Disability in an urban black community in Zimbabwe

What low back pain is and why we need to pay attention

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Musculoskeletal health conditions among older populations in urban slums in sub-Saharan Africa

BACKGROUND

Debate on the burden of musculoskeletal (MSK) conditions in lower and middle income countries is intensifying; yet, little knowledge so far exists on patterns and impacts of such conditions among general or older adult populations in sub-Saharan Africa (SSA). The objectives of this study are to examine the prevalence, potential predictors, and sequelae of MSK among older adults residing in two low resource informal urban settlements or "slums" in Nairobi Kenya.

METHODS

Data on older adults aged 60 years and over from two unrelated cross-sectional surveys on the older slum populations are used: a 2006/7 survey on the social, health, and overall well-being of older people (sample N = 831), and a 2016 survey on realities and impacts of long-term care and social protection for older adults (sample n = 1026). Uni and multivariate regressions on the 2006/7 data are employed to examine relationships of back pain and symptoms of arthritis with sex, age, wealth, unemployment, diagnoses of hypertension, and diabetes; and with indicators of subjective well-being and functional ability. Descriptive frequencies and chi-squared tests of association are used on 2016 data to identify the overall prevalence and locations of activity limiting MSK pain, and sex differences in these.

RESULTS

Prevalence of past month back pain and past 2 week symptoms of arthritis was 44% and 42.6%, respectively. Respective prevalence of past month activity limiting back pain and joint pain was 13.9% and 22.7%. A total of 42.6% of slum residents with a current health problem report MSK as the most severe problem. In multivariate regressions, female sex, unemployment, and diagnosis of hypertension are predictive of back pain and symptoms of arthritis. Both conditions are associated with raised odds of having lower quality of life, poorer life satisfaction, and depressive symptoms, and with mobility impairments and self-care difficulties.

CONCLUSIONS

MSK conditions are salient, and a likely key cause of impaired subjective well-being and functioning among older slum populations in SSA. Further research on determinants and consequences of such conditions in older slum populations is required to inform debate on responses to MSK as part of efforts to reorient SSA health systems to aging and to improve slum health.

[Formalized consensus: clinical practice recommendations for the management of the migraine in African adult patients]

Migraine is a primary headache disorder (according to the latest International Headache Society criteria) affecting approximately 8% of African population. Women are more often affected than men and attacks usually occur before the age of 40 years Although some treatments, hygienic-dietary measures and other non-pharmacological methods can reduce the intensity and frequency of attacks, medicinal treatment of migraine attack is often necessary. Availability of treatments and access to care differ in Africa and led to the implementation of the first expert consensus recommendations for the management of the migraine in african adult patients. This multinational collaborative study is intended for health practitioners. It aims to provide 16 simple, evidence-based recommendations and is adapted to african medical practice.

The spectrum of neurological presentations in an outpatient clinic of rural Zimbabwe

BACKGROUND

Previous studies to estimate burden of neurological disorders in Africa are limited to inpatients in urban hospitals. The spectrum of neurological conditions in rural Africa remains unclear.

OBJECTIVE

To determine the spectrum of neurological presentations in an outpatient setting in rural Zimbabwe.

METHODS

Clinical data was collected from outpatient records at Karanda Mission Hospital, a rural community hospital in Northern Zimbabwe from February 2013 to February 2014. Each patient visit was entered in an outpatient record book by a registered nurse or a nurse trainee. Demographic details such as age, sex, weight and address of the patient, and clinical details such as diagnosis on discharge and medications prescribed were recorded in the record book following assessment by a physician or nurse practitioner. Each visit corresponded to a separate entry in the study.

RESULTS

We recorded a total of 19,206 visits in the outpatient registry. The average age was 46.41 years (standard deviation=21.46), and there were more visits from women (57.81%). 11.63% (2233) of all visits had a neurological diagnosis at discharge. The most common neurological diagnoses were epilepsy/seizures (24.38%), followed by neuropathies (13.63%), headaches (11.4%) and strokes (4.6%).

