Antiretroviral treatment in the private sector in Namibia.

Antiretroviral treatment (ART) has been available in the private sector in Namibia since 1998. National guidelines were developed by the Ministry of Health and clinicians of the public and private sector in 2003 and launched at the start of the public sector ART programme by the Ministry of Health. The Namibian HIV Clinicians Society was established around this period to promote adherence to the national guidelines and to provide comprehensive training for health professionals. To monitor adherence to national ART guidelines, in 2003, the Society requested access to anonymized data on ART dispensing from the medical insurance industry. Dispensing data from all Namibian medical insurance companies were obtained. ART regimens were categorized as recommended (non-nucleoside reverse transcriptase inhibitor-based and boosted protease inhibitor [PI]-based), not recommended (non-boosted PI-based or stavudine/didanosine-containing regimens), ineffective (dual therapy) and second line or salvage regimens. This analysis was repeated in 2004, 2005 and 2008. In 2003, only 2306 adult private patients received ART, of which only 1527 (66%) were recommended regimens. In 2008, 7010 private patients received ART, of which 6372 (91%) were recommended regimens. The private sector covered about 15% of the total number of 46,732 reported ART patients reported in the year 2008. Many of these private patients might not have accessed ART in the public sector.

Clinical experience with pericardiocentesis and extended drainage in a population with a high prevalence of HIV.

BACKGROUND: The data presented were generated in a prospective study on the immunopathogenesis and management of tuberculous (TB) pericarditis at Tygerberg Hospital in Cape Town. We report our experience with 2D echocardiographically guided pericardiocentesis in 170 consecutive patients who presented to us with large pericardial effusions since 1995. METHODS: All patients referred to our department with echocardiographically confirmed large pericardial effusions underwent a clinical assessment followed by pericardiocentesis and drainage by an indwelling pigtail catheter. The appearance and amount of drained effusion were noted and fluid was sent for diagnostic assessment. The pigtail catheter was kept in place and fluid was aspirated once daily until the aspirate was less than 100 ml, at which stage the catheter was removed. RESULTS: A chest wall puncture site was chosen in 165 of the 170 patients (97%), while the subcostal approach was only used in five patients. Echocardiographic signs of tamponade were seen in 88% of cases. In the majority of patients (68.2%) a diagnosis of TB could be established and of these 46.6% were HIV positive. TB could not be proven in only three HIV-positive patients (1.8% of all patients). Neither hospital stay nor complications were increased in the HIV-positive group when compared with the HIV-negative group and no patient developed intrapericardial sepsis. No death could be attributed with certainty to the procedure. One patient developed non-fatal tamponade within 24 hours after the tap and in another patient a left ventricular thrombus was noted on echo after 16 days. Twenty-four patients underwent a pericardial window procedure according to protocol for diagnostic purposes. In another four patients a window was performed for therapeutic reasons. The most common minor complication was local pain at the site of catheter insertion. Repeat drainage was necessary in only six (3.5%) cases. CONCLUSIONS: 2D echocardiographically directed pericardiocentesis with extended catheter drainage has an excellent profile in terms of simplicity, safety and efficacy, even in a population with a very high prevalence of HIV.

Twelve-lead electrocardiography in tuberculous pericarditis.

OBJECTIVES: This study is part of an ongoing initiative started in 1995 to investigate the therapeutic efficacy of adjuvant corticosteroids in the management of tuberculosis (TB) pericarditis. In this retrospective, descriptive study we describe the changes found on the 12-lead electrocardiogram (ECG) in patients with TB pericarditis, with and without cardiac tamponade. We determined the diagnostic accuracy of ECG parameters for cardiac tamponade. METHODS: All patients referred to our department with echocardiographically confirmed large pericardial effusions underwent a thorough clinical assessment followed by pericardiocentesis and drainage using an indwelling pigtail catheter. The amount of drained effusion was measured, and fluid was sent for diagnostic assessment. Patients were grouped into those with or without cardiac tamponade. The following ECG parameters were assessed: rate, rhythm, microvoltage, electrical alternans, PR segment and ST segment abnormalities. RESULTS: Of the 157 patients assessed, 88 were diagnosed with TB pericarditis All had abnormal ECGs and 83% had changes of chronic pericarditis. Microvoltage in the extremity and/or precordial leads correlated with the presence of large effusions (> 750 ml). None of the studied parameters correlated with the presence of cardiac tamponade. CONCLUSIONS: Twelve-lead ECG is of supportive but not diagnostic value in cardiac tamponade. The presence of microvoltage suggests the presence of a large effusion. The absence of microvoltage makes the presence of cardiac tamponade unlikely.