Browsing by Author "Magula, Nombulelo Princess."

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Access to healthcare : investigating the barriers to accessing antiretroviral treatment at a public sector antiretroviral clinic in Durban, South Africa.
(2013) Kriel, Yolandie.; De la Porte, Susan.; Magula, Nombulelo Princess.
South Africa has the largest HIV/AIDS epidemic in the world and due to the rapid scale up of access to antiretroviral drugs now has the largest antiretroviral program in the world. However access to antiretroviral treatment remains a challenge and the scale up of the drug programs has caused an additional burden on an already stretched and stressed public healthcare sector. At present there are only two lines of drug regimens available to the general public that rely on the public healthcare sector for the supply of their antiretroviral drugs. Resistance to the current regimens is a major concern that is not effectively being addressed. One of the major aspects that can contribute to a rise in resistance is barriers to continually accessing antiretroviral treatment. This ethnographic investigation into the barriers to accessing antiretroviral treatment was conducted in a public health sector clinic based at a large hospital in Durban. The specific objectives of the study were to elucidate the major barriers to accessing the treatment as perceived by the patients of the clinic, to understand the structural drivers behind the barriers and to capture the patients’ reactions to these obstacles that they face on a continuous basis. Unlike most studies that focuses only on adherence this study’s focus was rather on the concept of access to healthcare and how barriers perceived by the patients influence their ability to effectively access their treatment. Thus the concept of access to healthcare is explored in detail and an argument is made for the importance of understanding and applying the holistic concept of access to healthcare within the ART setting. An ethnographic approach was adopted to conduct this study, and the study utilized a triangulation of data collection techniques including participant observation, in-depth interviews, focus groups and a questionnaire. The research was done over a period of seven months and focused on adults who were already part of a regimen for a period of at least one year. Antiretroviral treatment regimens are for life and once people start with these regimens they cannot stop. However this study found that a range of barriers exist that present obstacles for patients to continually access ART drugs. Structural violence theory provided the framework for contextualizing the specific barriers that were reported and is important in terms of situating the barriers within the larger structures that create them. What is evident is that poor healthcare related policies, stigma, discrimination, economic inequality, gender and poverty are the structural drivers behind barriers to accessing ART. By incorporating a broader understanding of access to healthcare a deeper understanding of the barriers is gained and better interventions can be created to prevent disengagement from life-long ART services.
Assessment of the liver in an HIV era: clinical, laboratory and radiological abnormalities.
(2020) Mbanjwa, Bavumile.; Magula, Nombulelo Princess.
Background: Liver – related mortality and morbidity are an increasing burden worldwide. Aim: To outline the pattern of liver abnormalities at a tertiary hospital in KwaZulu Natal (KZN), Durban, South Africa, during the era of the HIV epidemic. Methods: This cross-sectional, retrospective study conducted medical records review of all patients found to have liver abnormalities based on clinical, laboratory, and radiological profile, admitted to the medical wards for the period between June 2016 to December 2016. Results: A total of 157 patients were included, of which 63.1% were males, and 91.7% were black, with a median age of 41 years (IQR, 32–54). Sixty – six (42.0%) patients were HIV negative; 91 (57.9%) were HIV infected, of which 51 (56.0%) were on antiretroviral therapy. Only 15 (29.4%) had an HIV viral load of < 50 copies/mL and 21 (30.9%) with a CD4+ count of ≥ 200 cells/mm3. In HIV negative, heart failure (48.5%) was the main cause of liver abnormalities (p-value < 0.001), whereas in HIV infected, abdominal TB (24.2%) and DILI (18.7%) were the commonest. Sixty- seven (42.7%) patients died while admitted, and leading causes were HIV/AIDS (40.3%), hypertension (13.4%), and metastatic cancer (13.4%). Conclusion: In HIV infected patients, abdominal TB was common, which was consistent with the common presenting symptoms of fever and vomiting in this group; whereas in HIV negative, heart failure was the commonest which was also consistent with the leading presenting symptoms of abdominal distension and ascites, and comorbid conditions of hypertension, diabetes mellitus, and dyslipidaemia which are all risk factors of cardiac diseases. Also, mortality was significantly high, and the leading causes were HIV/AIDS, hypertension, and advanced malignancy, which underscores the need to strengthen community-based screening programs for both communicable and noncommunicable disease for early detection and referral to care.
