Direct-acting antiviral therapies for hepatitis C infection: global registration, reimbursement, and restrictions

Direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection have delivered high response rates (>95%) and simplified the management of HCV treatment, permitting non-specialists to manage patients without advanced liver disease. We collected and reviewed global data on the registration and reimbursement (government subsidised) of HCV therapies, including restrictions on reimbursement. Primary data collection occurred between Nov 15, 2021, and July 24, 2023, through the assistance of a global network of 166 HCV experts. We retrieved data for 160 (77%) of 209 countries and juristrictions. By mid-2023, 145 (91%) countries had registered at least one of the following DAA therapies: sofosbuvir-velpatasvir, sofosbuvir-velpatasvir-voxilaprevir, glecaprevir-pibrentasvir, sofosbuvir-daclatasvir, or sofosbuvir. 109 (68%) countries reimbursed at least one DAA therapy. Among 102 low-income and middle-income countries (LMICs), 89 (87%) had registered at least one HCV DAA therapy and 53 (52%) reimbursed at least one DAA therapy. Among all countries with DAA therapy reimbursement (n=109), 66 (61%) required specialist prescribing, eight (7%) had retreatment restrictions, seven (6%) had an illicit drug use restriction, five (5%) had an alcohol use restriction, and three (3%) had liver disease restrictions. Global access to DAA reimbursement remains uneven, with LMICs having comparatively low reimbursement compared with high-income countries. To meet WHO goals for HCV elimination, efforts should be made to assist countries, particularly LMICs, to increase access to DAA reimbursement and remove reimbursement restrictions-especially prescriber-type restrictions-to ensure universal access.

Trends and factors associated with illicit drug use in South Africa: Findings from multiple national population-based household surveys, 2002-2017

BACKGROUND

Illicit drug use results in considerable global morbidity, but there is little data on its trends and factors associated with it in sub-Saharan Africa. We consider these questions using national data from South Africa for 2002-2017.

METHODS

We analysed data among individuals aged 15 years or older from five national population-based household surveys in South Africa (2002-2017; n = 89,113). Recent drug use was defined as the last three-months use of illicit drugs, i.e., any use of cannabis, cocaine, amphetamine, inhalants, sedatives, hallucinogens, opioids, and/or other illicit drugs. Time trends in recent drug use were assessed using logistic regression. Multivariable logistic regression assessed the association between recent drug use and socio-demographic factors and between drug use and sexual risk behaviours, HIV-related and other well-being variables.

RESULTS

The prevalence of recent drug use increased from 1·5% to 10·0% from 2002 to 2017, driven by increases in cannabis use (1·5% to 7·8%) and use of opioids (0·01% to 1·6%), cocaine (0·02% to 1·8%), or amphetamines (0·1% to 1·5%). In adjusted analyses, male gender, younger age, living in urban areas, mixed-ancestry or white ethnicity (compared to black-African), and unemployment were positively associated with recent drug use. Recent drug use was associated with: multiple sexual partners (adjusted odds ratio [aOR] 2·13, 95% confidence interval [CI]: 1·80-2·51); sexual debut before 15 years old (aOR 1·70, 95%CI: 1·29-2·23); hazardous/harmful alcohol use (aOR 2·50, 95%CI: 2·14-2·93) or alcohol dependence (aOR 3·33, 95%CI 2·92-3·80); ever experiencing intimate partner violence (aOR 1·56, 95%CI 1·12-2·17); psychological distress (aOR 1·53, 95%CI: 1·28-1·82); and lower chance of ever testing for HIV (aOR 0·89, 95%CI 0·80-1·00). Recent drug use was not associated with HIV positivity, condom use or being on antiretroviral therapy.

CONCLUSION

Illicit drug use has increased substantially in South Africa and is associated with numerous socio-demographic characteristics, higher sexual risk behaviours and other well-being variables.

'I went for rehab many times and it never worked, but the harm reduction process has given me renewed hope'. Perceptions on the effectiveness of harm reduction and community-based opioid substitution therapy

ISSUE ADDRESSED

The accessibility of opioid substitution therapy (OST), one of the recommended treatments for opioid dependence, remains low. This study sought to explore the perceived effectiveness of OST from the perspectives of peer outreach workers and OST clients in a community-based harm reduction programme.

METHODS

The research was done within the Community-Oriented Substance Use Programme (COSUP) in Tshwane, South Africa. Fifteen peer educators (13 males and 2 females) took part in two focus group discussions. Thereafter, there were semi-structured interviews in which 15 OST clients (11 males and 4 females) participated. A convenience cross-sectional study was used. Interviews were audio-recorded. Using thematic analysis, themes were examined to evaluate how OST and the harm reduction approach were perceived to contribute to the improved health status of people with opioid dependence.

RESULTS

Peer outreach workers and COSUP clients significantly endorsed OST as an effective treatment for opioid dependence. Participants perceived greater effectiveness of OST compared to abstinence-centred inpatient rehabilitation programmes. However, there were sentiments that more community education on OST was needed to motivate people with opioid dependence to access services and to address misconceptions about OST.

CONCLUSIONS

There is a lack of multi-level and multi-sectoral engagement of various stakeholders in opioid dependence services, needed to accelerate utilisation of OST services. SO WHAT?: The research unpacks the need for an integrated approach to service use optimisation, and the need to evaluate the role that increased awareness and community education on harm reduction strategies can play in enhancing the utilisation of OST services.

Assessing cardiac safety among clients receiving methadone as part of opioid agonist maintenance therapy (OAMT) in Durban, South Africa

Methadone is a recommended medication for opioid agonist maintenance therapy (OAMT). However, methadone can have cardiac side effects. There is limited South African cardiac safety data on methadone.

To describe baseline and 12-month electrocardiographic (ECG) features and cardiac symptomology in people receiving OAMT in Durban, South Africa.

Twelve-lead ECGs were conducted at baseline and 12 months. Clinical interviews were used to assess cardiac symptomatology. Baseline ECG parameters (PR interval, QRS interval, QT and QTc duration, heart rate) were analyzed using descriptive statistics. Baseline and 12-month ECG characteristics were compared using paired T-tests in retained participants. The association between QTc and methadone dose was assessed using Spearman's Rho at 12 months.

