Prolongation of Acid-Fast Bacilli Sputum Smear Positivity in Patients with Multidrug-Resistant Pulmonary Tuberculosis

The study sought to determine factors associated with prolonged smear positivity in multidrug-resistant tuberculosis (MDR-TB) patients following appropriate management. Newly diagnosed patients were enrolled between June 2017 and May 2018. Sputum samples were collected for Xpert® MTB/RIF and line probe assays (LiPAs). Microscopic tests were performed at baseline and 4, 8, and 12 weeks post-anti-TB therapy. Of the 200 patients, 114 (57%) were HIV-positive. After 12 weeks of treatment, there was a significant microscopy conversion rate among DS-TB patients compared to MDR-TB patients irrespective of their HIV status (p = 0.0013). All MDR-TB patients who had a baseline smear grade ranging from scanty to +1 converted negative, while 25% ranging from +2 to +3 remained positive until the end of 12 weeks (p = 0.014). Factors associated with smear positivity included age <35 years (p = 0.021), initial CD4+ T-cell count ≥200 cells/mm3 (p = 0.010), and baseline smear grade ≥2+ (p = 0.014). Cox regression showed that only the baseline smear grade ≥2+ was independently associated with prolonged smear positivity in MDR-TB patients (p = 0.011) after adjusting for HIV status, CD4+ T-cell count, and age. Baseline sputum smear grade ≥2+ is a key determinant for prolonged smear positivity beyond 12 weeks of effective anti-TB therapy in MDR-TB patients.

Models of integration of TB and HIV services and factors associated with perceived quality of TB-HIV integrated service delivery in O. R Tambo District, South Africa

BACKGROUND

Tuberculosis is the leading infectious cause of death among people living with HIV. Reducing morbidity and mortality from HIV-associated TB requires strong collaboration between TB and HIV services at all levels with fully integrated, people-centered models of care.

METHODS

This is a qualitative study design using principles of ethnography and the application of aggregate complexity theory. A total of 54 individual interviews with healthcare workers and patients took place in five primary healthcare facilities in the O.R. Tambo district. The participants were purposively selected until the data reached saturation point, and all interviews were tape-recorded. Quantitative analysis of qualitative data was used after coding ethnographic data, looking for emerging patterns, and counting the number of times a qualitative code occurred. A Likert scale was used to assess the perceived quality of TB/HIV integration. Regression models and canonical discriminant analyses were used to explore the associations between the perceived quality of TB and HIV integrated service delivery and independent predictors of interest using SPSS® version 23.0 (Chicago, IL) considering a type I error of 0.05.

RESULTS

Of the 54 participants, 39 (72.2%) reported that TB and HIV services were partially integrated while 15 (27.8%) participants reported that TB/HIV services were fully integrated. Using the Likert scale gradient, 23 (42.6%) participants perceived the quality of integrated TB/HIV services as poor while 13 (24.1%) and 18 (33.3%) perceived the quality of TB/HIV integrated services as moderate and excellent, respectively. Multiple linear regression analysis showed that access to healthcare services was significantly and independently associated with the perceived quality of integrated TB/HIV services following the equation: Y = 3.72-0.06X (adjusted R2 = 23%, p-value = 0.001). Canonical discriminant analysis (CDA) showed that in all 5 municipal facilities, long distances to healthcare facilities leading to reduced access to services were significantly more likely to be the most impeding factor, which is negatively influencing the perceived quality of integrated TB/HIV services, with functions' coefficients ranging from 9.175 in Mhlontlo to 16.514 in KSD (Wilk's Lambda = 0.750, p = 0.043).

CONCLUSION

HIV and TB integration is inadequate with limited access to healthcare services. Full integration (one-stop-shop services) is recommended.

The Detection of Mutations and Genotyping of Drug-Resistant Mycobacterium tuberculosis Strains Isolated from Patients in the Rural Eastern Cape Province

Drug-resistant tuberculosis (DR-TB) is still a major public health concern in South Africa. Mutations in M. tuberculosis can cause varying levels of phenotypic resistance to anti-TB medications. There have been no prior studies on gene mutations and the genotyping of DR-TB in the rural Eastern Cape Province; hence, we aimed to identify DR-TB mutations, genetic diversity, and allocated lineages among patients in this area. Using Xpert^® MTB/RIF, we assessed the rifampin resistance of sputum samples collected from 1157 patients suspected of having tuberculosis. GenoType MTBDR plus VER 2.0 was used for the detection of mutations causing resistance to anti-TB medications. The next step was to spoligotype 441 isolates. The most prevalent rifampin resistance-conferring mutations were in rpoB codon S531L in INH-resistant strains; the katG gene at codon S315TB and the inhA gene at codon C-15TB had the most mutations; 54.5% and 24.7%, respectively. In addition, 24.6% of strains showed mutations in both the rpoB and inhA genes, while 69.9% of strains showed mutations in both the katG and rpoB genes. Heteroresistance was seen in 17.9% of all cases in the study. According to spoligotyping analysis, Beijing families predominated. Investigation of the evolutionary lineages of M. tuberculosis isolates can be carried out using the information provided by the study's diversity of mutations. In locations wherein these mutations have been discovered, decision-making regarding the standardization of treatment regimens or individualized treatment may be aided by the detection frequency of rpoB, katG, and inhA mutations in various study areas.