Compliance with the guidelines for the management of cardiovascular risk factors in patients with hypertension and/or diabetes mellitus.
(2022) Nqiwa, Khayakazi.; Magula, Nombulelo Princess.; Mbanjwa, Bavumile.
Background: Globally, the burden of cardiovascular diseases (CVDs) is increasing. In South Africa (SA), evidence-based management guidelines and clinical tools containing symptom-based algorithms and checklists have been implemented as interventions for use by clinicians at the primary health care (PHC) level. Clinicians are expected to fully comply with these guidelines to improve the quality of care and clinical outcomes. Objective: To determine clinician compliance with Primary Care (PC) 101 guidelines for the management of cardiovascular risk factors in patients with hypertension (HTN) and diabetes mellitus (DM). Method: In this retrospective study, we reviewed medical records of patients aged 18 years and older who were receiving chronic care for HTN, DM, or both, at a PHC clinic, in KwaZulu Natal, SA, between June 2015 and August 2016, excluding newly diagnosed patients. Results: Of the 99 patients included, 82 (83%) were females, and 88 (89%) were black; 70 (71%) patients had HTN, 27 (27%) had both HTN and DM, and 2 (2%) had DM only. The mean (SD) age was 60 (12) years. Of those with HTN (n = 70), blood pressure (BP) was measured in 57 (81%) at baseline, 56 (80%) at 6 months, and 62 (87%) at 12 months; body mass index (BMI) was documented in 10 (14%) and an estimated glomerular filtration rate (eGFR) done in 59 (84%). In those diagnosed with both HTN and DM (n = 27), BP was measured in 25 (93%) at baseline, 26 (96%) at 6 months, and 24 (89%) at 12 months; glucometer reading (GR) was checked in 22 (82%) at baseline and 6 months, and 20 (74%) at 12 months; feet examination and urine dipsticks analysis were documented in 1 (4%), and eye examination and BMI in 2 (7%); eGFR was performed in 21 (78%) and hemoglobin A1c (HbA1c) in 16 (59%). Of the patients with DM only (n =2), BMI, eye and feet examination were recorded in 0% and urine dipsticks analysis done in 1 (50%). Conclusion: This study showed low rate of clinician compliance with PC101 guidelines at a PHC clinic. However, reasons for clinicians’ non-compliance were not explored. This emphasizes the need for future investigations to identify barriers to following guidelines.
Evaluation of the left ventricular ejection fraction post right ventricular pacing at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, KwaZulu-Natal (KZN).
(2016) Kasipersad, Sherlina.; Magula, Nombulelo Princess.
Since the implantation of the first artificial pacemaker in 1958, these devices have become the treatment of choice in bradycardias. Despite its widespread use, only a few studies have looked at the effects of single chamber right ventricular(RV) pacing on left ventricular(LV) function in patients with sinus node dysfunction or atrioventricular node dysfunction. In addition, these studies have produced conflicting results with no consensus reached. Furthermore, the limitation to these studies were the small sample sizes and the absence of sequential echocardiographic monitoring of LV function in each patient. To the best of the authors’ knowledge, no such studies have been conducted in South Africa. This study reviewed data collected from Inkosi Albert Luthuli Central Hospital (IALCH), which is a government hospital in Durban, KwaZulu-Natal (KZN), South Africa. The objective of the study was to evaluate the effects of RV pacing on LV function in a setting where the majority of patients requiring a permanent pacemaker receive single chamber RV apical pacing. The focus of this study was to assess the effect of RV pacing on LV function by assessing the ejection fraction(EF), on echocardiography, pre and post pacemaker insertion. A retrospective chart review of 465 patients managed at the IALCH pacemaker clinic from 2003 up to 2012 was undertaken. Adult patients 18 years and older with a documented EF at the time of insertion of a pacemaker were included in the study. Patients were excluded from the study if they had coronary artery disease (CAD), unrepaired valvular heart disease, atrial fibrillation or dual chamber pacemakers. After enforcing the exclusion criteria, 430 patients were excluded and only 35 patients were eligible for the study. LV dysfunction was pre-defined as a left ventricular ejection fraction (LVEF) of < 50%. This study showed that RV pacing did not have a statistically significant effect on LV function post pacemaker insertion, based on the assessment of EF. The study was limited by the low number of eligible patients as it was a retrospective study and obtaining data was difficult as most patients who require a pacemaker do not routinely