Fifty-three clients (51 men, 2 women [median age 29.0]) were initiated on OAMT. Normal baseline ECG variants included 4 (7.5%) with sinus bradycardia and 3 (5.7%) with ST segment elevation. Mean baseline ECG intervals were PR interval: 156 ± 23 ms, QRS duration: 87 ± 9 ms, QT interval: 404 ± 22 ms and QTc interval: 406.9 ± 21.9 ms. At 12 months, 39 participants returned for reassessment (mean methadone dose: 37 ± 8 mg in women; 27 ± 10 mg in men). QTc intervals among male participants increased (406.4 ± 22 to 417 ± 24; p = 0.026 [-19.6; -1.4]). No significant correlation (r = 0.22; p = 0.185) between methadone dose and QTc interval at 12 months, nor reports of adverse cardiac symptomatology, were detected.

Methadone at the doses provided, caused mild and clinically insignificant QTc interval prolongation in men at 12 months. We provide additional cardiac safety data for the use of methadone for OAMT among people with opioid use disorder.

Diagnosis and treatment of opioid-related disorders in a South African private sector medical insurance scheme: A cohort study

BACKGROUND

The use of opioids is increasing globally, but data from low- and middle-income countries on opioid-related mental and behavioural disorders (hereafter referred to as opioid-related disorders) are scarce. This study examines the incidence of opioid-related disorders, opioid agonist use, and excess mortality among persons with opioid-related disorders in South Africa's private healthcare sector.

METHODS

We analysed longitudinal data of beneficiaries (≥ 11 years) of a South African medical insurance scheme using reimbursement claims from Jan 1, 2011, to Jul 1, 2020. Beneficiaries were classified as having an opioid-related disorder if they received an opioid agonist (buprenorphine or methadone) or an ICD-10 diagnosis for harmful opioid use (F11.1), opioid dependence or withdrawal (F11.2-4), or an unspecified or other opioid-related disorder (F11.0, F11.5-9). We calculated adjusted hazard ratios (aHR) for factors associated with opioid-related disorders, estimated the cumulative incidence of opioid agonist use after receiving an ICD-10 diagnosis for opioid dependence or withdrawal, and examined excess mortality among beneficiaries with opioid-related disorders.

RESULTS

Of 1,251,458 beneficiaries, 1286 (0.1%) had opioid-related disorders. Between 2011 and 2020, the incidence of opioid-related disorders increased by 12% (95% CI 9%-15%) per year. Men, young adults in their twenties, and beneficiaries with co-morbid mental health or other substance use disorders were at increased risk of opioid-related disorders. The cumulative incidence of opioid agonist use among beneficiaries who received an ICD-10 diagnosis for opioid dependence or withdrawal was 18.0% (95% CI 14.0-22.4) 3 years after diagnosis. After adjusting for age, sex, year, medical insurance coverage, and population group, opioid-related disorders were associated with an increased risk of mortality (aHR 2.28, 95% CI 1.84-2.82). Opioid-related disorders were associated with a 7.8-year shorter life expectancy.

CONCLUSIONS

The incidence of people diagnosed with or treated for an opioid-related disorder in the private sector is increasing rapidly. People with opioid-related disorders are a vulnerable population with substantial psychiatric comorbidity who often die prematurely. Evidence-based management of opioid-related disorders is urgently needed to improve the health outcomes of people with opioid-related disorders.

Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting

Background

The coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane’s Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response.

Aim

To describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal.

Setting

Three community-based COSUP sites in Mamelodi (Tshwane, South Africa).

Methods

A retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data.

Results

Of the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants’ median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol.

Conclusion

Tramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.

Contribution

This research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

Personal experience and awareness of opioid overdose occurrence among peers and willingness to administer naloxone in South Africa: findings from a three-city pilot survey of homeless people who use drugs

Background

Drug overdoses occur when the amount of drug or combination of drugs consumed is toxic and negatively affects physiological functioning. Opioid overdoses are responsible for the majority of overdose deaths worldwide. Naloxone is a safe, fast-acting opioid antagonist that can reverse an opioid overdose, and as such, it should be a critical component of community-based responses to opioid overdose. However, the burden of drug overdose deaths remains unquantified in South Africa, and both knowledge about and access to naloxone is generally poor. The objective of this study was to describe the experiences of overdose, knowledge of responses to overdose events, and willingness to call emergency medical services in response to overdose among people who use drugs in Cape Town, Durban, and Pretoria (South Africa).

Methods

We used convenience sampling to select people who use drugs accessing harm reduction services for this cross-sectional survey from March to July 2019. Participants completed an interviewer-administered survey, assessing selected socio-demographic characteristics, experiences of overdose among respondents and their peers, knowledge about naloxone and comfort in different overdose responses. Data, collected on paper-based tools, were analysed using descriptive statistics and categorised by city.

Results

Sixty-six participants participated in the study. The median age was 31, and most (77%) of the respondents were male. Forty-one per cent of the respondents were homeless. Heroin was the most commonly used drug (79%), and 82% of participants used drugs daily. Overall, 38% (25/66) reported overdosing in the past year. Most (76%, 50/66) knew at least one person who had ever experienced an overdose, and a total of 106 overdose events in peers were reported. Most participants (64%, 42/66) had not heard of naloxone, but once described to them, 73% (48/66) felt comfortable to carry it. More than two-thirds (68%, 45/66) felt they would phone for medical assistance if they witnessed an overdose.

Conclusion

Drug overdose was common among participants in these cities. Without interventions, high overdose-related morbidity and mortality is likely to occur in these contexts. Increased awareness of actions to undertake in response to an overdose (calling for medical assistance, using naloxone) and access to naloxone are urgently required in these cities. Additional data are needed to better understand the nature of overdose in South Africa to inform policy and responses.

996Factors predicting retention among people accessing outpatient methadone maintenance therapy in Tshwane, South Africa

Background

In South Africa, increasing illicit opioid use and associated health challenges can be managed with opioid substitution therapy (OST), like methadone, provided it is prescribed at the recommended dose and duration. The Community Oriented Substance Use Programme (COSUP) provides free methadone to patients with Opiod Use Disorder across Tshwane, South Africa on need-based criteria.

Methods

A retrospective cohort using secondary data of patients treated with methadone at eight COSUP sites. The factors associated with the retention of 575 participants for the period December 2016 to September 2018 were analysed.