Analysis of Discordance between Genotypic and Phenotypic Assays for Rifampicin-Resistant Mycobacterium tuberculosis Isolated from Healthcare Facilities in Mthatha

The study sought to determine the rate of discordant results between genotypic and phenotypic tests for the diagnosis of drug-resistant tuberculosis (DR-TB). Sputum samples and cultured isolates from suspected DR-TB patients were, respectively, analyzed for Mycobacterium tuberculosis by Xpert^® MTB/RIF (Cepheid, Sunnyvale, CA, USA) and line probe assays (LPA) (Hain, Nehren, Germany). Discrepant rifampicin (RMP)-resistant results were confirmed using BACTEC MGIT960 (BD, New York, NY, USA). Of the 224 RMP-resistant results obtained by Xpert MTB/RIF, 5.4% were susceptible to RMP by LPA. MGIT960 showed a 75% agreement with LPA. The discrepancy was attributed to either heteroresistance or DNA contamination during LPA testing in 58.3% of cases. In 25% of the samples showing agreement in RMP resistance between Xpert MTB/RIF and MGIT960, the discrepancy was attributed to laboratory errors causing false RMP susceptible results with LPA. In 16.7% of the cases, the discrepancy was attributed to false RMP susceptible results with Xpert MTB/RIF. Out of the 224 isolates, susceptibility to isoniazid (INH) by LPA was performed in 73.7% RMP-resistant isolates, of which, 80.6% were resistant. All RMP-resistant isolates by Xpert MTB/RIF were confirmed in 98.5% by LPA if TB isolates were resistant to INH, but were only confirmed in 81.3% if TB isolates were susceptible to INH (p < 0.001). In conclusion, laboratory errors should be considered when investigating discordant results.

Treatment Outcomes and Associated Factors among Tuberculosis Patients from Selected Rural Eastern Cape Hospitals: An Ambidirectional Study

An essential metric for determining the efficacy of tuberculosis (TB) control programs is the evaluation of TB treatment outcomes; this study was conducted to investigate treatment outcomes and associated factors among tuberculosis patients in rural areas of Eastern Cape, South Africa. Assessing treatment outcomes is fundamental to facilitating the End TB Strategy's set target. Clinic records from 457 patients with DR-TB were examined for data collection while 101 patients were followed up prospectively. Data were analyzed using Stata version 17.0. The odds ratio and 95% confidence interval were calculated to check the association between variables. p ≤ 0.05 was considered statistically significant. Of the 427 participants, 65.8% had successful treatment whilst 34.2% had unsuccessful TB treatment. A total of 61.2% and 39% of the HIV-positive and HIV-negative participants had a successful TB treatment whilst 66% and 34% of both HIV-negative and positive participants had unsuccessful TB treatment. From the 101 patients that were followed up, smokers took longer to have treatment outcomes compared to non-smokers. In the study with HIV/TB co-infection, men predominated. HIV and tuberculosis co-infection made therapy difficult with unfavorable effects on TB management. The treatment success rate (65.8%) was lower than the WHO threshold standard with a high proportion of patients being lost to the follow up. The co-infection of tuberculosis and HIV resulted in undesirable treatment outcomes. Strengthening TB surveillance and control is recommended.

Developing a Model for Integrating of Tuberculosis, Human Immunodeficiency Virus and Primary Healthcare Services in Oliver Reginald (O.R) Tambo District, Eastern Cape, South Africa

Despite the policy, frameworks for integration exist; integration of TB and HIV services is far from ideal in many resource-limited countries, including South Africa. Few studies have examined the advantages and disadvantages of integrated TB and HIV care in public health facilities, and even fewer have proposed conceptual models for proven integration. This study aims to fill this vacuum by describing the development of a paradigm for integrating TB, HIV, and patient services in a single facility and highlights the importance of TB-HIV services for greater accessibility under one roof. Development of the proposed model occurred in several phases that included assessment of the existing integration model for TB-HIV and synthesis of quantitative and qualitative data from the study sites, which were selected public health facilities in rural and peri-urban areas in the Oliver Reginald (O.R.) Tambo District Municipality in the Eastern Cape, South Africa. Secondary data on clinical outcomes from 2009-2013 TB-HIV were obtained from various sources for the quantitative analysis of Part 1. Qualitative data included focus group discussions with patients and healthcare workers, which were analyzed thematically in Parts 2 and 3. The development of a potentially better model and the validation of this model shows that the district health system was strengthened by the guiding principles of the model, which placed a strong emphasis on inputs, processes, outcomes, and integration effects. The model is adaptable to different healthcare delivery systems but requires the support of patients, providers (professionals and institutions), payers, and policymakers to be successful.

Spatial Distribution of Drug-Resistant Mycobacterium tuberculosis Infections in Rural Eastern Cape Province of South Africa

Tuberculosis (TB), an infectious airborne disease caused by Mycobacterium tuberculosis (Mtb), is a serious public health threat reported as the leading cause of morbidity and mortality worldwide. South Africa is a high-TB-burden country with TB being the highest infectious disease killer. This study investigated the distribution of Mtb mutations and spoligotypes in rural Eastern Cape Province. The Mtb isolates included were 1157 from DR-TB patients and analysed by LPA followed by spoligotyping of 441 isolates. The distribution of mutations and spoligotypes was done by spatial analysis. The rpoB gene had the highest number of mutations. The distribution of rpoB and katG mutations was more prevalent in four healthcare facilities, inhA mutations were more prevalent in three healthcare facilities, and heteroresistant isolates were more prevalent in five healthcare facilities. The Mtb was genetically diverse with Beijing more prevalent and largely distributed. Spatial analysis and mapping of gene mutations and spoligotypes revealed a better picture of distribution.

