriers were: fear of contagion; fear of losing patients; unwillingness to care; and inadequate knowledge /training about treating HIV patients. Barriers to treating HIV infected patients is frequently reported in many countries and it is important for developing countries such as South Africa to learn from these experiences by identifying local problems so that constructive interventions and strategies can be developed to address these barriers; thereby improving the quality of patient care. Further research in respect of the local situation is requiredIntroduction: Over the last two decades acquired immunodeficiency syndrome (AIDS) has emerged as one of the most serious public health problems in the world; and by the end of 2003 it was estimated that 5.3 million South Africans were human immunodeficiency virus (HIV) positive; which corresponds to 21.5of the population. In the early phase of the HIV epidemic few doctors saw infected patients and treatment options were limited. As a result many doctors were reluctant to provide care to HIV infected patients and homophobia amongst doctors; fear of contact with patients and unwillingness to care were frequently reported. However; there has been an exponential increase in the number of HIV and AIDS related cases and more doctors are encountering infected individuals. This review summarizes our current knowledge of barriers to treatment of HIV infected patients by doctors.Method: A comprehensive literature review was undertaken by searching the MEDLINE database; Psychlit; ISI Web; EBSCOHost; and Sabinet on line; for eng language literature published between 1985 and 2004. The database search terms included keywords such as fear/s; barrier/s; concern; HIV; AIDS; attitudes; physician/s (doctor/s); practice; treatment; care and knowledge. A variety of combinations of these words were entered. All duplicate articles were removed and only studies that used doctors as the sample population were considered. Titles expressing comment; news items; opinion pieces or letters were rejected.Results: Thirty two relevant studies were identified from the literature search. The four most commonly reported barriers were: fear of contagion; fear of losing patients; unwillingness to care; and inadequate knowledge /training about treating HIV patients