Results

Participants on lower methadone doses had decreased odds of being retained (0 to 20mg: adjusted odds ratio (aOR) 0.25, p-value (p)=0.002, 95% Confidence Interval (CI) 0.10 - 0.61; 20 to 40mg: aOR 0.20, p < 0.001, 95% CI 0.08 - 0.49). Participants receiving free methadone had 3.75 the odds to be retained (p < 0.001, 95% CI 2.47 - 5.70). Inner-city participants had 5.19 the odds to be retained (p < 0.001, 95% CI 2.99 - 9.03). White participants had 3.39 the odds of being retained (p = 0.001, 95% CI 1.64 - 7.00). Injecting heroin users had 0.63 the odds of being retained (p = 0.032; 95% CI 0.41 - 0.96).

Conclusions

Methadone doses above 50mg, access to free methadone, accessing care within the inner-city and the white population group were positively associated with retention. Injecting drug use was negatively associated.

Key messages

Provision of free methadone at adequate doses can aid in retaining patients within an outpatient OST programme.

The performance of hepatitis C virus (HCV) antibody point-of-care tests on oral fluid or whole blood and dried blood spot testing for HCV serology and viral load among individuals at higher risk for HCV in South Africa

BACKGROUND AND AIMS

To enhance screening and diagnosis in those at-risk of hepatitis C virus (HCV), efficient and improved sampling and testing is required. We investigated the performance of point-of-care (POC) tests and dried blood spots (DBS) for HCV antibody and HCV RNA quantification in individuals at higher risk for HCV (people who use and inject drugs, sex workers and men who have sex with men) in seven South African cities.

METHODS

Samples were screened on the OraQuick HCV POC test (471 whole blood and 218 oral fluid); 218 whole blood and DBS paired samples were evaluated on the ARCHITECT HCV antibody (Abbott) and HCV viral load (COBAS Ampliprep/COBAS TaqMan version 2) assays. For HCV RNA quantification, 107 dB were analyzed with and without normalization coefficients.

RESULTS

POC on either whole blood or oral fluid showed an overall sensitivity of 98.5% (95% CI 97.4-99.5), specificity of 98.2% (95% CI 98.8-100) and accuracy of 98.4% (95% CI 96.5-99.3). On the antibody immunoassay, DBS showed a sensitivity of 96.0% (95% CI 93.4-98.6), specificity of 97% (95% CI 94.8-99.3) and accuracy of 96.3% (95% CI 93.8-98.8). A strong correlation (R 2 = 0.90) between viral load measurements for DBS and plasma samples was observed. After normalization, DBS viral load results showed an improved bias from 0.5 to 0.16 log10 IU/mL.

CONCLUSION

The POC test performed sufficiently well to be used for HCV screening in at-risk populations. DBS for diagnosis and quantification was accurate and should be considered as an alternative sample to test. POC and DBS can help scale up hepatitis services in the country, in light of our elimination goals.

Hepatitis B, hepatitis C and HIV prevalence and related sexual and substance use risk practices among key populations who access HIV prevention, treatment and related services in South Africa: findings from a seven-city cross-sectional survey (2017)

Background

People who use drugs including people who inject drugs (PWUD/ID), sex workers (SWs) and men who have sex with men (MSM) are at increased risk of HIV and viral hepatitis infection. Limited epidemiological data on the infections exists in key populations (KPs) in South Africa. We investigated the prevalence of hepatitis B (HBV), hepatitis C (HCV) and HIV and selected risk factors among these KPs to inform effective responses.

Methods

We used convenience sampling to recruit a targeted 3500 KPs accessing HIV-related health services across Cape Town (SWs, MSM, PWUD/ID), Durban (SWs, PWUD/ID), Pietermaritzburg (SWs), Mthatha (SWs), Port Elizabeth (SWs), Johannesburg (MSM) and Pretoria (MSM and PWUD/ID) into a cross-sectional survey. An interviewer questionnaire to assess socio-demographic characteristics, drug use and sexual risk practices, was administered. HBV surface antigen (HBsAg); HCV antibody, viral load and genotype, and HIV antibody, was tested.

Results

Among the 3439 people included in the study (1528 SWs, 746 MSM, 1165 PWUD/ID) the median age was 29 years, most participants were black African (60%), and 24% reported homelessness. 82% reported substance use in the last month, including alcohol (46%) and heroin (33%). 75% were sexually active in the previous month, with condom use at last sex at 74%. HIV prevalence was 37% (highest among SWs at 47%), HBsAg prevalence 4% (similar across KPs) and HCV prevalence was 16% (highest among PWUD/ID at 46%).

Conclusions

HBV, HCV and HIV pose a health burden for KPs in South Africa. While HIV is key for all included KPs, HCV is of particular importance to PWUD/ID. For KPs, HBV vaccination and behavioural change interventions that support consistent condom and lubricant access and use are needed. Coverage of opioid substitution therapy and needle and syringe services, and access to HCV treatment for PWUD/ID need to be expanded.

Harm reduction in an emergency response to homelessness during South Africa's COVID-19 lockdown

BACKGROUND

Caledonian Stadium, the main mass temporary shelter for homeless people in the City of Tshwane, was created as a local response to the imperatives of the novel coronavirus disease (COVID-19) National State of Disaster lockdown in South Africa. This is a case study of the coordinated emergency healthcare response provided by the University of Pretoria's Department of Family Medicine between 24 March and 6 April 2020.

METHODS

This study uses a narrative approach to restory situated, transient, partial and provisional knowledge. Analysis is based on documented data and iteratively triangulated interviews on the operational experiences of selected healthcare first responders directly involved in the shelter.

RESULTS

The impending lockdown generated intense interactions by UP-DFM to prepare for the provision of COVID-19 and essential generalist primary with partners involved in the Community Oriented Substance Use Programme (COSUP). With approximately 2000 people at the shelter at its peak, the numbers exceeded expectations. Throughout, while government officials tried to secure bedding, food and toilets, the shelter was poorly equipped and without onsite management. The COSUP clinical team prioritised opioid substitution therapy using methadone and COVID-19 screening over generalist healthcare to manage withdrawal and contain tension and anxiety. COSUP and its partners helped the city plan and implement the safe re-sheltering of all Caledonian residents.

CONCLUSION

The Caledonian shelter is an account of organisational resilience in the face of homelessness and substance use emergencies triggered by lockdown. Through community-oriented, bottom-up self-organisation, a clinically led team navigated a response to the immediate needs of people who are homeless and/or use drugs that evolved into a more sustainable intervention. Key lessons learnt were the importance of communicating with people directly affected by emergencies, the value of using methadone to reduce harms during emergencies and the imperative of including OST in essential primary healthcare.

