"There is not a safe space where they can find themselves to be free": (Un)safe spaces and the promotion of queer visibilities among township males who have sex with males (MSM) in Cape Town, South Africa.

Males who have sex with males (MSM) are prioritised in the global fight against HIV/AIDS, as a key affected population to receive HIV prevention, treatment, and HIV-related care and support (WHO, 2016). There is, however, limited empirical research conducted on how to engage communities of South African MSM in clinical HIV prevention research programs. The development of LGBTIQ safe spaces may potentially be a viable option to promote community-based engagement by bridging the divides between HIV-prevention researchers, marginalised queer populations, and other HIV-prevention stakeholders located in heteronormative spaces (Molyneux et al., 2016). We conducted ten in-depth, qualitative interviews with MSM safe space members who have been involved in HIV prevention research programs. Data were analysed using a thematic analytic strategy (Braun and Clarke, 2006). Our results indicate that the "safe spaces" currently operational in Cape Town are not stable spaces nor are they always safe, but they form part of a broader and much more long-term political and geographical strategy of inclusion and emancipation.

Access to health care for persons with disabilities in rural South Africa.

BACKGROUND: Global research suggests that persons with disabilities face barriers when accessing health care services. Yet, information regarding the nature of these barriers, especially in low-income and middle-income countries is sparse. Rural contexts in these countries may present greater barriers than urban contexts, but little is known about access issues in such contexts. There is a paucity of research in South Africa looking at "triple vulnerability" - poverty, disability and rurality. This study explored issues of access to health care for persons with disabilities in an impoverished rural area in South Africa. METHODS: The study includes a quantitative survey with interviews with 773 participants in 527 households. Comparisons in terms of access to health care between persons with disabilities and persons with no disabilities were explored. The approach to data analysis included quantitative data analysis using descriptive and inferential statistics. Frequency and cross tabulation, comparing and contrasting the frequency of different phenomena between persons with disabilities and persons with no disabilities, were used. Chi-square tests and Analysis of Variance tests were then incorporated into the analysis. RESULTS: Persons with disabilities have a higher rate of unmet health needs as compared to non-disabled. In rural Madwaleni in South Africa, persons with disabilities faced significantly more barriers to accessing health care compared to persons without disabilities. Barriers increased with disability severity and was reduced with increasing level of education, living in a household without disabled members and with age. CONCLUSIONS: This study has shown that access to health care in a rural area in South Africa for persons with disabilities is more of an issue than for persons without disabilities in that they face more barriers. Implications are that we need to look beyond the medical issues of disability and address social and inclusion issues as well.

A phase I, pharmacokinetic and pharmacodynamic study of GSK2256098, a focal adhesion kinase inhibitor, in patients with advanced solid tumors.

BACKGROUND: Focal adhesion kinase (FAK) is important in cancer growth, survival, invasion, and migration. The purpose of this study was to determine the maximum tolerated dose (MTD), safety, pharmacokinetics (PK), and pharmacodynamics (PD) of the FAK inhibitor, GSK2256098, in cancer patients. PATIENTS AND METHODS: The dose of GSK2256098 was escalated, in cohorts of patients with advanced cancer, from 80 to 1500 mg, oral twice daily (BID), until the MTD was determined. Serial blood samples were obtained from all patients, and the PK was determined. Paired tumor biopsies were obtained in select patients, and the level of phospho-FAK (pFAK) was determined. RESULTS: Sixty-two patients (39 males, 23 females; median age 61 y.o., range 21-84) received GSK2256098. Dose-limiting toxicities of grade 2 proteinuria (1000 mg BID), grade 2 fatigue, nausea, vomiting (1250 mg BID), and grade 3 asthenia and grade 2 fatigue (1500 mg BID) were reported with the MTD identified as 1000 mg BID. The most frequent adverse events (AEs) were nausea (76%), diarrhea (65%), vomiting (58%), and decreased appetite (47%) with the majority of AEs being grades 1-2. The PK was generally dose proportional with a geometric mean elimination half-life range of 4-9 h. At the 750, 1000, and 1500 mg BID dose levels evaluated, the pFAK, Y397 autophosphorylation site, was reduced by ∼80% from baseline. Minor responses were observed in a patient with melanoma (-26%) and three patients with mesothelioma (-13%, -15%, and -17%). In the 29 patients with recurrent mesothelioma, the median progression-free survival was 12 weeks with 95% CI 9.1, 23.4 weeks (23.4 weeks merlin negative, n = 14; 11.4 weeks merlin positive, n = 9; 10.9 weeks merlin status unknown, n = 6). CONCLUSIONS: GSK2256098 has an acceptable safety profile, has evidence of target engagement at doses at or below the MTD, and has clinical activity in patients with mesothelioma, particularly those with merlin loss.

Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM.

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

Non-use of Formal Health Services in Malawi: Perceptions from Non-users.

BACKGROUND: The study upon which this paper is based was undertaken to understand users' and non-users' perceptions concerning facilitators and barriers to equitable and universal access to health care in resource-poor countries such as Malawi. In this study, non-users of health services were defined as people who were not in need of health services or those who had stopped using them due to significant barriers. METHODS: A total of 80 interviews with non-users of health services were conducted in Rumphi, Ntchisi, Phalombe and Blantyre Districts of Malawi. Interviews focused on why informants were not using formal health services at the time of data collection. In order to identify non-users, snowballing was used health surveillance assistants, village headmen and community members also helped. One focus group discussion was also conducted with non-users of health services who were members of the Zion Church. RESULTS: Informants described themselves as non-users of health services due to several reasons: cost of health services; long distances to health facilities; poor attitude of health workers; belief in the effectiveness of traditional medicines; old age and their failure to walk. Others were non-users due to their disability; hence they could not walk over long distances or could not communicate effectively with health providers. Some of these non-users were complete non-users, namely members of the Zion Church and those who believed in traditional medicine, and they stated that nothing could be done to transform them into users of health services. Other non-users stated that they could become users if their challenges were addressed e.g. for those who were non-users of health services due to poor attitudes of health workers, they stated that if these health workers were transferred they would be able to access health services. CONCLUSIONS: Public health education targeting both health workers and non-users, ensuring a functional outreach program and addressing other health system challenges such as shortage of drugs and human resources would assist in transforming non-users into users of health services.

The accuracy of interpreting key psychiatric terms by ad hoc interpreters at a South African psychiatric hospital.

OBJECTIVE: This study examined the competence and accuracy of ad hoc interpreters in interpreting key psychiatric terms at a South African psychiatric hospital METHODS: Nine individuals were asked to translate key psychiatric terms from English to Xhosa. These translations were then back-translated by independent translators, who do not have knowledge of psychiatric terminology. These back-translations were then compared with the original English. RESULTS: It was clear that not all the participants were fully competent in English. None had formal training in interpreting or psychiatric terminology. Not all of the participants were familiar with the psychiatric concepts that clinicians use and they often made mistakes while interpreting. CONCLUSION: The competency levels of interpreters are unsatisfactory to ensure the optimal delivery of mental health care. It is clear that there is a need for trained interpreters in South Africa, as the continuous use of untrained interpreters compromises the effectiveness of mental health care and could lead to adverse health outcomes.

Organising for self-advocacy in mental health: experiences from seven African countries.

OBJECTIVE: This paper reports on overarching strategies which supported the establishment and sustainability of 9 mental health self-help organisations in seven African countries. METHOD: Eleven key informants were identified through snowballing and interviewed regarding their experience in the organisations. Thematic analysis of the interview data and other documentary evidence was guided by a coding scheme derived using a framework analysis approach to defining, categorising, mapping and interpreting textual data. RESULTS: Sustainability strategies include: commitment to members' advocating for their rights and rebuilding their lives within their communities; independent decision-making, user-led membership and leadership; financial self sufficiency, alliances with donor organisations, non-governmental organisations (NGOs), disabled people's organisations (DPOs) and ministries which support self-determination and promote control over agenda-setting and responsiveness to members' needs. Organisations' work include advocacy to destigmatise mental disorders and promote the protection of users rights, activities to improve access to health care and to income generation and social support, participation in legislative and policy reform, and capacity building of members. CONCLUSION: Self-help organisations can provide crucial support to users' recovery in resource-poor settings in Africa. Support of Ministries, NGOs, DPOs, development agencies and professionals can assist to build organisations' capacity for sustainable support to members' recovery.