have a baseline echocardiograph done prior to insertion of the pacemaker. Another limiting factor in the study was that EF was the only modality of LV function that was assessed. Moreover, evaluation of the EF on echocardiography is subjective and user dependent. International studies have shown that the site of RV pacing has an impact on the degree of LV dyssynchrony and function. This factor could not be assessed in the current study as the site of RV pacing was not documented and was not standardised. Pacing in the correct clinical context is a necessity and is lifesaving. Current literature shows that RV pacing is a safe, relatively simple, convenient procedure that is well tolerated and is effective. This study showed no deterioration in LV function in patients post RV pacemaker insertion, which is important as the RV remains the most common site of lead placement especially in the resource limited state sector. Some studies have reported that RV pacing is associated with LV dysfunction. However, since there is a paucity of level 1 evidence regarding this aspect of RV pacing, the need for prospective studies on the long-term effects of RV pacing on LV function is required. In addition, the impact of alternative pacing sites on LV function should be explored.
Evolution of the CD4 count in the first 12 months following initiation of antiretroviral therapy in a South African public-sector patient population.
(2017) Mathenjwa, Mfundo Falethu.; Hift, Richard Jefcoate.; Magula, Nombulelo Princess.
Abstract not available.
Extrapulmonary tuberculosis at King Edward hospital : a descriptive retrospective study.
(2016) Gounden, Strinivasen.; Magula, Nombulelo Princess.
Background Globally, South Africa remains one of the top twenty high tuberculosis(TB) burden countries. In addition, South Africa has the highest burden of tuberculosis/Human Immunodeficiency virus (TB/HIV) coinfection in the world, with the province of KwaZulu-Natal representing the global epicenter of TB/HIV. With the scaling up of one of the world’s largest antiretroviral therapy programs, it was envisioned that the burden of tuberculosis would be reduced. While significant progress has been made to improve the diagnosis of pulmonary tuberculosis, the diagnosis of extrapulmonary TB(EPTB) remains a significant challenge in resource constrained settings. This study describes the profile of patients with EPTB at a tertiary hospital in a TB/HIV hyperendemic setting in Durban, South Africa. Methods A retrospective chart review was conducted, and included all adult patients diagnosed with EPTB at a tertiary hospital in Durban, South Africa, between 1 January 2016 and 31 March 2016. Data was extracted from the facility TB register, as well as patient clinical records. All data was analysed using SPSS software (SPSS 23.0, Armonk NY: IBM Corp). For all statistical comparisons, a 5% level of significance was used; correspondingly 95% confidence intervals were used to describe effect size. All data was assessed for normality, and non-parametric tests were used where necessary. Medians and interquartile ranges were used for data not amenable to parametric description. Pearson’s Chi-square test was utilised for comparison between subgroups. All p values were 2-tailed and considered significant below 0.05. Significant findings were analysed for association using Phi and Kramers V test for symmetric measures. Results There were 188 new cases of TB during the study period, with 80 patients diagnosed with EPTB. The mean age of patients was 34.73 years (SD ±9.44). Forty two (52.5%) patients were female, while 76(96%) were black African. The most common risk factor for EPTB was HIV co-infection (88.8%). The median CD4 cell count was 68 (IQR 32-165) cells/mm3. Pleural (36.3%), lymph node (28.7%) and abdominal(27.5%) involvement were the most common sites of extrapulmonary disease Eleven of the 80 patients (13.8%) presented with EPTB involving more than one anatomical system. Weight loss, fever, night sweats and cough were amongst the most common symptoms reported. Signs varied according to the site of infection. Non-specific symptoms were common. In the majority of cases, more than one diagnostic method was used to confirm the presence of TB in distant organs. Conclusion A high index of suspicion is required when assessing a patient with known risk factors for EPTB. Immunosuppression remains the most significant risk factor for the development of EPTB. In our setting, HIV co-infection remains the most common risk factor. Advancements in Xpert MTB/Rif and computer tomography have greatly assisted in rapidly diagnosing EPTB. Despite improved access to antiretroviral therapy over the past years, advanced HIV disease remains a significant challenge to eradicating TB.