Motivations, facilitators and barriers to accessing hepatitis C treatment among people who inject drugs in two South African cities

Background

Treatment of hepatitis C (HCV) among people who inject drugs (PWID) is a critical component of efforts to eliminate viral hepatitis. A recent study found high HCV prevalence among PWID in two cities, Pretoria (84%) and Cape Town (44%). Very few (< 5%) HCV-infected individuals attended follow-up appointments. This sub-study explores differences between stated desire for cure and appointment attendance in light of perceived facilitators and barriers to HCV treatment and care access among PWID.

Method

Two sets of semi-structured interviews were implemented in a group of HCV-infected participants opportunistically sampled and recruited at harm reduction service sites. Initial interviews, conducted before the planned hospital appointment date, asked participants (N = 17, 9 in Pretoria and 8 in Cape Town) about past experiences of healthcare provision, plans to attend their referral appointment and perceived barriers and facilitators to seeking hepatitis treatment. Second interviews (n = 9, 4 in Pretoria, 5 in Cape Town), conducted after the planned referral appointment date, asked about appointment attendance and treatment experience. Trained social scientists with experience with PWID conducted the interviews which were recorded in detailed written notes. Data was thematically analysed in NVivo 11.

Results

Despite routine experiences of being stigmatised by the healthcare system in the past, most participants (n = 16, 94%) indicated a desire to attend their appointments. Attendance motivators included the desire to be cured, fear of dying and the wish to assist the research project. Perceived barriers to appointment attendance included fear of again experiencing stigmatisation and concerns about waiting periods and drug withdrawal. Perceived facilitators included the knowledge they would be treated quickly, and with respect and access to opioid substitution therapy. In the end, very few participants (n = 5) went to their appointment. Actual barriers to attendance included lack of finances, lack of urgency and forgetting and fatalism about dying.

Conclusions

South Africa can learn from other countries implementing HCV treatment for PWID. Successful linkage to care will require accessible, sensitive services where waiting time is limited. Psychosocial support prior to initiating referrals that focuses on building and maintaining a sense of self-worth and emphasising that delayed treatment hampers health outcomes is needed.

Harm reduction in practice - The Community Oriented Substance Use Programme in Tshwane

BACKGROUND

The Community Oriented Substance Use Programme (COSUP) is the first publicly funded, community-based programmatic response to the use of illegal substances in South Africa. It is founded on a systems thinking, public health and clinical care harm reduction approach.

AIM

To describe the critical components, key issues and accomplishments in the initiation and delivery of evidence-based, community-oriented, substance-use health and care services.

SETTING

The Community Oriented Substance Use Programme is implemented by the University of Pretoria in four of seven Tshwane Metropolitan Municipality regions.

METHODS

Quantitative and qualitative data were extracted and triangulated from plans, reports, minutes and other documents.

RESULTS

Between 2016 and 2019, COSUP engaged in national and local policy and guidelines development. In Tshwane, it created practical working relations with 169 organisations and institutions and set up 17 service sites. These provide counselling, linkage to care and opioid substitution therapy services to 1513 adults (median age of 30 years), most of whom are male (90%), with similar proportions of clients who smoke (51%) or inject (49%) heroin. It also offers needle and syringe services (approximately 17 000 needles distributed/month) and has built human resource capacity in harm reduction among staff, clients and personnel in partner organisations.

CONCLUSION

The Community Oriented Substance Use Programme offers an evidence-based, public-health informed, feasible alternative to an abstinence-based approach to substance use. However, to translate the programme's achievements into sustainable outcomes at scale requires health system integration; generalist, patient-centred care; affordable medication in a comprehensive package of harm reduction services; multisectoral partnerships; systematic, continuous capacity development; financial investment; and sustained political commitment.

High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion

Background

Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa’s first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome.

Methods

Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants’ pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature.

Results

The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another’s life, leading to interdependence and care, contributing to them remaining in the project.

Conclusions

We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.

Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa

BACKGROUND

Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa.

METHODS

We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency.

RESULTS

The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254).

CONCLUSIONS

Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.

'We must treat them like all the other people': Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa

Background

Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The ‘Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa’ aimed to improve access to appropriate and non-judgemental health services for ‘key populations’, specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers.

Objectives

The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa.

Methods

This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex.

Results

The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes.

Conclusion

The findings suggest that sensitisation training increases healthcare workers’ knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services.

Understanding hepatitis B, hepatitis C and HIV among people who inject drugs in South Africa: findings from a three-city cross-sectional survey

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C (HCV), hepatitis B (HBV) and HIV without accessible harm reduction programmes. Coverage of needle and syringe and opioid substitution therapy (OST) services in South Africa is below global recommendations and no hepatitis services exist for PWID. We assessed HCV, HBV and HIV prevalence and risk factors among PWID accessing harm reduction services in Cape Town, Durban and Pretoria to inform policy and programming.

METHODS

We conducted a cross-sectional survey among PWID in these cities between August 2016 and October 2017. Participants were opportunistically sampled while accessing services. Study team members administered a questionnaire that assessed sociodemographic characteristics, drug use and sexual risk practices. We tested for HCV (antibody, viral load and genotype), HBV surface antigen (HBsAg) and HIV. Bivariate and multivariate analyses assessed associations with HCV serostatus.

RESULTS

Nine hundred and forty-three PWID were included in the per protocol analysis. The majority (87%, 819/943) were male, the overall median age was 29 and most lived on the street (66%, 626/943). At last injection, 77% (722/943) reported using a new needle and syringe and 17% (163/943) shared equipment. HIV prevalence was 21% (196/926), HBsAg positivity 5% (47/936), HCV seroprevalence 55% (513/937), HCV viraemic prevalence (proportion tested with detectable HCV) 43% (404/937) and HCV viraemic rate (proportion HCV antibody positive with detectable HCV) 79% (404/513). HCV genotype 1a (73%, 270/368) was the most prevalent. In multivariate analysis, HCV infection was positively associated with residing in Pretoria (adjusted odds ratio (aOR) 1.27, 95% CI 1.21-1.34), living on the street (aOR 1.90, 95% CI 1.38-2.60), frequent injecting (aOR 1.58, 95% CI 1.15-2.16) and HIV infection (aOR 1.69, 95% CI 1.15-2.47), and negatively associated with black race (aOR 0.52, 95% CI 0.36-0.74) and sexual activity in the previous month (aOR 0.61, 95% CI 0.42-0.88).

CONCLUSIONS

HCV and HIV are major health threats affecting PWID in these cities. Access to OST and needle and syringe services needs to be increased and integrated with HCV services. Social and structural factors affecting PWID who live on the street need to be addressed.