Mental health promotion and the prevention of mental disorders in South Africa.

The need for greater attention to mental health promotion and the prevention of mental disorders in South Africa is highlighted by the cycle of poverty and mental ill-health, the potential for social gains, the question of affordability of treatment in the face of the increasing burden of mental disorders, and the limitations of existing treatment methods. This article, which provides a desk review of the current status of mental health promotion and prevention of mental disorders in South Africa, suggests that South Africa has a number of policies that bode well for promoting mental health from infancy through to old age. There is, however, a need for programmatic interventions to promote resilience in vulnerable populations. Of note, is the need for programmes to address maternal depression and strengthen attachment and psychosocial stimulation during infancy, strengthen families, promote health enhancing school environments, and address intimate partner violence and build health enhancing social capital. Given the multifaceted nature of risk and protective influences, the need for a multi-sectoral plan of action is highlighted.

Family therapy for schizophrenia: cultural challenges and implementation barriers in the South African context.

Family therapy is an effective, evidence based intervention for schizophrenia. This literature review explores the impact of culture on family therapy as a treatment model for schizophrenia and examines how cultural beliefs impact on access to care. Although there is a good deal of evidence to suggest that certain principles of family therapy such as empathy and psycho-education are universal, there is a paucity of literature about the role of culture in designing family interventions for people living with schizophrenia in a culturally diverse setting such as South Africa. It is well acknowledged that cultural ideologies influence families' belief systems of schizophrenia, expected expressed emotion, and levels of stigma in relation to mental illness. Additionally, in adapting models designed for first-world settings, consideration needs to be given to aspects such as language, educational level and accessibility of mental health care facilities. Family therapists are increasingly recognising the need for the study and implementation of evidence based culture-relevant and culture-responsive therapeutic techniques. These techniques need to be cost-effective and will require training, supervision, staff support, and management input in order to become generally available.

Structural barriers to ART adherence in Southern Africa: Challenges and potential ways forward.

Structural barriers to antiretroviral therapy (ART) adherence are economic, institutional, political and cultural factors, that collectively influence the extent to which persons living with HIV follow their medication regimens. We identify three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, limited access to mental health services and difficulties in ensuring adequate counselling. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, migration, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, we identify ways in which individuals, communities and health care systems may overcome some of these structural barriers. Finally, we make recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.

Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean.

BACKGROUND: Studies suggest a paucity of and lack of prioritisation in mental health research from low- and middle-income (LAMI) countries. AIMS: To investigate research priorities in mental health among researchers and other stakeholders in LAMI countries. METHOD: We used a two-stage design that included identification, through literature searches and snowball technique, of researchers and stakeholders in 114 countries of Africa, Asia, Latin America and the Caribbean; and a mail survey on priorities in research. RESULTS: The study identified broad agreement between researchers and stakeholders and across regions regarding research priorities. Epidemiology (burden and risk factors), health systems and social science ranked highest for type of research. Depression/anxiety, substance use disorders and psychoses; and children and adolescents, women, and people exposed to violence/trauma were prioritised among the disorders and population groups respectively. Important criteria for prioritising research were burden of disease, social justice, and availability of funds. Stakeholder groups differed in the importance they gave to the personal interest of researchers as a criterion for prioritising research. Researchers' and stakeholders' priorities were consistent with burden of disease estimates, however suicide was underprioritised compared with its burden. Researchers' and stakeholders' priorities were also largely congruent with the researchers' projects. CONCLUSIONS: The results of this first ever conducted survey of researchers and stakeholders regarding research priorities in mental health suggest that it should be possible to develop consensus at regional and international levels regarding the research agenda that is necessary to support health system objectives in LAMI countries.