Voices from the Patients: A Qualitative Study of the Integration of Tuberculosis, Human Immunodeficiency Virus and Primary Healthcare Services in O.R. Tambo District, Eastern Cape, South Africa

Tuberculosis (TB), a disease of poverty and inequality, is a leading cause of severe illness and death among people with human immunodeficiency virus (HIV). In South Africa, both TB and HIV epidemics have been closely related and persistent, posing a significant burden for healthcare provision. Studies have observed that TB-HIV integration reduces mortality. The operational implementation of integrated services is still challenging. This study aimed to describe patients' perceptions on barriers to scaling up of TB-HIV integration services at selected health facilities (study sites) in Oliver Reginald (O.R) Tambo Municipality, Eastern Cape province, South Africa. We purposely recruited twenty-nine (29) patients accessing TB and HIV services at the study sites. Data were analyzed using qualitative content analysis and presented as emerging themes. Barriers identified included a lack of health education about TB and HIV; an inadequate counselling for HIV and the antiretroviral drugs (ARVs); and poor quality of services provided by the healthcare facilities. These findings suggest that the O.R. Tambo district needs to strengthen its TB-HIV integration immediately.

Contributory Factors to Successful Tuberculosis Treatment in Southwest Nigeria: A Cross-Sectional Study

Tuberculosis (TB) is one of the oldest human diseases, and preventing treatment failure is critical. This is because TB cases pose a risk to the immediate and remote communities due to the potential for spread, particularly for multidrug-resistant (MDR) strains that have been associated with higher morbidity and mortality rates. Hence, this study looked at the factors that influence TB treatment outcomes in Southwest Nigeria. We conducted a cross-sectional study with 712 TB patients from 25 directly observed treatment short course (DOTS) centers, out of which 566 (79.49%) were new treatment cases, and 102 (14.33%) were retreatment cases. The outcome variable was computed into successful treatment where ‘Yes’ was assigned to TB treatment completed and cured, and ‘No’ was assigned to all the remaining outcomes following the standard TB definition. Independent variables included in the analysis were the patient’s socio-demographic characteristics (such as age, sex, distance from the facility, marital status, family type, education, and computed socioeconomic status from modified DHS household assets), clinical and facility parameters (such as the HIV status, facility of access to healthcare, healthcare workers attitudes, services offered at the facility, appearance of the facility, number of people seeking care and waiting time at the facility). Bivariate analysis showed that HIV status (OR: 3.53, 95% CI: 1.83–6.82; p = 0.001), healthcare worker attitude (OR: 2.13, 95% CI: 1.21–3.74; p = 0.01), services offered at the facility (OR: 0.67, 95% CI: 0.49–0.92; p = 0.01), appearance of facility (OR: 0.67, 95% CI: 0.46–0.98; p = 0.04), and number of people seeking care (OR: 2.47, 95% CI: 1.72–3.55; p = 0.001) were associated with higher odds of successful treatment outcome with statistical significance. After multivariate analysis, reactive HIV status (aOR: 3.37, 95% CI: 1.67–6.80; p = 0.001), positive attitude of healthcare workers (aOR: 2.58, 95% CI: 1.36–4.89; p = 0.04), excellent services offered at the healthcare facility (aOR: 0.53, 95% CI: 0.36–0.78; p = 0.001) and few people seeking care (aOR: 2.10, 95% CI: 1.21–3.84; p = 0.001) became independent significant determinants of successful treatment outcome. The study concluded that reactive HIV status, positive attitude of healthcare workers, few people seeking healthcare, and excellent service provided were all factors that contributed to successful treatment outcomes.

The association of MTHFR (rs1801133) with hypertension in an indigenous south African population

Aims: The current study sought to investigate the association between the methylenetetrahydrofolate reductase (MTHFR) variant (rs1801133) and the risk of developing hypertension (HTN) in an indigenous South African population.

Methods: A total of 442 participants (hypertensive, n = 279 and non-hypertensive, n = 163) from the indigenous tribe residing in Mthatha, Eastern Cape (South Africa) were recruited. HTN was defined as a systolic (SBP) and diastolic blood pressure (DBP) of ≥130/80 mmHg following American Heart Association guidelines. The genotyping of MTHFR (rs1801133) was assessed using MassARRAY^® System. Thereafter, the association between rs1801133 in various genetic models and HTN was determined by logistic regression model analysis. Furthermore, the interaction between rs1801133 and selected risk factors on HTN was performed using the open-source multifactor dimensionality reduction (MDR).

Results: The low frequency of the T allele (5%) was also observed when compared with the C allele (95%) in both cases and controls. After adjusting for confounding factors (gender, smoking status, BMI, and blood glucose levels), there were no significant associations were observed between rs1801133 and the risk of HTN in all genetic models: genotypic (OR 0.75, 95% CI 0.29–1.95, p = 0.56), dominant (OR 0.86, 95% CI 0.35–2.16, p = 0.75), co-dominant (OR 1.33, 95% CI 0.51–3.48, p = 0.55) and allelic (OR 0.80, 95% CI 0.49–1.62, p = 0.70) in logistic regression analysis. However, a significant interaction was reported among rs1801133, age, and gender (p < 0.0001) with the risk of HTN.

Conclusion: The present study reports on the lack of association between MTHFR (rs1801133) and the risk of HTN in an indigenous South African tribe. However, an interaction between gender, age, and rs1801133 was observed. Thus, future studies with a large sample size are required to further validate these findings.

Lifestyle determinants of diabetes mellitus amongst people living with HIV in the Eastern Cape province, South Africa

Background

Type 2 diabetes mellitus (DM) has serious consequences for those affected. Little is documented on the lifestyle determinants of type 2 DM in people living with human immunodeficiency virus (PLWHIV).

Aim

This study aimed to assess the lifestyle determinants of type 2 DM amongst PLWHIV who were on antiretroviral treatment (ARV).

Setting

This study was undertaken in 10 community health clinics and 140 clinics in South Africa’s Eastern Cape province.

Methods

This case control study was undertaken amongst PLWHIV who were on ARV in OR Tambo district.

