Prevalence of HIV-1 in blood donations following implementation of a structured blood safety policy in South Africa.

CONTEXT: The South African National Blood Service collects more than 700,000 units of blood annually from a population in which 11.4% is infected with human immunodeficiency virus 1 (HIV-1). The prevalence of HIV-1 in blood donations increased to 0.26% (1:385) in 1998, indicating that a significant number of window-period infective units were entering the blood supply (risk 3.4/100,000). OBJECTIVES: To determine whether the implementation of a new donor selection policy and educational program introduced in 1999 was associated with reductions in the incidence and prevalence of HIV-1 in blood donations and the reduced transmission risk. DESIGN: We compared the prevalence of HIV-1 in 880,534 blood donations collected from 1999 through 2000 with the 791,639 blood donations collected from 2001 through 2002. We estimated the incidence of HIV-1 in 93,378 (1999-2000) and 67,231 (2001-2002) first-time donations and the residual risk for all donations in 2001-2002 using the less-sensitive enzyme-linked immunoassay and incidence-window period model. SETTING: All blood donors in the Inland region of the South African National Blood Service were analyzed. INTERVENTION: Donor clinics in high HIV prevalence areas were closed. Programs targeting repeat donors and youth were initiated and HIV risk behavior education programs were developed. Structured donor interviews and an enhanced donor self-exclusion questionnaire were institutionalized. RESULTS: The prevalence of HIV-1 in blood donations declined from 0.17% in 1999-2000 to 0.08% in 2001-2002 after the implementation of the new donor selection and education policy. The number of high-risk donations collected decreased from 2.6% to 1.7% (P<.001), and the likelihood of these donations being infected decreased from 4.8% to 3.25%. The likelihood of first-time donors being recently infected with HIV-1 decreased from 18% to 14% (P = .07) and respective incidence of high-risk donations collected decreased from 2.6% to 1.7%. Donations from the majority black population declined from 6.6% to 4.2% (P<.001). Analysis of HIV-1 incidence in 2001-2002 suggests a residual risk of collecting a window period infectious unit of 2.6/100,000. CONCLUSION: The implementation of enhanced education and selection policies in South Africa was associated with decreased prevalence of HIV-1 in blood donations.

Transfusion-transmissible virus and hepatocellular carcinoma: a case-control study.

Although transfusion-transmissible virus (TTV) is often present in the serum of patients with acute and chronic non-A-C liver diseases, its hepatotropism, pathogenicity to the liver and hepatocarcinogenicity have not been proven. We used a case-control format to compare the prevalence of TTV infection among 148 southern African Blacks with hepatocellular carcinoma and 148 matched hospital-based controls, and to test for possible interactive effects between this virus and hepatitis B virus (HBV) and hepatitis C virus (HCV) in the development of the tumour. We also determined the prevalence of TTV in 988 blood donors in Gauteng province of South Africa. The presence of TTV DNA in serum samples was detected by using the polymerase chain reaction, Southern hybridization and nucleotide sequencing. Individuals infected with TTV did not have an increased risk of developing hepatocellular carcinoma (relative risk 1.1; 95% confidence limits 0.5-2.4). Moreover, co-infection with TTV did not further increase the risk of tumour development in patients chronically infected with HBV and/or HCV. TTV was present in the serum of 2.2% of blood donors: 4.0% in Black and 1.5% in White donors. We conclude that TTV is unrelated to the development of hepatocellular carcinoma in Black Africans.

National HIV surveillance in South Africa--1993-1995.

OBJECTIVE: To determine the point prevalence of HIV infection by serological examination which, performed consistently over several years, serves to monitor the distribution and trend of the HIV epidemic in South Africa. DESIGN: Annual cross-sectional surveys conducted nationally, in October/November. SETTING: South Africa, including areas that used to be known as self-governing and independent national states. SUBJECTS: Pregnant women in the age group 15-49 years who attend antenatal clinic services provided by the public health services. OUTCOME MEASURES: HIV positivity as determined serologically. RESULTS: The rising trend found previously continues: HIV positivity in South Africa was found to be 4.25% in 1993, 7.57% in 1994 and 10.44% in 1995. In 1995 the highest rate was recorded in KwaZulu-Natal (18.23%) and the lowest in the Western Cape (1.66%). On the basis of certain assumptions it is estimated that these rates are indicative of 1.7 million sexually active adults having been infected with HIV by October/November 1995, plus a cumulative total of 40,000 infants. Women in their 20s had the highest age-specific prevalence rates, viz. 13.12% (20-24 years) and 11.03% (25-29 years). HIV positivity in pregnant teenagers was 9.5%. CONCLUSIONS: The HIV epidemic is firmly established in South Africa with a wide variation in provincial prevalence rates. Of particular public health significance is the finding of a high and rising prevalence rate in pregnant teenagers. The observed prevalence rate for 1995 is lower than expected, giving rise to guarded hope that provinces with the highest recorded rates are moving away from the exponential growth found hitherto.

The South African HIV epidemic, reflected by nine provincial epidemics, 1990-1996.