Metabolic complications of antiretroviral therapy (ART) in a South African black population..
(2014) Magula, Nombulelo Princess.; Lalloo, Umesh Gangaram.; Motala, Ayesha Ahmed.
Aims To determine the prevalence and incidence of lipodystrophy (fat distribution [lipoatrophy and lipohypertrophy] and metabolic complications [insulin resistance-dysglycaemia and dyslipidemia]) in HIV-1 infected adult subjects of second generation Zulu descent at baseline and during 24 months of follow-up on antiretroviral therapy (ART). Methods The total study group included three groups: HIV infected ART naive patients eligible for ART (HIV-ART, n=150), age, gender and ethnically matched HIV infected not eligible for ART (HIV-no ART, n=88) and HIV negative (control, n=88) subjects. All participants had demographic, anthropometric, biochemical and radiological assessments at baseline; in addition, the HIV-ART group had follow-up assessments for 24 months on ART (tenofovir, lamivudine and nevirapine or efavirenz). Fat distribution was assessed using FRAM questionnaires, computerized tomography (CT) scans and dual energy absorptiometry X-ray (DXA). Disorders of glycaemia (diabetes mellitus (DM), impaired glucose tolerance and impaired fasting glucose) were defined using WHO criteria. Total, LDL, HDL cholesterol and triglycerides were measured for each group; CD4 cell count and HIV RNA for group 2 and 3, at baseline, 3, 6, 12, 18 and 24 months. Poisson approximations estimated incidence of disorders of glycaemia. Results At baseline, when compared with the control group, the mean BMI (kg/m2) was significantly lower in the HIV-ART and HIV-no ART subjects (26.4 vs. 28.6 vs. 29.1; p =0.01). Prevalence of lipoatrophy as measured by participant and physician examination questionnaires was similar in the three groups. Visceral and subcutaneous fat area by CT scan were similar between the groups but limb and trunk fat mass by DXA scan was significantly lower in the HIV-ART compared to control subjects. In the HIV-ART group, at the 24 month follow-up, there was a significant mean reduction in HIV RNA (p<0.0001) and increase in CD4 cell count (p<0.0001). The mean BMI increased to 29.4 kg/m2 and no lipoatrophy developed; DXA scan showed a 33.6% increase in trunk fat mass (mean difference 4.2 kg, p <0.0001) and 30.8% increase in total fat mass (mean difference 9.4 kg, p < 0.0001); visceral (p 0.005) and subcutaneous (p 0.0002) fat area also increased. At baseline, the prevalence of DM was 0% in HIV-ART and HIV-no ART and 4.9% in control subjects (p 0.005); the prevalence of “any dysglycaemia” was 3.7% in HIV-ART and HIV-no ART compared to 8.6% in control subjects. When compared with group 1, mean values in group 3 were lower for the following serum lipids: total cholesterol (p<0.0001), LDL (p=0.0007) and HDL (p<0.0001). There was no difference in mean total triglycerides in the three groups (p=0.3). During follow-up, in the HIV-ART group, using glucose-based WHO criteria, the incidence of diabetes mellitus was 2.3 per 100 person year follow-up (PYFU) and of “any dysglycaemia” 7.6 per 100 PYFU. The only independent predictor of DM was visceral: subcutaneous fat ratio measured by CT scan (HR 2.95 [95% CI 1.25-6.98], p 0.01). Significant predictors for development of “any dysglycaemia” included systolic blood pressure (HR 1.04 [95%CI 1.02-1.07], p=0.0006), serum albumin (HR 0.85 [95% CI 0.76-0.94], p=0.002), CD4 cell count (HR 0.988 [95%CI 0.978-0.997], p=0.01) and efavirenz (HR 6.27 [95%CI 1.65-23.80], p=0.01) Serum total (p<0.0001), LDL (p<0.0001) and HDL-cholesterol (p<0.0001) increased significantly during follow-up. Conclusion: In this cohort of South Africans with HIV-1 infection, at baseline (prior to ART) there was no significant fat redistribution or lipoatrophy and an absent to low prevalence of dysglycaemia. In the follow-up study, ART use was not associated with lipoatrophy although there was significant increase in BMI and in limb and trunk fat mass by DXA scan. ART was associated with increased incidence of dysglycaemia. These findings underscore the importance of clinical monitoring on ART. The association of efavirenz with dysglycaemia warrants further evaluation.