CONCLUSIONS

One in ten cases in an outpatient setting in rural Zimbabwe were neurologically related. Further studies are required to determine the public health burden of neurological disorders in rural Africa. The development and funding of educational initiatives in resource-limited areas is needed to improve neurological diagnosis and care.

The need for a Rehabilitation Model to address the disparities of public healthcare for people living with HIV in South Africa

Rehabilitation in the context of HIV management in Africa is still a neglected field which holds great promise for the improvement of the quality of life as well as integration of people living with HIV back into their communities and homes. However, rehabilitation has not been incorporated into HIV care despite the fact that a large number of people living with HIV experience disability. The dearth of literature and lack of models of care to roll out rehabilitation for people living with HIV in Africa are astounding. Well-resourced countries have emerging approaches on the management of disability in the context of HIV. However, epidemic countries are still lacking such an approach neglecting the devastating effects of disability on individual livelihoods and antiretroviral treatment adherence. Thus, rehabilitation needs to be integrated into the response to HIV. This article advocates for the development and implementation of a model of care to guide rehabilitation of people living with HIV in South Africa.

The UWEZO project-musculoskeletal health training in Kenya

A major cause of disability and pain, musculoskeletal conditions (MSC) affect all aspects of people's lives and have a significant socioeconomic impact. Access to early diagnosis, effective treatments and rehabilitation enables people with MSCs to maintain their mobility, to work and to have a good quality of life. Despite the significant impact of MSC on health, social and economic well-being in Africa, services for MSC health remain extremely under-resourced. The UWEZO project is a collaboration between Kenyan, UK and Swedish rheumatologists, patients and researchers. It aims to improve access to basic musculoskeletal health care at the local level in communities across Kenya through the development of a sustainable training programme to raise the knowledge and skills of health professionals working in the community in the early detection, diagnosis and management of MSC. A team of physicians and patients have been trained to deliver an MSC education programme to health providers working in 11 locations across Kenya. Over 500 health providers have been trained. The programme has the potential to be adapted for use in other low resource countries where access to care for musculoskeletal conditions is limited.

Patterns of knee osteoarthritis in a hospital setting in sub-Saharan Africa

Osteoarthritis (OA), the most prevalent joint disease in adults, ranks among the top 5 causes of disability. The burden of OA is expected to be greater in developing countries, where life expectancy is increasing and access to joint replacement therapy is not readily available. Risk factors associated with knee OA in Africa may differ from those identified in other parts of the world. This study aimed to establish the prevalence, clinical presentation, and associated factors of knee OA in two large referral centers in Cameroon. Between February and July 2012, we performed a cross-sectional analysis of 148 patients with knee OA followed at two rheumatology units in Douala. We included all patients with mechanical knee pain, who fulfilled the 1986 ACR for the classification and reporting of knee OA. One thousand four hundred ninety-six patients with musculoskeletal complaints were seen; 148 (9.9%) with knee OA were analyzed. Mean age was 56.9 ± 10.7 years, 75% were females, and 68% were post-menopausal. The VAS of pain at the time of diagnosis was higher than 50/100 mm in 64.2% of patients. Mean pain duration was 1 year (7 months-3.5 years). Obesity (BMI > 30) was present in 52% of patients, hypertension in 37.2%, and diabetes in 8.8%. Knee x-ray showed 35.5% of patients with grades III and IV on Kellgren and Lawrence classification. Bilateral bi-compartmental knee OA was found in 38.5% of patients and bilateral tricompartmental in 14.2%. The mean Lequesne disability index (LDI) was 8.4 ± 2.8. Pain intensity did not correlate with radiological findings whereas there was an association between pain and LDI. Knee OA is not rare among patients in Cameroon. Multiple factors including limited access to health care may account for why knee OA patients present at later stages of the disease with severe disability.

The emerging pattern of disability in Rwanda

PURPOSE

The purpose of this paper is to describe the emerging pattern of disability (activity limitation) in terms of its prevalence, age and gender distribution in Rwanda.

METHOD

A door-to-door survey was conducted in all households in villages from two districts selected through a multi-stage sampling procedure. Identified persons were screened for activity limitations using age-appropriate instruments developed from domains in the ICF. Proportions were computed and disaggregated by age group, gender, district and activity limitation. A multi-disciplinary rehabilitation team including community members participated in the development of instruments, community mobilisation, data collection and collation.