Women's knowledge and attitudes related to cervical cancer and cervical cancer screening in Isiolo and Tharaka Nithi counties, Kenya: a cross-sectional study

Background

Cervical cancer is the most common cancer among women in Kenya. However, only 3% of women are routinely screened. This study aimed to assess women’s knowledge and attitudes towards cervical cancer and cervical cancer screening in Kenya’s Isiolo and Tharaka Nithi counties.

Methods

A cross-sectional survey was conducted between January and March 2017. Using a multistage cluster sampling methodology, 451 women 18 years of age and older participated in the study. Interviewers administered a 35-item questionnaire collecting demographic information, knowledge of risk factors and attitudes towards cervical cancer and cervical cancer screening. Bivariate and multivariate analyses of cervical cancer knowledge and demographic characteristics were conducted.

Results

The response rate for the study was 98% (451/460). Two-thirds of the study participants originated from Tharaka Nithi county (n = 318). Respondents reported a median age of 32; 70.5% were married; and 35.0% had primary education. Eighty percent of the participants were aware of cervical cancer, 25.6% of whom had previously undergone a cervical screening examination, and 44.4% had above-average knowledge of risk factors of cervical cancer. Knowledge of cervical cancer risk factors was significantly associated with employment status (adjusted odds ratio = 1.6; 95% CI: 1.0–2.6) and county of origin (adjusted odds ratio = 2.8; 95% CI: 1.6–5.0). Almost all (89.2%) of those who had heard of cervical cancer categorised it as “scary”. There was a marginal significant difference in the overall attitude assessment score towards cervical cancer between participants from Isiolo and Tharaka Nithi counties; the mean (SD) score was 2.13 (0.34) and 2.20 (0.30) respectively. The score was comparatively higher among participants residing in Tharaka Nithi (95% CI: 0.002–0.146; p = 0.043).

Conclusions

Interventions to increase cervical cancer knowledge are needed in Isiolo and Tharaka Nithi counties, Kenya. Additional research is needed to further understand and assess the effectiveness of different strategies to improve attitudes regarding cervical cancer in order to increase the uptake of screening services, particularly among less-educated women and those in hard-to-reach areas.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4642-9) contains supplementary material, which is available to authorized users.

'Scared of going to the clinic': Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities

Background

Men who have sex with men (MSM), sex workers (SW) and people who use drugs (PWUD) are at increased risk for HIV because of multiple socio-structural barriers and do not have adequate access to appropriate HIV prevention, diagnosis and treatment services.

Objective

To examine the context of access to healthcare experienced by these three ‘Key Populations’, we conducted a qualitative study in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province.

Method

We carried out in-depth interviews to explore healthcare workers’ perceptions, beliefs and attitudes towards Key Populations. Focus group discussions were also conducted with members of Key Populations exploring their experiences of accessing healthcare.

Results

Healthcare workers described their own attitudes towards Key Populations and demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing Key Populations. Female SW, MSM and PWUD described their experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. Our findings suggest that the uptake and effectiveness of health services amongst Key Populations in South Africa is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers.

Conclusion

This research highlights the need to address the broader healthcare provision environment, improving alignment of policies and programming in order to strengthen provision of effective health services that people from Key Populations will be able to access.

ANALYSIS OF TISSUE OXYGENATION IN CHRONIC LEG ULCERS BY COMBINATION OF A MULTI-SPECTRAL CAMERA AND A HYPER-SPECTRAL PROBE

Objective evaluation of chronic wounds, such as leg ulcers, by the use of non-invasive techniques is of importance for diagnosis, monitoring treatment response, and probably leads to improved treatment strategies. We performed a feasibility study for the combined use of a multi-spectral camera and a hyper-spectral probe to evaluate chronic leg ulcers with a focus on tissue oxygenation. Sixty patients - 40 females and 20 males were enrolled in the study. The age range was 46 to 85 years for males (mean 65.8 years, median 73.0 years) and 51 to 91 years for females (mean 74.4 years, median 77.0 years). Measurements were performed by hyper-spectral wound (HySkinII) probe and multi-spectral (DeMuk) camera on wounds and surrounding skin. The investigation results demonstrate a high variability of oxygenation within ulcers and the surrounding tissue. The methods allow an investigator to independently assess of tissue oxygenation in superficial and deeper layers. Non-invasive multi- and hyper-spectral imaging techniques offer new opportunities of an objective assessment of chronic wounds.

Using a programmatic mapping approach to plan for HIV prevention and harm reduction interventions for people who inject drugs in three South African cities

BACKGROUND

Stigma, criminalisation and a lack of data on drug use contribute to the "invisibility" of people who inject drugs (PWID) and make HIV prevention and treatment service delivery challenging. We aimed to confirm locations where PWID congregate in Cape Town, eThekwini and Tshwane (South Africa) and to estimate PWID population sizes within selected electoral wards in these areas to inform South Africa's first multi-site HIV prevention project for PWID.

METHODS

Field workers (including PWID peers) interviewed community informants to identify suspected injecting locations in selected electoral wards in each city and then visited these locations and interviewed PWID. Interviews were used to gather information about the accessibility of sterile injecting equipment, location coordinates and movement patterns. We used the Delphi method to obtain final population size estimates for the mapped wards based on estimates from wisdom of the crowd methods, the literature and programmatic data.

RESULTS

Between January and April 2015, we mapped 45 wards. Tshwane teams interviewed 39 PWID in 12 wards, resulting in an estimated number of accessible PWID ranging from 568 to 1431. In eThekwini, teams interviewed 40 PWID in 15 wards with an estimated number of accessible PWID ranging from 184 to 350. The Cape Town team interviewed 61 PWID in 18 wards with an estimated number of accessible PWID ranging between 398 and 503. Sterile needles were only available at one location. Almost all needles were bought from pharmacies. Between 80 and 86% of PWID frequented more than one location per day. PWID who reported movement visited a median of three locations a day.

CONCLUSIONS

Programmatic mapping led by PWID peers can be used effectively to identify and reach PWID and build relationships where access to HIV prevention commodities for PWID is limited. PWID reported limited access to sterile injecting equipment, highlighting an important HIV prevention need. Programmatic mapping data show that outreach programmes should be flexible and account for the mobile nature of PWID populations. The PWID population size estimates can be used to develop service delivery targets and as baseline measures.