Morbidity and mortality in the modern antiretroviral treatment era in a tertiary teaching hospital in Durban, South Africa.
(2020) Riziki, Manimani Ghislain.; Magula, Nombulelo Princess.
Background: Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) is recognized as the chief cause of morbidity and mortality in Sub-Saharan Africa. South Africa is known to bear the highest number of people living with HIV globally, while KwaZulu-Natal is the worst affected province in this country. Aim: To identify the determinant of morbidity and mortality in the modern antiretroviral therapy (ART) era in South Africa. Study design: A cross-sectional study. To achieve the objective, a mixed data acquisition method was applied using qualitative and quantitative data. These included a systematic review and a retrospective chart review. Data collection and analysis: For the systematic review, relevant studies were searched from the following databases: Google Scholar, PubMed, CINAHL. Two review authors independently screened titles abstracts and full-text articles in duplicate, extract data and assess the bias. Discrepancies were resolved by discussion or arbitration of a third review author. The study used the Preferred Reporting Item of Systematic Review (PRISMA 2015) guideline. This study used R software version 3.6.2. to synthesis the data, graphic displays were used to visually compare the prevalence of comorbidities across the study region. With the retrospective chart review, we conducted a study of all patients admitted at King Edward medical wards, Durban, South Africa from January to December 2018. Data were obtained from medical records, including demographic profile, clinical attributes and laboratory records. Data were analysed using R software version 3.6.2. In addition, the association between the covariates was tested either with the Chi-Square test, Kruskal Wallis or Wilcoxon rank-sum test depending on the type of variables. A p-value < 0.05 was used as a benchmark for determining the level of statistical significance Results: For the systematic review a total of 409 articles were obtained from the database search, finally12 articles were eligible for data extraction. All 12 studies included were published between 2008 and 2018 in English and they were conducted in Sub-Saharan Africa. Among them, three were conducted in Nigeria, two were conducted in Uganda, three were conducted in South Africa, one in Gabon, one in Ethiopia, one in Ghana, and one in Burkina Faso. In most of the included studies, tuberculosis was the first commonest causes of hospitalization accounted for 40.7% followed by anaemia with 34.2% and toxoplasmosis with 29.3%. It was as well the first cause of death accounted for 44.3% followed by anaemia with 30.2% and toxoplasmosis 27.5%. Contrary one study reported anaemia as the first causes of hospitalization and two studies reported each respectively wasting syndrome and meningitis as the first causes of death. With regards to the chart review, a total of 577 (50.6%) females and 564 (49.4%) males were included in the study. The mean age of all the participants was 39.6±12.2, 506 (44.3%) patients had CD4 less than 200 cells /mm3 and 273 (23.9%) had VL ˃ 1000 copies/ml. Male gender [OR 1.39(1.07-1.8) p=0.015], age [OR1.02(1.01-1.03) p˂ 0.001], CD4 <200 cells/mm3 [OR 2.14(1.37-3.45) p=0.001], VL ˃ 1000 copies/ml [ OR 1.93(1.08-3.63) p=0.032] were associated with mortality among HIV infected patients admitted in the cohort. Tuberculosis (TB) was the most common diagnosis on admission and the leading cause of death which accounted for 257 (22.5%) and 73 (24.3%) respectively, followed by kidney disease with 83(7.2%) for admission and with 38(12.6) for death. Only 70% of patients had been reported to be on ART. Age, men gender, CD4 cell and viral load were associated with mortality. Association between CD4 cell count and viral load was found. Conclusion: Despite the recent improvement of modern antiretroviral treatment, HIV/AIDS still causes hospitalization and death among HIV infected patients. For the systematic review as well as for the chart review, tuberculosis was the commonest cause of hospitalization and death in Sub-Saharan Africa and South Africa, but it was always followed by other opportunistic infection and other non-AIDS related conditions. There is a need to prevent opportunistic infection (especially tuberculosis) and to tackle the non-communicable disease related to HIV infection. Also, a need to start antiretroviral treatment early for patients living with HIV. Keywords: Morbidity, Mortality, Antiretroviral therapy, Sub-Saharan Africa, South Africa.