Results

Cases and controls showed statistically significant differences on the duration of time on ARV (p < 0.0001), vigorous work (p = 0.019), participation in moderate sport (p = 0.007) and consuming daily fruit and vegetable servings (p = 0.021). Those reporting to be on ARVs for 6 to 10 years were three times more likely to be diabetic than those who had only been on ARV for a year or less (odds ratio [OR] = 3.0; p = 0.017) and in comparison, to participants who reported having one serving, participants who had four fruit and vegetable servings daily were 3.2 times more likely to be diabetic (OR = 3.2; p = 0.002).

Conclusion

This study revealed significant nutritional imbalances on fruit and vegetable servings and on participation in moderate sport resulting in poor diabetic control. Routine screening and measurements need to focus on dietary and physical lifestyle determinants of type 2 DM in order to counsel patients on ARV on balanced nutrition and optimise outcomes in the quality care of PLWHIV.

Methylenetetrahydrofolate Reductase Polymorphism (rs1801133) and the Risk of Hypertension among African Populations: A Narrative Synthesis of Literature

In this review, we have gathered and analyzed the available genetic evidence on the association between the methylenetetrahydrofolate reductase gene (MTHFR), rs1801133 and the risk of Hypertension (HTN) in African populations, which was further compared to the global data evidence. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and Human Genome Epidemiology Network (HuGENet) guidelines. Literature was retrieved through major search databases, including PubMed, Scopus, Web of Science, and African Journal Online. We identified 64 potential studies, of which 4 studies were from the African continent and 60 studies were reported globally. Among the studies conducted in Africa, only two (n = 2) reported a significant association between the MTHFR (rs1801133) and the risk of developing HTN. Only one (n = 1) study population was purely composed of black Africans, while others were of other ethnicities. Among studies conducted in other continents (n = 60), forty-seven (n = 47) studies reported a positive association between MTHFR (rs1801133) and the risk of developing HTN, whereas the remaining studies (n = 14) did not show a significant association. Available literature suggests an apparent association between rs1801133 and HTN in global regions; however, such information is still scarce in Africa, especially in the black African population.

Predictors of tuberculosis incidence and the effects of multiple deprivation indices on tuberculosis management in OR Tambo district over a 5-year period

Background

This study investigated the associations between socio-economic deprivation and tuberculosis (TB) treatment outcomes, alongside well-known TB risk factors. The effects of healthcare expenditures and their growth on trends in TB incidence from 2009 to 2013 were also assessed.

Methods

Secondary data analysis was performed on data obtained from various sources including governmental, non-governmental and research institutions. Indicators for TB treatment outcomes included TB death rate, TB rate among the household contacts of the Index TB cases, TB treatment failure, HIV associated TB death rate, TB defaulter rate, and new TB smear positive cases. Analysis of variance (ANOVA) and Turkey’s tests for post-hoc analysis were used to compare means of variables of interest considering a type I error rate of 0.05. Regression models and canonical discriminant analysis (CDA) were used to explore the associations between trends in TB incidence and independent TB predictors. During CDA, Fischer’s linear functions, Eigen values, and Mahalanobis distances were determined with values of Wilk’s Lambda closer to zero being the evidence for well discriminated patient groups. Data analysis was performed using SPSS® statistical software version 23.0 (Chicago, IL).

Results

In total, 62 400 records of TB notification were analyzed for the period 2009–2013. The average TB incidence rate over a 5-year period was 298 cases per 100,000 inhabitants per year. The incidence of TB was reduced by 79.70% at the end of the evaluation as compared to the baseline data in 2009. Multiple linear regression analysis showed that the Expenditure per patient day equivalent (PDE) and PHC expenditure per capita were significantly and independently associated with the decline of TB incidence (adjusted R² = 60%; ρ = 0.002) following the equation: Y = (- 209× Expenditure per PDE) + (- 0.191 × PHC expenditure per capita). CDA showed that in the most socio-economically deprived communities (quintile 1), HIV associated TB death rates were significantly more likely to be higher as compared to the least socio-economically deprived group (quintile 5) [Eigen value (12.95), function coefficient (1.49) > (.77); Wilk’s Lambda = .019, p < .0001].

Conclusions

Although TB control programs in OR Tambo district have averted thousands of TB incident cases, their effects on HIV associated TB deaths among the most deprived communities remain insignificant. There is an urgent need for strengthening integration of TB/HIV services in most deprived settings.

[Epidemiological, Clinical And Therapeutic Profile Of Hiv-Infected Patients On Antiretroviral Treatment In Kisangani, Democratic Republic Of Congo]

MATERIAL AND METHOD

This was a cross-sectional and descriptive study with retrospective collection conducted from 1 January 2020 to 31 December 2021 in Kisangani on HIV-infected patients. Sociodemographic, clinical and therapeutic data of patients were recorded and analyzed.

RESULTS

A total of 124 patients were identified, 71% of whom were females. The majority were aged 26-35, female and unemployed. Provider-initiated testing and counselling was the most common circumstance of discovery of HIV diagnosis (56.4%). Weight loss (48.4%), fever (40.3%) and cough (37.9%) were the main clinical manifestations found in patients. At the time of the discovery of HIV infection, the majority of patients were in category C at stage III of the disease according to the 1993 CDC classification. The most frequently encountered antecedents were sexually transmitted infections (22.6%) and tuberculosis (14.5%). HIV infection mainly affects young adults, females, married, unemployed, urban residents, secondary school and who consult health facilities at the advanced stage of the disease.

CONCLUSION

Public awareness (targeting especially youth) and early use of screening could improve this situation.