RESULTS

Prevalence rates of 8.6% (Bugesera) and 14.7% (Musanze) were obtained. The prevalence of disability was higher in adults than in children in both districts (10.4% versus 6.6% in Bugesera and 19.6% versus 7.7% in Musanze). Visual limitations occurred the most frequently in both adults and children in both districts. Mobility and mental health limitations also notably contributed to the overall disability burden.

CONCLUSION

The prevalence of disability obtained was higher than all previously reported data for Rwanda. Despite the limitations, the findings provide useful information for planning rehabilitation services and to direct future enquiry into the epidemiology of disability in Rwanda. Implications for Rehabilitation It is important to design specific surveys to measure disability using contemporary methods to gauge the situation accurately and qualitatively. Currently, the ICF provides the best framework to describe the epidemiology of disability meaningfully; it enables comparisons within and between countries and regions of the world; and enables the active participation of a wide range of rehabilitation stakeholders including PWDs and lay community members. The vast majority of disabilities in Rwanda are limitations in visual, mobility and mental health functions.

Prevalence and correlates of mental distress among working adults in ethiopia

Objective:

To evaluate the prevalence of mental distress and its correlates among working Ethiopian adults.

Methods:

This cross-sectional study of 2,180 individuals (1,316 men and 864 women) was conducted among working adults in Addis Ababa, Ethiopia. A structured questionnaire was used to collect information on socio-demographic and lifestyle characteristics of participants. Mental distress was assessed using the self-reporting questionnaire (SRQ). Logistic regression was employed to estimate adjusted odds ratios (OR) and 95% confidence intervals (95% CI).

Results:

The prevalence of mental distress in the study sample was 17.7% (25.9% in women and 12.4% in men). Younger participants (age ≤24 years) had the highest prevalence of mental distress (35.5% in women and 16.7% in men). The odds of mental distress was 2.47-fold higher among women as compared with men (OR=2.47, 95% CI 1.97-3.09). Participants reporting excellent health status had a 50% reduced odds of mental distress (OR=0.47; 95%CI: 0.38-0.59); and moderate alcohol consumption was associated with a slight increased odds of mental distress (OR=1.26; 95%CI: 1.00-1.67).

Conclusion:

A high prevalence of mental distress was observed among working adults in Ethiopia. Our findings suggest that the workforce institutions should provide targeted prevention and intervention programs to improve the mental health state of their employees. National mental health policy that clearly outlines and addresses mental distress among working adults is also warranted.

Neurodevelopmental impairment among infants born to mothers infected with human immunodeficiency virus and uninfected mothers from three peri-urban primary care clinics in Harare, Zimbabwe

AIM

The aim of this article is to document the risk of neurodevelopmental impairment (NDI) among infants enrolled in a programme for the prevention of mother-to-child transmission of HIV (human immunodeficiency virus) in Zimbabwe using the Bayley Infant Neurodevelopmental Screener (BINS).

METHOD

We prospectively followed up infants at three primary care clinics in Harare, Zimbabwe. Neurodevelopmental assessments using the BINS were conducted during the first 12 months of life. NDI risk category and associated risk factors were examined.

RESULTS

Of the 598 infants assessed, 305 (51%) were female and 293 (49%) were male. Sixty-five infants (11%) were infected with HIV, 188 (31%) were exposed but uninfected, 287 (48%) were unexposed, and 58 (10%) were of unknown status. The prevalence of a high risk of NDI was 9.4% (95% confidence interval [CI] 7.1-11.1%): 9.2% in males and 9.6% in females. Of the 598 infants, 549 (92%) had ever been breastfed, 49% of whom had mothers infected with HIV. The risk of NDI was higher among infants infected early with HIV, i.e. by 3 months of age (p value <0.001). The NDI high-risk category included twice as many infants infected with HIV as uninfected infants (odds ratio [OR] 2.1; 95% CI 1.0-4.3). After adjusting for other factors, head circumference and family financial subsistence remained risk factors for NDI with an OR of 2.22 (1.04-4.82) and 2.55 (1.02-6.36) respectively.