Genetic Research; Behavioural Science; and Child and Adolescent Mental Health in South Africa: an Important New Agenda

Background: Since the announcement of the results of the international research project to unravel the human genome in the early 1990s there has been a burgeoning of research into the genetic basis of psychopathology and development. South African behavioural researchers; however; have reasons to be cautious about the benefits of genetic research in the light of the historical link between eugenic interests and practices which were attractive to ideologies such as Nazism and apartheid. Methods: In this article we discuss the burgeoning interface internationally between behavioural and genetic research. We describe a number of areas of recent research that are particularly relevant to child and adolescent mental health in South Africa (antisocial behaviour; disorganised attachment and depression) that are beginning to illuminate the interactions between the behavioural and genetic domains. Discussion: We argue that we need to engage more actively with what the sciences of the brain and behaviour have to offer; and in so doing make a case for the urgent inclusion of genetic research in mental health research in South Africa

Genetic Research; Behavioural Science; and Child and Adolescent Mental Health in South Africa: An Important New Agenda

Background: Since the announcement of the results of the international research project to unravel the human genome in the early 1990s there has been a burgeoning of research into the genetic basis of psychopathology and development. South African behavioural researchers; however; have reasons to be cautious about the benefits of genetic research in the light of the historical link between eugenic interests and practices which were attractive to ideologies such as Nazism and apartheid. Methods: In this article we discuss the burgeoning interface internationally between behavioural and genetic research. We describe a number of areas of recent research that are particularly relevant to child and adolescent mental health in South Africa (antisocial behaviour; disorganised attachment and depression) that are beginning to illuminate the interactions between the behavioural and genetic domains. Discussion: We argue that we need to engage more actively with what the sciences of the brain and behaviour have to offer; and in so doing make a case for the urgent inclusion of genetic research in mental health research in South Africa

Is participation in HIV vaccine trials a health promoting behaviour?

Health behaviours are individual acts by which people aim to preserve or enhance their health. Theories commonly used to understand health behaviour include the Health Belief Model, the Theories of Reasoned Action and Planned Behaviour, the Transtheoretical Model of Change, Social Cognitive Theory and Problem-Behaviour Theory. Targets for health-promotion interventions include exercise, smoking cessation and condom use. Some behaviours that may contribute to changes in population health, however, are not health behaviours as traditionally understood. For example, participating in an HIV vaccine trial may have the potential to contribute long-term to lowering HIV incidence. To what extent, though, can or should we apply models of health behaviour to HIV vaccine trial participation? This article grapples with the theoretical challenges facing social scientists who conduct research related to HIV vaccine trial participation. We initially consider decision making regarding trial participation from both the participant and investigator perspectives, before considering how these alternate decision-making narratives might impact on the conduct of HIV vaccine trials. We conclude by arguing that social scientists need to move beyond a narrow focus on health promotion theory and to engage in the interrelated scientific activities of theory testing and theory building.

Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach.

As antiretroviral therapy becomes more widely available in low-resource settings and children with HIV/AIDS live for longer periods, disclosure of HIV diagnosis to infected children is becoming increasingly important. This article reviews the current literature on HIV-related disclosure in light of theories of cognitive development, and argues for the adoption of a process-oriented approach to discussing HIV with infected children. Disclosure presents unique challenges to healthcare workers and caregivers of children with HIV/AIDS that include controlling the flow of information about the child's HIV status to him/her and deciding on what is in his/her best interest. Health care workers' and caregivers' views regarding disclosure to children may often be contradictory, with healthcare workers likely to support disclosing the diagnosis of HIV/AIDS to children and caregivers more reluctant to discuss the disease with them. There is a clear need for practical interventions to support paediatric HIV disclosure which provide children with age-appropriate information about the disease.

Post-partum depression and infant growth in a South African peri-urban settlement.

AIM: To examine the association between maternal post-natal depression and infant growth. BACKGROUND: Infant growth has recently been shown, in two studies from South Asia, to be adversely affected by maternal depression in the early post-partum period. It is uncertain whether a similar association obtains in developing countries outside Asia. METHOD: A sample of 147 mother-infant dyads was recruited from a peri-urban settlement outside Cape Town and seen at 2 and 18 months post partum. RESULTS: No clear effect of post-partum depression on infant growth was found. Although maternal depression at 2 months was found to be associated with lower infant weight at 18 months, when birthweight was considered this effect disappeared. CONCLUSIONS: Possible explanations for the non-replication of the South Asian findings are considered.

A randomised control study of a fully automated internet based smoking cessation programme.