Phylogenetic analysis of carbapenem-resistant Acinetobacter baumannii isolated from different sources using Multilocus Sequence Typing Scheme

The emergence and worldwide distribution of carbapenem-resistant Acinetobacter baumannii strains has become a major public health threat. The objective of this study was to investigate the clonal relatedness of A. baumannii isolates collected from clinical and extra-hospital environments in Mthatha, South Africa. Forty carbapenem-resistant isolates comprising of clinical (20) and extra-hospital (20) were identified and tested for antimicrobial susceptibility. Detection of carbapenemase encoding genes was performed by Real-time PCR. The clonal relationship of clinical isolates relative to extra-hospital isolates was determined via multilocus sequence typing (MLST). All isolates (clinical and extra-hospital) were resistant to most common antibiotics including carbapenems (imipenem; MIC ≥32 μg/mL and meropenem; MIC ≥32 μg/mL) with the only exception being amikacin (with 3 isolates susceptible), tigecycline (14 isolates susceptible) and colistin (all isolates susceptible). The bla OXA-23-like and the intrinsic bla OXA-51 -like genes were detected in all the isolates tested. The bla OXA-58-like and bla IMP-type genes were detected in 2 clinical isolates whilst the bla OXA-24-like, bla VIM-type, bla NDM-1, bla SIM, and bla AmpC were not detected. The bla OXA-24-like, bla OXA-58-like, bla IMP-type, bla VIM-type, bla NDM-1, bla SIM, and bla AmpC were negative in the extra-hospital isolates. Co-occurrence of bla OXA-23 -like, bla OXA-58-like and bla IMP-type was observed in 2 clinical isolates. The MLST performed on 33 isolates identified 5 existing sequence types (ST) (ST1, ST2, ST25, ST85 and ST215) in clinical isolates and 2 existing STs (ST1 and ST2) in extra-hospital isolates. The most dominant ST was ST2 accounting for 68.8% of the clinical isolates and 82.4% of the extra-hospital isolates. The study demonstrated high prevalence and potential clonal spread of globally-disseminated clonal complex 2 carrying bla OXA-23-like within our local settings. However, ST25 might be an emerging lineage carrying the bla OXA-23-like . Continuous monitoring is important in limiting the spread of these strains in other healthcare settings and the community.

Hypertension in African Populations: Review and Computational Insights

Hypertension (HTN) is a persistent public health problem affecting approximately 1.3 billion individuals globally. Treatment-resistant hypertension (TRH) is defined as high blood pressure (BP) in a hypertensive patient that remains above goal despite use of ≥3 antihypertensive agents of different classes including a diuretic. Despite a plethora of treatment options available, only 31.0% of individuals have their HTN controlled. Interindividual genetic variability to drug response might explain this disappointing outcome because of genetic polymorphisms. Additionally, the poor knowledge of pathophysiological mechanisms underlying hypertensive disease and the long-term interaction of antihypertensive drugs with blood pressure control mechanisms further aggravates the problem. Furthermore, in Africa, there is a paucity of pharmacogenomic data on the treatment of resistant hypertension. Therefore, identification of genetic signals having the potential to predict the response of a drug for a given individual in an African population has been the subject of intensive investigation. In this review, we aim to systematically extract and discuss African evidence on the genetic variation, and pharmacogenomics towards the treatment of HTN. Furthermore, in silico methods are utilized to elucidate biological processes that will aid in identifying novel drug targets for the treatment of resistant hypertension in an African population. To provide an expanded view of genetic variants associated with the development of HTN, this study was performed using publicly available databases such as PubMed, Scopus, Web of Science, African Journal Online, PharmGKB searching for relevant papers between 1984 and 2020. A total of 2784 articles were reviewed, and only 42 studies were included following the inclusion criteria. Twenty studies reported associations with HTN and genes such as AGT (rs699), ACE (rs1799752), NOS3 (rs1799983), MTHFR (rs1801133), AGTR1 (rs5186), while twenty-two studies did not show any association within the African population. Thereafter, an in silico predictive approach was utilized to identify several genes including CLCNKB, CYPB11B2, SH2B2, STK9, and TBX5 which may act as potential drug targets because they are involved in pathways known to influence blood pressure. Next, co-expressed genes were identified as they are controlled by the same transcriptional regulatory program and may potentially be more effective as multiple drug targets in the treatment regimens for HTN. Genes belonging to the co-expressed gene cluster, ACE, AGT, AGTR1, AGTR2, and NOS3 as well as CSK and ADRG1 showed enrichment of G-protein-coupled receptor activity, the classical targets of drug discovery, which mediate cellular signaling processes. The latter is of importance, as the targeting of co-regulatory gene clusters will allow for the development of more effective HTN drug targets that could decrease the prevalence of both controlled and TRH.

Detection of extended spectrum beta-lactamase genes in Pseudomonas aeruginosa isolated from patients in rural Eastern Cape Province, South Africa

The proliferation of extended spectrum beta-lactamase (ESBL) producing Pseudomonas aeruginosa represent a major public health threat. In this study, we evaluated the antimicrobial resistance patterns of P. aeruginosa strains and characterized the ESBLs and Metallo- β-lactamases (MBL) produced. Strains of P. aeruginosa cultured from patients who attended Nelson Mandela Academic Hospital and other clinics in the four district municipalities of the Eastern Cape between August 2017 and May 2019 were identified; antimicrobial susceptibility testing was carried out against thirteen clinically relevant antibiotics using the BioMérieux VITEK 2 and confirmed by Beckman autoSCAN-4 System. Real-time PCR was done using Roche Light Cycler 2.0 to detect the presence of ESBLs; bla_SHV, bla_TEM and bla_CTX-M genes; and MBLs; bla_IMP, bla_VIM. Strains of P. aeruginosa demonstrated resistance to wide-ranging clinically relevant antibiotics including piperacillin (64.2%), followed by aztreonam (57.8%), cefepime (51.5%), ceftazidime (51.0%), piperacillin/tazobactam (50.5%), and imipenem (46.6%). A total of 75 (36.8%) multidrug-resistant (MDR) strains were observed of the total pool of isolates. The bla_TEM, bla_SHV and bla_CTX-M was detected in 79.3%, 69.5% and 31.7% isolates (n = 82), respectively. The bla_IMP was detected in 1.25% while no bla_VIM was detected in any of the strains tested. The study showed a high rate of MDR P. aeruginosa in our setting. The vast majority of these resistant strains carried bla_TEM and bla_SHV genes. Continuous monitoring of antimicrobial resistance and strict compliance towards infection prevention and control practices are the best defence against spread of MDR P. aeruginosa.