INTERPRETATION

The background prevalence of high-risk NDI category of 9.4% across groups seems high but is similar to that reported previously in developing countries. Integration of an early infant neurodevelopmental screening programme into child HIV management protocols will assist in the early referral of children exposed to HIV.

The prevalence and functional impact of musculoskeletal conditions amongst clients of a primary health care facility in an under-resourced area of Cape Town

BACKGROUND

The extent of disease burden of musculoskeletal conditions (MSC) not due to injury has not been well determined in sub-Saharan Africa. The 1999 Global Burden of Disease study estimated the prevalence of osteoarthritis and rheumatoid arthritis to be 150/100,000 compared to 1,500/100,000 in Europe. The objective of the study was to determine the prevalence of MSC and the functional implications in a sample of people attending community health centres in Cape Town, South Africa.

METHODS

A cross-sectional, descriptive study was conducted in clinics in two resource poor communities. Phase I consisted of screening and those who screened positive for peripheral or spinal joint pain went on to complete Phase II, which included the Stanford Health Assessment Questionnaire.

RESULTS

1005 people were screened in Phase I. Of these, 362 (36%) reported MSC not due to injury in the past three months. Those with MSC had higher rates of co-morbidities in every category than those without. The mean Disability Index for those with MSC was mild to moderate and moderate to severe in those over 55 years.

CONCLUSIONS

Although the sample may not be representative of the general community, the prevalence is considerably greater than those reported elsewhere even when the population of the catchment area is used as a denominator, (367/100 000). The common presentation of MSC with co-morbid diabetes and hypertension requires holistic management by appropriately trained health care practitioners. Any new determination of burden of disease due to MSC should recognise that these disorders may be more prevalent in developing countries than previously estimated.

The health-related quality of life of people living with HIV/AIDS

PURPOSE

The prevalence of people living with HIV/AIDS (PLWA) in South Africa is estimated to be approximately 14.2% of the total population. In the absence of anti-retroviral therapy, PLWA are likely to experience a steady decline in function, as their immune systems become increasingly compromised. However, there is limited information available to determine the potential role of rehabilitation interventions in the management of PLWA in a resource-poor community.

SUBJECTS

Subjects were recruited from the population of beneficiaries of HIV/AIDS clinics run by Medecins Sans Frontières, which provides anti-retroviral therapy to PLWA within a resource poor community. The subjects, who were either in WHO Stage 3 or 4 of the disease and/or had a CD4 count of less than 200, were interviewed after enrolment on the anti-retroviral programme and before treatment was initiated. They were therefore not yet receiving anti-retroviral therapy. The control group consisted of a community sample randomly selected from the same area and who were in the same age range.

METHODS

As all participants were Xhosa speaking, the Xhosa version of the EQ-5D measure of HRQoL was utilized.

ANALYSIS

The Mann-Whitney U-test was used to determine whether there was a difference in the rank ordering of responses to the five different domains of the EQ-5D and the Visual Analogue Scale of Health Status scores.

RESULTS

There were 123 and 108 subjects in the experimental and control groups, respectively. In the domain of mobility 30.9% of the subjects reported some or severe problems, compared to 14.8% of the control group (p < 0.001). The corresponding figures for the other domains were: self-care 14.8% and 4.6% (p = 0.016), usual activity 31.7% and 10.2% (p < 0.001), pain/discomfort 69.1% and 33.3% (p < 0.001) and anxiety/depression 33.4% and 24.2% (p = 0.123) for the experimental and control groups respectively. PLWA reported a VAS score of 60.4 (SD 22.1), which was significantly lower than that of the community sample (80.13, SD 20.4, p < 0.001).

CONCLUSION

Self-reporting indicates that Health Related Quality of Life is severely comprised in PLWA in Stages 3 and 4 and limitations in the four domains of mobility, usual activities, pain/discomfort and anxiety/depression constitute major problems for PLWA. There is an obvious need to provide a continuum of care, encompassing not only medical but also physical and mental rehabilitation services as well. In an area of high HIV prevalence, the provision of appropriate, multi-disciplinary health care services to PLWA presents a major challenge to the health services.

Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya

BACKGROUND

Depression greatly burdens sub-Saharan Africa, especially populations living with HIV/AIDS, for whom few validated depression scales exist. Patient Health Questionnaire-9 (PHQ-9), a brief dual-purpose instrument yielding DSM-IV diagnoses and severity, and PHQ-2, an ultra-brief screening tool, offer advantages in resource-constrained settings.

OBJECTIVE

To assess the validity/reliability of PHQ-9 and PHQ-2.

DESIGN

Observational, two occasions 7 days apart.

PARTICIPANTS

A total of 347 patients attending psychosocial support groups.

MEASUREMENTS

Demographics, PHQ-9, PHQ-2, general health perception rating and CD4 count.

RESULTS

Rates for PHQ-9 DSM-IV major depressive disorder (MDD), other depressive disorder (ODD) and any depressive disorder were 13%, 21% and 34%. Depression was associated with female gender, but not CD4. Construct validity was supported by: (1) a strong association between PHQ-9 and general health rating, (2) a single major factor with loadings exceeding 0.50, (3) item-total correlations exceeding 0.37 and (4) a pattern of item means similar to US validation studies. Four focus groups indicated culturally relevant content validity and minor modifications to the PHQ-9 instructions. Coefficient alpha was 0.78. Test-retest reliability was acceptable: (1) intraclass correlation 0.59 for PHQ-9 total score, (2) kappas 0.24, 0.25 and 0.38 for PHQ-9 MDD, ODD and any depressive disorder and (3) weighted kappa 0.53 for PHQ-9 depression severity categories. PHQ-2 > or =3 demonstrated high sensitivity (85%) and specificity (95%) for diagnosing any PHQ-9 depressive disorder (AUC, 0.97), and 91% and 77%, respectively, for diagnosing PHQ-9 MDD (AUC, 0.91). Psychometrics were also good within four gender/age (18-35, 36-61) subgroups.

CONCLUSIONS

PHQ-9 and PHQ-2 appear valid/reliable for assessing DSM-IV depressive disorders and depression severity among adults living with HIV/AIDS in western Kenya.

Headache Disorders in Developing Countries: Research Over The Past Decade

The majority of people with primary headache disorders live in the developing world. The contribution of low and middle income (LAMI) countries to headache research has not been previously characterized. A search was performed for clinical research publications between the years 1997 and 2006, using the search terms ‘headache’ OR ‘headache disorders’ AND ‘primary’ OR ‘migraine’ AND ‘each of the LAMI countries’ in 67 databases. Articles in English or with abstracts in English translation were included. These publications were scrutinized for study characteristics. Two hundred and twenty-seven publications from 32 LAMI countries were found. Half (50.2±) of these were from three middle-income countries (Brazil, Turkey and Iran), whereas 24 (10.6±) came from low-income countries. Most of the research focused on migraine. Only 29.5± of the articles involved treatment of headache. The understanding of headache disorders in LAMI countries is derived from a limited number of publications from relatively few countries. Identifying gaps in headache research in the developing world is strategic for targeting research policy.

Health-related quality of life (HRQoL) domains most valued by urban IsiXhosa-speaking people

PURPOSE

The aim of the study was to investigate and identify aspects of health-related quality of life (HRQoL) that are most valued by IsiXhosa-speaking people resident in underresourced areas of Cape Town, South Africa.

METHODOLOGY

Fifty-seven domains of HRQoL were identified as important through group discussions with IsiXhosa-speaking people. Participants randomly selected from the community (n = 601) and from individuals seeking medical attention at a local clinic (n = 102) graded the domains on a visual analogue scale (VAS) ranging from 0 for "not at all important" to 10 for " very important". The domains were then mapped to the categories of the International Classification of Functioning, Disability and Health.