Highlights from the 3rd international HIV/viral hepatitis Co-infection meeting - HIV/viral hepatitis: improving diagnosis, antiviral therapy and access

The International AIDS Society convened the 3rd International HIV/Viral Hepatitis Co-Infection Meeting on 17 July 2016 as part of the pre-conference program preceding the 21st International AIDS Conference held in Durban, South Africa. The meeting brought together a diversity of scientific, technical and community interests to discuss opportunities and challenges for increased prevention, diagnosis and treatment of viral hepatitis in people living with HIV, particularly in low- and middle-income settings. The objectives of the meeting were:i.To review the latest therapeutic developments in viral hepatitis;ii.To identify challenges such as high cost of medications for hepatitis C virus (HCV) and risk of developing viral resistance, and successes, such as the provision of HCV treatment in community-based settings, movements to reduce drug costs and increasing access, in relation to scaling up diagnosis, screening, antiviral treatment and prevention of viral hepatitis;iii.To advance the agenda for elimination of viral hepatitis as a public health problem. Discussions centred around the six key interventions outlined by the World Health Organization Global Health Sector Strategy on Viral Hepatitis 2016-2021: hepatitis B virus (HBV) vaccination (including birth dose); safe injection practices plus safe blood; harm reduction among people who inject drugs; safer sex practices; hepatitis B treatment; and hepatitis C cure. This article summarizes the main issues and findings discussed during the pre-conference meeting. One of the recommendations from the meeting delegates is universal implementation of birth dose vaccination for HBV without further delay to prevent mother-to-child transmission of infection. There is also the need to implement screening and treatment of hepatitis among pregnant women. A call was made for concerted efforts to be put together by all stakeholders towards addressing some of the structural barriers, including criminalization of drug use, discrimination and stigma that people living with viral hepatitis face. Finally, the need for greater advocacy was highlighted to enable access to therapy of viral hepatitis at lower cost than currently prevails. Implementation of these resolutions will help in achieving the target of eliminating viral hepatitis as a public health threat.

Finding solid ground: law enforcement, key populations and their health and rights in South Africa

INTRODUCTION

Sex workers, people who use drugs, men who have sex with men, women who have sex with women and transgender people in South Africa frequently experience high levels of stigma, abuse and discrimination. Evidence suggests that such abuse is sometimes committed by police officers, meaning that those charged with protection are perpetrators. This reinforces cycles of violence, increases the risk of HIV infection, undermines HIV prevention and treatment interventions and violates the constitutional prescriptions that the police are mandated to protect. This paper explores how relationship building can create positive outcomes while taking into account the challenges associated with reforming police strategies in relation to key populations, and vice versa.

DISCUSSION

We argue that relationships between law enforcement agencies and key populations need to be re-examined and reconstituted to enable appropriate responses and services. The antagonistic positioning, "othering" and blame assignment frequently seen in interactions between law enforcement officials and key populations can negatively influence both, albeit for different reasons. In addressing these concerns, we argue that mediation based on consensual dialogue is required, and can be harnessed through a process that highlights points of familiarity that are often shared, but not understood, by both parties. Rather than laying blame, we argue that substantive changes need to be owned and executed by all role-players, informed by a common language that is cognisant of differing perspectives.

CONCLUSIONS

Relational approaches can be used to identify programmes that align goals that are part of law enforcement, human rights and public health despite not always being seen as such. Law enforcement champions and representatives of key populations need to be identified and supported to promote interventions that are mutually reinforcing, and address perceived differences by highlighting commonality. Creating opportunities to share experiences in mediation can be beneficial to all role-players. While training is important, it is not a primary mechanism to change behaviour and attitudes.

HIV prevalence and risk among people who inject drugs in five South African cities

BACKGROUND

Policy and programming for people who inject drugs (PWID) in South Africa is limited by the scarcity of epidemiological data.

METHODS

We conducted a cross-sectional survey among 450 PWID (362 males and 88 females) from five South African cities in 2013, using outreach and peer referral to recruit participants. We carried out rapid HIV tests on participants' saliva and assessed drug-using and sexual practices by means of a questionnaire.

RESULTS

We found that 26% of females and 13% of males reported to always share injecting equipment, while 49% of all participants had used contaminated injecting equipment the last time they injected. Only 6% of participants usually used bleach to clean their injecting equipment. We found that half of participants reported using a condom the last time they had sex. A quarter of participants reported symptoms of a sexually transmitted infection (STI) in the previous 12 months and 22% had ever worked as a sex worker (51% of females). HIV prevalence among participants was 14% (18% among females and 13% among males). In multivariate analysis HIV was significantly associated with being 25 years and older (adjusted odds ratio (aOR) 2.1, 95% confidence interval (CI) 1.0-4.6, p=0.06), belonging to a racial group other than white (aOR 4.2, 95% CI 1.9-9.4, p<0.001), coming from Gauteng province (aOR 2.3, 95% CI 1.1-5.5, p=0.023), having ever worked as a sex worker (aOR 3.4, 95% CI 1.7-7.2, p=0.001) and the presence of STI symptoms in the last 12 months (aOR 2.4, 95% CI 1.1-4.4, p=0.019).

CONCLUSIONS

This study highlights the need for increased access to sterile injecting equipment, education around safer injecting practices and access to sexual and reproductive health services for PWID in South Africa. Programmes for PWID should also address the specific needs of female PWID, PWID who sell sex and PWID from previously disadvantaged communities.

Human Rights Violations among Men Who Have Sex with Men in Southern Africa: Comparisons between Legal Contexts

In 1994, South Africa approved a constitution providing freedom from discrimination based on sexual orientation. Other Southern African countries, including Botswana, Malawi, and Namibia, criminalize same-sex behavior. Men who have sex with men (MSM) have been shown to experience high levels of stigma and discrimination, increasing their vulnerability to negative health and other outcomes. This paper examines the relationship between criminalization of same-sex behavior and experiences of human rights abuses by MSM. It compares the extent to which MSM in peri-urban Cape Town experience human rights abuses with that of MSM in Gaborone, Botswana; Blantyre and Lilongwe, Malawi; and Windhoek, Namibia. In 2008, 737 MSM participated in a cross-sectional study using a structured survey collecting data regarding demographics, human rights, HIV status, and risk behavior. Participants accrued in each site were compared using bivariate and multivariate logistic regression. Encouragingly, the results indicate MSM in Cape Town were more likely to disclose their sexual orientation to family or healthcare workers and less likely to be blackmailed or feel afraid in their communities than MSM in Botswana, Malawi, or Namibia. However, South African MSM were not statistically significantly less likely experience a human rights abuse than their peers in cities in other study countries, showing that while legal protections may reduce experiences of certain abuses, legislative changes alone are insufficient for protecting MSM. A comprehensive approach with interventions at multiple levels in multiple sectors is needed to create the legal and social change necessary to address attitudes, discrimination, and violence affecting MSM.