Prevalence of Hypertension and Its Associated Risk Factors in a Rural Black Population of Mthatha Town, South Africa

Background: The occurrence of hypertension has been increasing alarmingly in both low and middle-income countries. Despite acknowledging hypertension as the most common life-threatening risk factor for cardiovascular disease (CVD), a dearth of data is available on the prevalence, awareness, and determinants of hypertension in rural parts of South Africa. The principal aim of the current study is to determine the prevalence and associated risk factors of hypertension among a black rural African population from the Mtatha town of Eastern Cape Province. Methods: This was a cross-sectional study, and individuals over 18 years of age were randomly screened using a World Health Organization stepwise questionnaire. Sociodemographic information, anthropometric measurements, fasting blood glucose levels, and three independent blood pressure (BP) readings were measured. Blood pressure measurements were classified according to the American Heart Association guidelines. Univariate and multivariate analyses were performed to determine the significant predictors of hypertension. Results: Of the total participants (n = 556), 71% of individuals had BP scores in the hypertensive range. In univariate analysis, age, westernized diet, education, income, and diabetic status, as well as overweight/obese status were positively associated with the prevalence of hypertension. However, in a multivariate logistic regression analysis only, age, body mass index (BMI), diabetic status, and westernized diet were significantly associated with a higher risk of developing hypertension. Gender, age, and BMI were potential factors having a significant association with the treatment of hypertension. Individuals who did not consider the importance of medicine had higher chances of having their hypertension being untreated. Conclusions: Prevalence of hypertension was high among the black rural African population of Mthatha town. Gender, age, westernized diet, education level, income status, diabetic as well as overweight/obese status were the most significant predictors of hypertension.

Socio-demographic associations of HIV among women attending antenatal care in selected rural primary care facilities in South Africa's Eastern Cape province

Background

To effectively reduce vertical HIV transmission requires a reduction of HIV prevalence and incidence among pregnant women and a full understanding of its epidemiology. The study aimed to determine the prevalence of HIV among women attending antenatal care and further determine spousal support during antenatal care attendance in rural areas in Eastern Cape province, South Africa.

Methods

A Cross-sectional study of women attending antenatal care in four Primary Care facilities was conducted using an interviewer-administered questionnaire which collected information on socio-demographic characteristics and medical history. Binomial logistic regression analyses were used to determine factors associated with HIV and to estimate the prevalence ratio (PR). The 95% confidence interval (95%CI) is used for precision of estimates; p≤0.05 for statistical significance.

Results

A total of 343 participants were included in the final analysis. The antenatal HIV prevalence was 38.2% (95%CI: 33.2–43.9). For 75% of the women, the HIV diagnosis was made 141 days before the date of the interview (median=77 days, interquartile range=42–141 days). Participants between the age of 30 to 39 years were 50% more likely to be HIV positive compared to those who were between the age of 20 to 29, these differences were statistically significant (PR=1.5; p-value=0.001). Furthermore, self-employed women were 30% less likely to be HIV positive when compared to unemployed participants, this was also statistically significant (PR=0.7; p-value< 0.0001).

Conclusion

Despite a 100% antenatal HIV testing rate, the antenatal HIV prevalence remains high in this population, coupled with no spousal attendance in antenatal care. It is important to move beyond awareness about the HIV status to actionable strategies of reducing the HIV incident cases. It is therefore important to remain vigilant and monitor mother-to-child transmission that could be associated with this increased prevalence.

The association between HIV tri-therapy with the development of Type-2 Diabetes Mellitus in a rural South African District: A case-control study

BACKGROUND

Combination antiretroviral drugs (cARVs) prolong patients' lives but are unfortunately thought to increase complications related to metabolic disorders including type-2 Diabetes Mellitus (DM). We sought to confirm the association of cARVs with type-2 DM and ascertain the extent of this association in a rural South African setting.

METHODS

A case-control study of 177 (33.33%) cases with HIV/AIDS and type-2 DM were selected and compared with 354 (66.67%) non-DM HIV/AIDS unmatched controls from a rural district of South Africa's third most populous province (Eastern Cape). Cases were identified from community health centres using the district health information system, and controls were identified using simple random sampling from the same health facilities. Odds Ratios (OR), together with 95% confidence intervals, were calculated for all the univariable and multivariable logistic analyses.

RESULTS

This study found that cARVs significantly increased the occurrence of type-2 DM among HIV patients. Patients on protease inhibitors (PIs) were at least 21 times significantly (p<0.0001) more likely to be diabetic than those on the fixed dose combination (FDC); those on stavudine (D4T) and zidovudine (AZT) were 2.45 times and 9.44 times respectively more likely to be diabetic than those on FDC (p<0.05). The odds of diabetes increased by more than three-folds for those who had been on antiretroviral drugs for more than 6 years (p<0.005).

CONCLUSION

This study has been able to establish the association between cARVs and type-2 DM. It therefore proposes consideration of the usage of AZT, D4T, lopivavir and ritonavir for the treatment of HIV. The study further proposes more prospective research to test these findings further.

In vitro antimicrobial photodynamic inactivation of multidrug-resistant Acinetobacter baumannii biofilm using Protoporphyrin IX and Methylene blue

BACKGROUND

Acinetobacter baumannii is a challenging pathogen due to the rapid development of antimicrobial resistance and biofilm formation. The objective of this study was to evaluate the effect of antimicrobial photodynamic inactivation against biofilms of multidrug-resistant A. baumannii isolated from clinical, abattoir and aquatic sources.