RESULTS

The domains regarded as being most important were Food availability [9.5, standard deviation (SD) = 1.52), Owning a brick house (9.4, SD = 1.57), Access to medical services (9.4, SD = 1.55) and Family safety (9.4, SD = 1.7). Having no bodily pain ranked 40th. Environmental Factors were valued significantly more than the other two categories, and those related to Body Functions were valued higher than domains in the category of Activity and Participation.

DISCUSSION AND CONCLUSION

Despite being asked specifically to answer the questions in relation to their health status, the participants apparently did not differentiate between general quality of life (QoL) and specific HRQoL. It appears that members of an underresourced community regard socioeconomic and service delivery aspects of their lives as integral to their perceived state of health. It may be that it is not possible to separate out factors relating to general QoL from those specifically related to HRQoL in an underresourced population, and such populations might not be suitable for inclusion in certain clinical trials where an improvement in HRQoL is the required outcome. Alternatively, if an HRQoL instrument is to be used to monitor the impact of medical interventions, the inclusion of Environmental Factors should be considered.

Health-related quality of life (HRQoL) domains most valued by urban isiXhosa-speaking people

PURPOSE

The aim of the study was to investigate and identify aspects of health-related quality of life (HRQoL) that are most valued by isiXhosa-speaking people resident in under-resourced areas of Cape Town.

METHODOLOGY

Fifty-seven domains of HRQoL were identified as important through group discussions with isiXhosa-speaking people. Participants randomly selected from the community (n = 601) and from individuals seeking medical attention at a local clinic (n = 102) graded the domains on a visual analogue scale (VAS) ranging from 0 as "not at all important" to 10 as " very important". The domains were then mapped to the categories of the International Classification of Functioning, Disability, and Health.

RESULTS

The domains regarded as being most important were food availability (9.5, SD = 1.52), owning a brick house (9.4, SD = 1.57), access to medical services (9.4, SD = 1.55), and family safety (9.4, SD = 1.7). Having no bodily pain was ranked 40th. Environmental factors were valued significantly more than the other two categories and those related to body functions were valued more highly than domains in the category of activity/participation.

DISCUSSION AND CONCLUSION

Despite being asked specifically to answer the questions in relation to their health status, the participants apparently did not differentiate between general quality of life (QoL) and specific HRQoL. It appears that members of an under-resourced community regard socioeconomic and service delivery aspects of their lives as integral to their perceived state of health. It may be that it is not possible to separate factors relating to general quality of life from those specifically related to HRQoL in an under-resourced population and such populations might not be suitable for inclusion in certain clinical trials where improvement in HRQoL is the required outcome. Alternatively, if a HRQoL instrument is to be used to monitor the impact of medical intervention, the inclusion of environmental factors should be considered.

An investigation into the health-related quality of life of individuals living with HIV who are receiving HAART

The health authorities have recently accepted the routine provision of highly active antiretroviral therapy to persons living with AIDS in South Africa. There is a need to investigate the impact of HAART on the health-related quality of life of people living with HIV/AIDS (PLWHA) in a resource-poor environment, as this will have an influence on compliance and treatment outcome. The aim of this study was to explore whether HAART is efficacious in improving the self-reported health-related quality of life (HRQoL) in a group of PWLA in WHO Stages 3 and 4 living in a resource-poor community. A quasi-experimental, prospective repeated measures design was used to monitor the HRQoL over time in participants recruited to an existing HAART programme. The HRQoL of 117 participants was determined through the use of the Xhosa version of the EQ-5D and measurements were taken at baseline, one, six and 12 months. At the time of the 12-month questionnaire, 95 participants had been on HAART for 12 months. Not all participants attended all follow-up visits, but only two participants had withdrawn from the HAART programme, after two or three months. At baseline, the rank order of problems reported in all domains of the EQ-5D was significantly greater than at 12 months. The mean score on the global rating of health status increased significantly (p < 0.001) from a mean of 61.7 (SD = 22.7) at baseline to 76.1 at 12 months (SD = 18.5) It is concluded that, even in a resource-poor environment, HRQoL can be greatly improved by HAART, and that the possible side effects of the drugs seem to have a negligible impact on the wellbeing of the subjects. This bodes well for the anticipated roll-out of HAART within the public health sector in South Africa.