The promise and peril of pre-exposure prophylaxis (PrEP): using social science to inform prep interventions among female sex workers

Advances in biomedical interventions to prevent HIV offer great promise in reducing the number of new infections across sub- Saharan Africa, particularly among vulnerable populations such as female sex workers. Several recent trials testing pre-exposure prophylaxis (PrEP) have demonstrated efficacy, although others have been stopped early for futility. Given the importance and complexities of social and behavioural factors that influence biomedical approaches to prevention, we discuss several key areas of consideration moving forward, including trial participation, adherence strategies, social relationships, and the structural factors that shape PrEP interest, use, and potential effectiveness among female sex workers in sub-Saharan Africa. Our review highlights the importance of involving social scientists in clinical and community-based research on PrEP. We advocate for a shift away from a singular "re-medicalization" of the HIV epidemic to that of a "reintegration" of interdisciplinary approaches to prevention that could benefit female sex workers and other key populations at risk of acquiring HIV.

Money, power and HIV: economic influences and HIV among men who have sex with men in sub-Saharan Africa

Despite consistent evidence, effective interventions and political declarations to reduce HIV infections among men who have sex with men (MSM), coverage of MSM programmes in sub-Saharan Africa (SSA) remains low. Punitive legal frameworks and hostile social circumstances and inadequate health systems further contribute to the high HIV burden among MSM in SSA. The authors use the Modified Social Ecological Model to discuss economic influences in relation to HIV and MSM in SSA. Nigerian, South African and Ugandan case studies are used to highlight economic factors and considerations related to HIV among MSM. The authors argue that criminalisation of consensual sexual practices among adults increases the frequency of human rights violations contributing to the incidence of HIV infections. Furthermore, marginalisation and disempowerment of MSM limits their livelihood opportunities, increases the prevalence of sex work and drug use and limits financial access to HIV services. Sexual and social networks are complex and ignoring the needs of MSM results in increased risks for HIV acquisition and transmission to all sexual partners with cumulative economic and health implications. The authors recommend a public health and human rights approach that employs effective interventions at multiple levels to reduce the HIV burden among MSM and the general population in SSA.

HIV prevention among female sex workers in Africa

Sex work occurs to meet the demand for sexual services and is a universal phenomenon. In Africa sex work takes many forms and is an important source of income for many women. Yet sex worker reproductive health needs remain largely unmet. The criminalisation of sex work; community and service provider stigma; violence; substance use and limited access to health services and prevention commodities contribute to the high HIV burden evident among female sex workers in Africa. Following UNAIDS' three pillar approach to HIV prevention and sex work we present an overview of current opportunities, barriers and suggestions to improve HIV prevention policy and programming for sex work in Africa. Universal access to a comprehensive package of HIV services is the first pillar. Reproductive health commodities; voluntary and anonymous HIV counselling and testing; treatment of sexually transmitted infections, HIV and opportunistic infections; harm reduction for substance use and psychosocial support services make up the recommended package of services. The second pillar is a sex worker-supportive environment. The inclusion of sex worker programmes within national HIV strategic planning; sex worker-led community mobilisation and the establishment of sex work community networks (comprised of sex workers, health service providers, law enforcers and other stakeholders) enable effective programme implementation and are recommended. The reduction of sex worker vulnerability and addressing structural issues form the final pillar. The decriminalisation of sex work; development of supportive policy; gender equality and economic development are key factors that need to be addressed to increase sex worker resilience. Evidence supports the public health benefit of human rights based approaches to HIV prevention; moralistic and restrictive policy and laws towards sex work are harmful and should be removed. The establishment of these pillars will increase sex worker safety and enhance the inclusiveness of the HIV response.

Assessing priorities for combination HIV prevention research for men who have sex with men (MSM) in Africa

A consultation was hosted in South Africa (March 2011) to assess the combination HIV prevention research priorities of academics, implementers and MSM community leaders. Sixty-nine participants, representing 17 African countries, participated. Interactive strategies were used to present current data on HIV interventions and discussions on research possibilities were facilitated with research priorities identified using the nominal group technique. Data were analysed using directed content analysis. Health worker training, social mobilisation, and community engagement were prioritised as structural interventions. Comprehensive counselling was identified as the most important behavioural intervention, with adherence, mental health, and risk reduction counselling identified as key counselling topics. Rectal microbicides, oral pre-exposure prophylaxis and condom and lubricant distribution were the most important biomedical interventions. This consultation resulted in the first combination HIV prevention research agenda for MSM in Africa. Outcomes will inform future research and be used to advocate for combination approaches to HIV prevention for MSM.

HIV risk and associations of HIV infection among men who have sex with men in peri-urban Cape Town, South Africa

Background

The HIV epidemic in Sub Saharan Africa has been traditionally assumed to be driven by high risk heterosexual and vertical transmission. However, there is an increasing body of data highlighting the disproportionate burden of HIV infection among MSM in the generalized HIV epidemics across of Southern Africa. In South Africa specifically, there has been an increase in attention focused on the risk status and preventive needs of MSM both in urban centers and peri-urban townships. The study presented here represents the first evaluation of HIV prevalence and associations of HIV infection among MSM in the peri-urban townships of Cape Town.

Methods

The study consisted of an anonymous probe of 200 men, reporting ever having had sex with another man, recruited through venue-base sampling from January to February, 2009.

Results

Overall, HIV prevalence was 25.5% (n = 51/200). Of these prevalent HIV infections, only 6% of HIV-1 infected MSM were aware of their HIV status (3/50). 0% of men reported always having safe sex as defined by always wearing condoms during sex and using water-based lubricants. Independent associations with HIV infection included inconsistent condom use with male partners (aOR 2.3, 95% CI 1.0-5.4), having been blackmailed (aOR 4.4, 95% CI 1.6-20.2), age over 26 years (aOR 4.2, 95% CI 1.6-10.6), being unemployed (aOR 3.7, 95% CI 1.5-9.3), and rural origin (aOR 6.0, 95% CI 2.2-16.7). Bisexual activity was reported by 17.1% (34/199), and a total of 8% (16/200) reported having a regular female partner. Human rights violations were common with 10.5% (n = 21/200) reporting having been blackmailed and 21.0% (n = 42/200) reporting being afraid to seek health care.