METHODS

The isolates were tested for susceptibility to imipenem, meropenem, tigecycline and colistin using autoSCAN-4 automated system and rechecked by the E-test. Methylene blue, Protoporphyrin IX, and a halogen lamp were used in the in vitro assay against biofilms of the isolates. The antimicrobial photodynamic inactivation was assessed by counting colony-forming units (CFU).

RESULTS

The isolates from abattoir and aquatic sources were resistant to carbapenems (>64 μg/mL) but susceptible to tigecycline (2 μg/mL) and colistin (Abattoir, 0.35 μg/mL and Aquatic, 0.24 μg/mL), whereas the clinical isolate was susceptible to only colistin (0.5 μg/mL) using the E-test. The log survival percentages of the control group at a concentration of 20 μM were 5 × 10^-6 % for Protoporphyrin IX and 2 × 10^-6 % for Methylene blue. Therefore, Methylene blue showed higher bacterial reduction of 7.0 log₁₀ colony forming units than 6.0 log₁₀ for Protoporphyrin IX. No significant difference was observed with respect to the origin of isolates and the minimum inhibitory concentrations.

CONCLUSION

The results indicate that antimicrobial photodynamic inactivation could be an alternative strategy for the control of infections caused by multi-drug resistant A. baumannii by significantly reducing biofilm growth at a sub-lethal concentrations.

Prevalence and molecular analysis of multidrug-resistant Acinetobacter baumannii in the extra-hospital environment in Mthatha, South Africa

Introduction

The presence of Acinetobacter baumannii outside hospitals remains unclear. This study aimed to determine the prevalence of multidrug-resistance (MDR) A. baumannii in the extra-hospital environment in Mthatha, South Africa and to investigate the frequency of carbapenemase-encoding genes.

Material and Methods

From August 2016 to July 2017 a total of 598 abattoir samples and 689 aquatic samples were collected and analyzed presumptively by cultural methods for the presence of A. baumannii using CHROMagar™ Acinetobacter medium. Species identification was performed by autoSCAN-4 (Dade Behring Inc., IL) and confirmed by the detection of their intrinsic bla_OXA-51 gene. Confirmed MDR A. baumannii isolates were screened for the presence of carbapenemase-encoding genes, ISAba1 insertion sequence and integrase intI1.

Results

In total, 248 (19.3%) Acinetobacter species were isolated. Acinetobacter. baumannii was detected in 183 (73.8%) of which 85 (46.4%) and 98 (53.6%) were recovered from abattoir and aquatic respectively. MDR A. baumannii was detected in 56.5% (48/85) abattoir isolates and 53.1% (52/98) aquatic isolates. Isolates showed high resistance to antimicrobials most frequently used to treat Acinetobacter infections such as piperacillin/tazobactam; abattoir (98% of isolates resistant), aquatic (94% of isolates resistant), ceftazidime (84%, 83%), ciprofloxacin (71%, 70%), amikacin (41%, 42%), imipenem (75%, 73%), and meropenem (74%, 71%). All the isolates were susceptible to tigecycline and colistin. All the isolates carried bla_OXA-51-like. The bla_OXA-23 was detected in 32 (66.7%) abattoir isolates and 11 (21.2%) aquatic isolates. The bla_OXA-58-like was positive in 7 (14.6%) and 4 (7.7%) abattoir and aquatic isolates, respectively. Both groups of isolates lacked bla_OXA-24-like, bla_IMP-type, bla_VIM-type, bla_NDM-1,bla_SIM, bla_AmpC, ISAba1 and inI1. Isolates showed high level of Multiple Antibiotic Resistance Index (MARI) ranging from 0.20-0.52.

Conclusion

Extra-hospital sources such as abattoir and aquatic environments may be a vehicle of spread of MDR A. baumannii strains in the community and hospital settings.

Species distribution and antifungal susceptibility patterns of Candida isolates from a public tertiary teaching hospital in the Eastern Cape Province, South Africa

Candida species are the leading cause of invasive fungal infections, and over the past decade there has been an increased isolation of drug resistant Candida species. This study aimed to identify the species distribution of Candida isolates and to determine their unique antifungal susceptibility and resistance patterns. During a cross-sectional study, 209 Candida isolates (recovered from 206 clinical samples) were collected and their species distribution was determined using ChromAgar Candida. The Vitek-2 system (Biomerieux, South Africa) was used to determine minimum inhibitory concentrations (MICs) to azoles (fluconazole, voriconazole), echinocandins (caspofungin, micafungin), polyenes (amphotericin B) and flucytosine. Four species of Candida were isolated, of which C. albicans was the most frequent, isolated in 45.4% (95/209) of the isolates, followed by C. glabrata: 31.1% (65/209). The MICs of the different antifungal drugs varied amongst the species of Candida. From the 130 isolates tested for MICs, 90.77% (112/130) were susceptible to all antifungal drugs and 6.9% (9/130) of the isolates were multi-drug resistant. C. dubliniensis (n=2) isolates were susceptible to all the above mentioned antifungal drugs. There was no significant difference in species distribution amongst clinical specimens and between patients' genders (P>0.05). An increase in MIC values for fluconazole and flucytosine towards the resistance range was observed. To our knowledge, this is the first report on surveillance of Candida species distribution and antifungal susceptibility at a public tertiary teaching hospital in Eastern Cape, South Africa.

Association of Helicobacter pylori infection with the metabolic syndrome among HIV-infected black Africans receiving highly active antiretroviral therapy

INTRODUCTION

The metabolic syndrome (MetS) is common in human immune deficiency virus (HIV)-infected individuals receiving highly active antiretroviral therapy (HAART). Immune deficiencies caused by HIV give rise to numerous opportunistic gastrointestinal pathogens such as Helicobacter pylori, the commonest cause of chronic gastritis. The study sought to determine the relationship between H pylori infection and the MetS among HIV-infected clinic attendees.