OBJECTIVES: To determine by serological examination the annual point prevalence rates of infection with the human immunodeficiency virus (HIV) in representative samples of subjects in the nine provinces of South Africa, 1990-1996. DESIGN: Annual cross-sectional point prevalence surveys conducted in October/November of each year. SETTING: South Africa, including areas that used to be known as self-governing and independent National States. SUBJECTS: Pregnant women in the age group 15-49 years who attend antenatal clinic services provided by the public health services, and who act as an indicator group of the HIV epidemic among the heterosexually active population. OUTCOME MEASURES: HIV positivity as determined serologically; done consistently over several years, this serves to monitor the distribution and trend of the HIV epidemic in each of the nine provinces of South Africa. RESULTS: Empirical data gained from seven annual, consecutive countrywide surveys demonstrate a wide geographical variation in the point prevalence rates of HIV infection. In October/November 1996 the point prevalence rates (%) were as follows: Western Cape 3.09, Northern Cape 6.57, Northern Province 7.96, Eastern Cape 8.10, Gauteng 15.49, Mpumalanga 15.77, Free State 17.49, KwaZulu-Natal 19.90 and North West 25.13. The weighted national average was 14.17%. There are indications that some of the provinces (KwaZulu-Natal and possibly Mpumalanga) might have passed a point of inflection suggesting deceleration in their specific rates of increase. These results are, however, counterbalanced by the exponential growth still being experienced in provinces with large populations such as Gauteng and the Eastern Cape. It is concluded that the net effect of these divergent trends currently affects the national figure only marginally. A major deflection from the exponential growth patterns seen hitherto can be anticipated only once all or most of the highly populated provinces have traversed their respective points of inflection. The exponential model significantly explains the HIV epidemics in the provinces. The combination of these provincial epidemics describes the initial exponential phase of the epidemic.

Diagnostic efficiency of the disposable Monotest in detecting tuberculosis infection by setting objective-specific cut-off points for positivity.

The disposable multiple-puncture tuberculin test device, Monotest, was recently introduced in South Africa for tuberculin test screening of tuberculosis infections. Three studies were carried out to compare the intradermal Mantoux test with the Monotest. In the first study, conducted on confirmed hospitalised tuberculosis patients, 307 subjects underwent a 2 TU RT 23 (Statens Seruminstitut, Copenhagen) Mantoux test, 155 a 5 TU test of the same antigen, and 111 a Monotest. In the second study, another group of 98 confirmed tuberculosis patients was double-tested with 5 TU RT 23 by Mantoux test and Monotest. In the first study, 100% of 5 TU Mantoux tests resulted in indurations > or = 5 mm, 97% of 2 TU Mantoux indurations were > or = 10mm, and 96% of Monotests produced indurations > or = 2 mm (manufacturer's recommended cut-off point). In the second study, 99% of the 5 TU Mantoux tests measured > or = 5 mm, and 100% of Monotest indurations were > or = 2 mm. In both studies, raising the cut-off point for the Monotest to > or = 4 mm produced sensitivities of 95% and and 100% respectively. All these tests may therefore be regarded as highly sensitive. In a third study, 58 healthy schoolchildren were double tested with 2 TU RT 23 and with Monotest. Results indicated that if the positivity cut-off point of the Monotest is set a 8 mm instead of at 2 mm, sensitivity suffers slightly, decreasing from 100% to 90%, while specificity increases considerably from 8% to well over 80%. Receiver operating characteristic analysis indicated the high likelihood that the Monotest as well as the Mantoux test could discriminate between infected and uninfected subjects. For both tests the Wilcoxon statistic exceeded 0.8. The Monotest is a useful alternative to the Mantoux test. It is recommended that if tuberculosis is suspected, reaction > or = 4 mm be interpreted as positive. For screening purposes, a cut-off point of 8 mm seems to distinguish best between the infected and the uninfected individual.

National HIV surveillance--South Africa, 1990-1992.

The findings of three annual surveys of women attending antenatal clinics (at the end of 1990, 1991 and 1992) are presented here. These surveys form part of the National HIV Surveillance Programme. This programme is probably the most useful means of monitoring the trend and distribution of the epidemic. In all strata, a consistent rise in the HIV prevalence rate was found; it doubled almost every 12 months. The point prevalence rate in antenatal clinic attenders in South Africa increased from 0.76% in 1990 to 1.49% in 1991 and 2.69% in 1992. The prevalence rate was found to vary widely geographically: Natal/KwaZulu formed the spearhead of the epidemic with a 4.77% rate of HIV infection in 1992. Venda and the Cape appeared to be the least affected with rates of 0.64% and 0.66% respectively.

[Cost estimation of an intensive care unit]. / Kosteberaming van 'n chirurgiese intensiewe eenheid.

The cost of health services has increased tremendously due to advances in technology, and the cost of intensive care units forms an important part of total hospital costs. A survey done over a 3-month period of all human and material resources utilised in a surgical intensive care unit showed that the average cost amounted to R1 298 per patient per day.