Conclusions

The conclusions from this study include that a there is a high risk and underserved population of MSM in the townships surrounding Cape Town. The high HIV prevalence and high risk sexual practices suggest that prevalence will continue to increase among these men in the context of an otherwise slowing epidemic. These data further highlight the need to better characterize risk factors for HIV prevention and appropriate targeted combination packages of HIV interventions including biomedical, behavioural, and structural approaches to mitigate HIV risk among these men.

Fluorescence remission spectroscopy of psoriatic lesions and the effect of topical anthralin therapy

BACKGROUND

Psoriatic lesions are characterized by induration, scaling and erythema. Erythema is a result of inflammation and increased microvascular blood flow. Anthralin is the strongest topical antipsoriatic drug that causes clearing of psoriatic lesions and temporary remission.

OBJECTIVE

The objective evaluation of skin perfusion might be a suitable way to gain a better insight in the pathophysiological process of this disease and to evaluate the response to antipsoriatic anthralin therapy.

METHODS

We evaluated 21 psoriatic lesions (plaques, patches and pinpoint lesions) including 4 lesions in remission with anthralin induced erythema and 4 controls of healthy, uninvolved skin. We performed the measurements with a combined fluorescence and remission imaging (FRIS). The FRIS sensor is coupled with a touch screen industrial computer. The equipment consists of a white-light halogen lamp (20 W), two VIS-spectrometer modules (Zeiss) for remission detection and references. Imaging is realized by CCD-colour camera module and white light ring-lighting. Fluorescence emission was realized using an ultraviolet LED with a wavelength of 370 nm. The fluorescence detector is a highly sensitive MCS CCD (Zeiss) with an integration time of 2.5 sec.

RESULTS

Spectral remission of psoriatic skin is characterized by a pronounced decrease (60-80%) of the haemoglobin double-peak compared to uninvolved skin. The NADH-fluorescence is diminished in lesional psoriatic skin including anthralin-treated areas with clinical remission.

CONCLUSIONS

Vascular perfusion is increased in psoriatic lesions as demonstrated by remission spectroscopy. NADH-fluorescence is reduced in lesional psoriatic skin and in anthralin-induced erythema. FRIS is a suitable tool for objective evaluation of the cutaneous response to antipsoriatic treatment.

Catalytic ammonia oxidation on platinum: mechanism and catalyst restructuring at high and low pressure

Catalytic ammonia oxidation over platinum has been studied experimentally from UHV up to atmospheric pressure with polycrystalline Pt and with the Pt single crystal orientations (533), (443), (865), and (100). Density functional theory (DFT) calculations explored the reaction pathways on Pt(111) and Pt(211). It was shown, both in theory and experimentally, that ammonia is activated by adsorbed oxygen, i.e. by O(ad) or by OH(ad). In situ XPS up to 1 mbar showed the existence of NH(x)(x= 0,1,2,3) intermediates on Pt(533). Based on a mechanism of ammonia activation via the interaction with O(ad)/OH(ad) a detailed and a simplified mathematical model were formulated which reproduced the experimental data semiquantitatively. From transient experiments in vacuum performed in a transient analysis of products (TAP) reactor it was concluded that N(2)O is formed by recombination of two NO(ad) species and by a reaction between NO(ad) and NH(x,ad)(x= 0,1,2) fragments. Reaction-induced morphological changes were studied with polycrystalline Pt in the mbar range and with stepped Pt single crystals as model systems in the range 10(-5)-10(-1) mbar.

[Thermal irritation of the organ of equilibrium by means of heat radiation (NIR)]

BACKGROUND AND OBJECTIVE

Convection and conduction are the main factors involved in caloric response. Heat radiation has also been discussed as an important factor. The present work tests whether heat radiation is an essential part of the caloric response and whether caloric irritation of the semicircular canals is possible using two sources with a different near infrared (NIR) spectrum. In addition, we tested whether it is possible to induce a detectable nystagmus reaction using either NIR-radiation sources.

RESULTS

NIR is able to penetrate bone tissue. The temperature elevation in dry and wet bones was almost immediately registered. With high optical power, specific temperature maxima could be seen by focal and selective broad spectrum and monochromatic NIR irritation of the three semicircular canals. Nystagmus could be generated after using both NIR emission sources in five probands.

CONCLUSIONS

NIR generates temperature differences and nystagmus. By using a broad scale as well as a monochromatic NIR-emission source, it is possible to generate a nystagmus. The procedure of NIR-irritation occurs without physical contact, is painless and quiet.

[Near infrared stimulation of the equilibrium organ--first clinical experiences]

BACKGROUND

A new method for the stimulation of the organ of equilibrium by means of a broad-scale and monochromatic near infrared emission was developed. This method should be examined within the framework of a pilot study, evaluated and its clinical possible applications examined.

PATIENTS AND METHODS

Healthy probands (n = 15), patients with a radical cave of the ear (n = 5), patients with a defect of the tympanic membrane (n = 5) and spontaneous nystagmus (n = 5) were examined. In healthy probands an irritation with broad-scale as well as monochromatic near infrared (NIR) was performed and compared with a water irrigation (44 degrees, 50 ml in 30 seconds). The subjective, local feelings during the application and the appearance of giddiness according to irritation were recorded and the nystagmus was registered by means of videonystagmography. In patients with radical cave of the ear and tympanic membrane defects, a broad-scale NIR-irritation before a comparative irritation with warm air (44 degrees) was performed exclusively.

RESULTS

In all healthy probands, a nystagmus reaction could be seen with broad-scale and monochromatic NIR. Compared to the hot water irritation slow phase velocity (SPV) was decreased however registrable by means of Frenzel glasses and electronystagmography during the culmination stage. In patients with radical cave (n = 4) and tympanic membrane defects (n = 3) showing paradoxical nystagmus reaction during hot air irritation, a nystagmus to the site of stimulation resulted by means of light calorisation. In patients with a spontaneous nystagmus an attenuation (n = 1) or inversion (n = 2) could be achieved by NIR-radiation.

CONCLUSIONS

The method of the NIR-radiation is suitable in clinical practice for the caloric test proofing warm reaction. Vaporization cold does not occur. The application of heat charm is better proportionable and steerable than during air irritation. The procedure is sterile, noiseless and non-contact. Difficulties in interpretation of results of vestibular tests because of evaporation coldness do not occur.