OBJECTIVE: The objective of this project was to test the short term (90 days) efficacy of an automated behavioural intervention for smoking cessation, the "1-2-3 Smokefree" programme, delivered via an internet website. DESIGN: Randomised control trial. Subjects surveyed at baseline, immediately post-intervention, and 90 days later. SETTINGS: The study and the intervention occurred entirely via the internet site. Subjects were recruited primarily via worksites, which referred potential subjects to the website. SUBJECTS: The 351 qualifying subjects were notified of the study via their worksite and required to have internet access. Additionally, subjects were required to be over 18 years of age, smoke cigarettes, and be interested in quitting smoking in the next 30 days. Eligible subjects were randomly assigned individually to treatment or control condition by computer algorithm. INTERVENTION: The intervention consisted of a video based internet site that presented current strategies for smoking cessation and motivational materials tailored to the user's race/ethnicity, sex, and age. Control subjects received nothing for 90 days and were then allowed access to the programme. MAIN OUTCOME MEASURES: The primary outcome measure was abstinence from smoking at 90 day follow up. RESULTS: At follow up, the cessation rate at 90 days was 24.1% (n = 21) for the treatment group and 8.2% (n = 9) for the control group (p = 0.002). Using an intent-to-treat model, 12.3% (n = 21) of the treatment group were abstinent, compared to 5.0% (n = 9) in the control group (p = 0.015). CONCLUSIONS: These evaluation results suggest that a smoking cessation programme, with at least short term efficacy, can be successfully delivered via the internet.

'What I've noticed what they need is the stats': lay HIV counsellors' reports of working in a task-orientated health care system.

Counselling has been recognized as an important component of HIV and AIDS care, and an essential part of HIV testing. In South Africa, a commonly used model is for lay counsellors to be trained by non-governmental organizations and then to work alongside professionals in public health clinics. In studies of counselling in health care settings in the context of HIV, there has been a relative lack of attention to the organizational and systemic issues faced by counsellors and counselling programmes. Counsellors are involved in a dynamic interrelationship not only with their clients but also with the organizations in which they work. In this paper we report on counsellors' accounts of the impact of their unclear position on their work. Twenty-nine counsellors were interviewed using individual interviews and focus group discussions. The findings reveal a clash between an holistic counselling approach and a task-oriented health system. The results provide some indication of the need to consider workplace issues in planning and researching VCT.

The cultural construction of healing in the Truth and Reconciliation Commission: implications for mental health practice.

The Truth and Reconciliation Commission (TRC) has been widely hailed by mental health practitioners and others as a source of psychological healing. In this article we consider this claim and its relevance to clinical practice. Recent research in anthropology and related disciplines in South Africa and elsewhere raises questions about the cultural construction of traumatic memory and healing. We argue that these questions have bearing on how we understand the role of mental health practitioners and mental health institutions in the post-TRC period. Case material is be used to illustrate our view that it is important to distinguish between individual and collective healing.

The determination of phosphorus in Haemophilus influenzae type b conjugate vaccines by inductively coupled plasma-atomic emission spectrometry.

This study describes a method for the determination of phosphorus in lyophilized Haemophilus influenzae type b conjugate vaccines by inductively coupled plasma-atomic emission spectroscopy (ICP-AES). The concentration of polysaccharide is directly related to the concentration of phosphorus as measured in the laboratory. Phosphorus is present in the polyribosyl-ribitol phosphate (PRP) group of the Haemophilus influenzae type b conjugate vaccine. The repeating unit of PRP is 3-B-D ribose[1-1]ribitol-5-phosphate. Phosphorus in the final container is measured in microg per dose. The amount of PRP is calculated from this and reported in microg per dose. The Haemophilus influenzae type b conjugate vaccine was analyzed for phosphorus content within the range of 1.34 to 2.02 microg phosphorus per ml. The relative difference of phosphorus concentrations determined by the ICP-AES method from the phosphorus concentrations determined by the traditional colorimetric molybdate method ranged from 2.2 to 10.6%. Phosphorus spike recovery for the vaccine ranged from 93 to 99% (1.93+/-0.13 microg P/ml). The phosphorus determination of NIST SRM 3139 phosphorus spectrometric solution differed by 3.0% from the certified phosphorus value (10.00 mg P/ml).