Outpatient treatment of drug-resistant tuberculosis in a hyperendemic setting.
(2021) Pillay, Jashen.; Gounden, Strinivasen.; Sadhabiriss, Dhiren.; Magula, Nombulelo Princess.
Background: The existence of multidrug-resistant tuberculosis (MDR-TB) represents a failure of effective infection control. There are over half a million new cases diagnosed annually with treatment success rates of only 57% reported in 2019. These numbers are highest in hyperendemic regions of the world, including South Africa, which has a high burden of tuberculosis and HIV co-infection. Treatment of MDR-TB is challenging and is usually managed at specialised centres. There is currently a transition into the decentralised treatment of MDR-TB for outpatients. Describing the features of DR-TB may influence improved treatment strategies for the future. Objectives: To determine the prevalence of DR-TB at a single, central outpatient site in a hyperendemic area of South Africa, and to evaluate known risk factors and their relationship with outcomes, including time between diagnosis and treatment initiation. Methods: A retrospective chart review of all new cases of DR-TB referred to a central hospital in Durban for outpatient care for the period 01/01/2017 to 31/03/2017 was conducted. Data included demographics, co-morbidities, time-to-treatment, treatment adverse effects and outcomes and were collected and collated from physical charts and the computerised registry. The data was then analysed using SPSS software. Results: The period prevalence of MDR-TB at the site was 44 cases/100 000 population. Of these cases, one hundred and eleven new cases of DR-TB were included in the analysis which comprised 57 (51.35%) males. Most patients were of African ethnicity (n = 107, 96.4%). Thirty-one (27.9%) patients did not have HIV co-infection. More than one-half of patients (n = 56, 51.5%) had a history of TB and was significantly higher in males than in females (n = 34, 59.6%) and n = 22, 40.7%) respectively; p= 0.020). Five (4.5%) patients had co-morbidities of hypertension, diabetes mellitus, or renal impairment. Most patients (n = 98, 88.3%) were treated within three months of diagnosis. The mean time-to-treatment was significantly longer in patients with extrapulmonary DR-TB (150.14 (±175.90) days compared to 53.21 (±66.01) days; p-value=0.002). Significantly more patients were treated within 6 weeks if they had a positive GeneXpert test (n = 35, 89.7% compared to n = 11, 17.5%, p=0.013). Fifty-one different treatment regimens were used, and 139 side-effects were reported, the most common being ototoxicity, hypothyroidism and peripheral neuropathy. Eighty-two (73.87%) patients completed follow-up until cure. Conclusion: The high burden of TB and HIV co-infection as well as a history of TB are associated with the elevated prevalence of MDR-TB in this setting. Side-effects are common and may impact toward poorer treatment adherence in addition to co-morbidities. Outcomes are favourable in specialised outpatient settings. A decentralised approach reduces the time-to-treatment in other studies, but large-scale implementation is recommended for further evaluation.
Prevalence and outcome of cryptococcal meningitis among HIV infected patients admitted to a tertiary level facility in an HIV endemic setting in art era.
(2018) Gasem-Agha, Najua.; Magula, Nombulelo Princess.; Naidoo, K.
Background: Cryptococcal meningitis (CM) is a common AIDS (acquired immunodeficiency syndrome) - defining illness that contributes to morbidity and mortality among HIV-infected adults in South Africa (SA). Methods: We conducted a retrospective study among HIV infected patients aged ≥13 years, admitted to medical wards to better understand factors that contribute to ongoing high mortality among patients presenting with cryptococcal meningitis. Results: There were 322 lumbar punctures (LP) received from medical wards, from patients presenting with features suggestive of meningitis. A total of 44 CSF samples were deemed abnormal.26 patients had confirmed cryptococcal meningitis. Among those patients, 51.8% (14/27) were female and 48.2% (13/27) were male. No further clinical data available for 3/27 patients due to missing charts,1/27 was HIV uninfected therefore excluded from the study. Headache was the most common 91.3% (21/23) presenting feature, with overall mean duration of symptoms of 2 weeks (range: 1 -3 weeks). On admission 87% (20/23) were known HIV positive, with 13.0% (3/23) confirmed HIV positive during admission. Mean length of stay was 18 days IQR (1-15 day). Lumbar puncture (LP) was done to 95.6% (22/23) and therapeutic LPs were done only in 31.8% (7/22). Renal impairment developed in 39 % (9/23), 2/23 (8.7%) patients developed hydrocephalus, 26.1% (6/23) died, 30.4% (7/23) required further care, while 43.4% (10/23) were discharged. XXII Conclusion: Improving medical management through more effective treatment and prevention services for cryptococcal disease is required.
Renal manifestations of human immunodeficiency virus in the era of antiretroviral treatment in South Africa.
(2016) Assaram, Shirelle.; Mashamba-Thompson, Tivani P.; Magula, Nombulelo Princess.
Background: Sub-Saharan Africa carries the global burden of human immunodeficiency virus (HIV) infection. Renal disease is a well-recognized and closely associated complication of HIV infection. The burden of kidney disease in Africa is aggravated by poor socio-economic factors and by the lack of access to healthcare and to resources. Most of what is known regarding HIV related kidney disease has come from research done in high income countries. Aim: Demonstrating the current stance on renal manifestations of HIV in South Africa in the era of antiretroviral treatment (ART). Study design: This is a cross-sectional study. Mixed data acquisition methods using qualitative and quantitative research approaches were applied in this study in order to achieve the objectives. These included a systematic scoping review and a retrospective chart review. Data collection and analysis: The systematic scoping review began with a database search of published literature based on studies conducted in South Africa. The following databases: Google Scholar, PubMed, Medline, Cochrane Library, Worldcat.org and EBSCO host were searched to obtain relevant literature. We formulated a standardized data extraction table according to the PICO model. We presented a narrative account of the findings by performing a thematic content analysis of the included studies. For the chart review we extracted data from medical records of all new patients initiated on ART from April 2010 to December 2013. The sample size was 350 patient records. We collected data at baseline (pre-ART) and then at 6, 12, 18 and 24 months on ART. Descriptive statistics were used to describe the characteristics of HIV-related renal manifestations at the King Edward VIII Hospital ART clinic. Results: The results of the systematic scoping review showed that normal renal function occurred in 28.4% to 79% of patients, mild renal impairment occurred in 19% to 57.1% and moderate renal impairment in 2% to 14.4%. Only 1.3% of patients had severe renal impairment. Both the Cockcroft-Gault equation (after correcting for bias) and the 4-variable Modification of Diet in Renal Disease equation (without the ethnicity factor for African Americans) have been validated for the estimation of glomerular filtration rate (eGFR) in Black South Africans. HIV-associated nephropathy was the most prevalent histology seen (57.2%). Older age, a lower CD4 count, a low haemoglobin and a detectable viral load were linked to renal impairment. Renal function improved in the first year of commencing ART. With regards to the chart review, 64% of the cohort was female, 99% were African and the mean age was 36.9±9.7 years. At baseline, 10 patients had hypertension, 6 had diabetes, 61 were co-infected with tuberculosis (TB) and 157 patients had a high body mass index (BMI) with 25.4% being categorized as overweight and 19.4% obese. Regarding baseline renal function, the majority of the patients had a normal renal function: 90.4% (95% confidence intervals (CI):86%-93%); 7.0% (CI:5%-10%) had moderate renal impairment; 1.3% (CI:0%-3%) had severe renal impairment; and 1.3% (CI:0%-3%) had kidney failure. The risk of renal impairment increased by 1.06 (CI: 1.03 – 1.10) times as BMI increased by one unit. The association of hypertension (HPT) with abnormal renal function was found to be insignificant, p>0.05. The majority of patients were initiated on tenofovir disoproxil fumarate (TDF) (90.6%), in combination with lamivudine (3TC) (100%) and either efavirenz (EFV) (56.6%) or nevirapine (NVP) (43.4%). Conclusion: The scoping review highlights age, CD4 cell count, haemoglobin, detectable viral load as factors associated with renal impairment and the improvement in renal function with use of ART. As more patients are started on ART according to the ‘test and treat’ approach to HIV prevention and management in South Africa, it is possible that the benefit may extend to the burden of kidney disease, however, hypertension, diabetes and obesity may reduce these benefits. The chart review found a low prevalence of baseline renal impairment in HIV-infected ART-naïve outpatients. An improvement in renal function after the commencement of ART has been demonstrated among this population. However, the long-term outcomes of patients with HIV-related renal disease is not known.
A retrospective review of the clinical outcomes in patients admitted to a newly established medical High Care Unit at King Edward VIII Hospital.
(2016) Naidoo, Darrin Ryan.; Magula, Nombulelo Princess.
Abstract available in PDF file.
A retrospective review of the demographic profile, disease activity, co-existent co-morbid disease and treatment in established rheumatoid arthritis at a tertiary center clinic.
(2016) Singh, Akira.; Paruk, Farhanah.; Magula, Nombulelo Princess.
Rheumatoid arthritis (RA) is one of the most common forms of chronic inflammatory arthritis and often results in joint damage, physical disability and premature mortality. The incidence of RA is increasing in developing countries, especially in urban areas amongst lower socio-economic groups. There is a dearth of data on non-communicable diseases such as RA in South Africa (SA) as resources and research is concentrated on addressing the high burden of communicable diseases due to human immunodeficiency virus (HIV) and tuberculosis (TB) compounded with addressing high maternal and infant mortality rates. Therefore despite the severity and resultant functional disability, RA remains poorly understood and often mismanaged. This study aims were to understand the natural history of patients with RA treated in a public sector tertiary clinic. The objectives of this retrospective study are to describe the demographic profile, disease activity, drug management and comorbid disease profile in patients with established RA attending a dedicated rheumatic clinic at King Edward VIII Hospital in Durban. A retrospective chart review was conducted of the files of all RA patients attending the arthritis clinic at King Edward VIII Hospital, for a period of at least ten years. The demographic data, serological status, current disease activity, functional class, co-morbid diseases, and treatment were recorded on a structured data collection tool. In this study, Indians comprised the majority (n=81, 58.7%) followed by Blacks (n = 51, 36.9%). All the patients met the clinical criteria for RA on the initial visit, with 73 (63.5%) having a positive rheumatoid factor (RF). Synovitis was still observed in 35.5% of patients at their last visit and in these patients the C-reactive protein remained elevated at ≥ 16 mg/dL (p < 0.0001). Radiographs showed a significant deterioration in terms of erosions between the two time points (p < 0.021). Hypertension was the most frequent co-morbid disease seen in 96 (69.6%) patients. There were several limitations as this was a retrospective study and therefore there were a number of files that had incomplete or missing data. The clinical assessment of disease was performed by several clinicians and inter-observer variability was another shortcoming. Further the study was limited to the public sector only and potentially excluded other ethnicities and therefore may also not be an accurate reflection of natural history of RA in SA. This study highlights the need for better and tighter RA control in the SA public sector and the need for prospective studies with adequate representation of all ethnic groups to evaluate the challenges faced in delivering an effective rheumatology service in SA.
Treatment outcomes of gene xpert positive tuberculosis patients in Kwamashu Community Health Centre, KwaZulu-Natal South Africa: a retrospective review.
(2020) Pillay, Sarusha.; Magula, Nombulelo Princess.
Abstract available in PDF.