METHODS

This cross-sectional study was carried out in a specialised heart clinic in Kinshasa, DR Congo. Between January 2004 and December 2008, 116 HIV-infected patients (61 with MetS and 55 without MetS) who underwent upper gastrointestinal endoscopy for dyspeptic symptoms were included in the study following an informed consent. Univariate associations were determined by odds ratios (OR), while multivariate logistic regression analysis was used to identify factors associated with the MetS.

RESULTS

H pylori infection (OR = 13.5, 95% CI: 10.3-17.6; p < 0.0001) and peripheral obesity (median hip circumference ≥ 97 cm) (OR = 4.7, 95% CI: 1.2-18.8; p = 0.029) were identified as MetS-related factors in HIV-infected patients. Higher rates of the MetS were associated with increased incidence of HIV-related immunocompromise using World Health Organisation (WHO) staging criteria. There was a univariate significant difference in the prevalence of the MetS between antiretroviral therapy (ART)-naïve patients and patients treated by means of a first-line HAART regimen of stavudine (d4T), lamivudine (3TC) and nevirapine (NVP). However, this difference was not significant in multivariate logistic analysis.

CONCLUSION

H pylori infection was significantly associated with the MetS in HIV-infected patients.

Factors Associated with Symptomatic Vulvovaginal Candidiasis: A Study among Women Attending a Primary Healthcare Clinic in Kwazulu-Natal, South Africa

Background:

Symptomatic vulvovaginal candidiasis (VVC) is one of the most common problems leading women to seek advice in primary healthcare facilities.

Aim:

The aim of this study is to describe the associations between some hypothesized factors and the presence of symptomatic VVC.

Subjects and Methods:

An analytical cross-sectional study was conducted. A total of 90 women diagnosed with symptomatic VVC and 108 women without symptomatic VVC were recruited when attending Umlazi D clinic, a primary health clinic in KwaZulu-Natal, South Africa between June 2011 and December 2011. Confirmed symptomatic VVC was determined by Gram stain and microbiological culture of vaginal swabs. For human immunodeficiency virus (HIV)-infected women, HIV ribonucleic acid load in plasma and genital fluid was determined by real-time-polymerase chain reaction (BioMerieux, Lyon, France). CD4 counts were obtained from patients’ medical records. Data were analyzed using the statistical package for the social sciences (SPSS) version 21.0 (SPSS Inc.; Chicago, IL, USA). Multiple logistic regression models were used to exclude univariate confounders. All tests were two-sided and a P < 0.05 was considered to be significant.

Results:

A total of 90% (81/90) of patients with symptomatic VVC complained of vulval itching, soreness and vaginal discharge when compared to 75.9% (82/108) of patients without symptomatic VVC (P < 0.01). Whilst pregnancy was independently associated with symptomatic VVC (P < 0.01), the latter was inversely related to Nugent's scores (P < 0.01). When compared with HIV negative women, the odds for symptomatic VVC increased among women with HIV-associated immunocompromise (CD4 counts < 200 cells/mm³, P < 0.001), significantly shedding HIV in their genital tracts (P = 0.04), with plasma HIV load > 1000 copies/mL (P < 0.001). There was a significant negative association between the use of highly active anti-retroviral therapy and the presence of symptomatic VVC in HIV-infected women (P < 0.01).

Conclusion:

Although symptomatic VVC is not classified as acquired immunodeficiency syndrome-related condition, HIV-related immune compromised women and particularly those who are anti-retroviral therapy-naïve are likely to develop symptomatic VVC.

Association between symptomatic vulvovaginal candidiasis and HIV RNA levels in plasma and genital secretions among women on HAART

Background. Genital tract (GT) inflammation plays a major role in HIV transmission. We aimed to determine the association between symptomatic vulvovaginal candidiasis (VVC) and HIV RNA levels in plasma and GTs of HIV-infected women on highly active antiretroviral therapy (HAART). Method. Women with VVC on HAART were recruited from a primary healthcare clinic in KwaZulu-Natal Province, South Africa, between June 2011 and December 2011. VVC was diagnosed clinically, supported by Gram staining and culture of genital secretions. HIV RNA load was determined by reverse transcription polymerase chain reaction. CD4+ counts were obtained from patients’ medical records.Results. Plasma HIV RNA was detected in 42 of 60 (70%) patients on HAART. The mean duration (± standard deviation) on HAART for these patients was 4.2 (±1.6) months v. 10.7 (±1.4) months for the remaining 18 patients (p<0.0001). Of the 42 women with detectable plasma HIV RNA, 12 (28.6%) had detectable genital HIV RNA. Plasma HIV RNA levels ranged from 2.5 (±0.8) to 4.1 (±0.8) log10 copies/ml. Genital HIV RNA levels ranged from 1.4 to 2.5 (±1.1) log10 copies/ml. The adjusted odds ratios of plasma HIV RNA levels increased for patients <35 years (p=0.039) and in those with VVC (p=0.008). Detectability of HIV in genital secretions was significantly increased in patients with a plasma HIV load ≥10 000 copies/ml (p=0.032) and genital absolute counts of neutrophils >10 cells/5 high microscopic fields (p=0.007). Conclusion. Given that the majority of women had recently initiated HAART (allowing a high rate of detectable plasma HIV RNA), there was insufficient evidence to conclude that VVC was predictive of high plasma HIV RNA levels. It is more likely that this cohort of immunosuppressed women were prone to develop VVC. Plasma HIV loads and local genital inflammation were predictors of genital HIV detectability.

An outbreak of foodborne salmonellosis in rural KwaZulu-Natal, South Africa

BACKGROUND

Salmonella enterica serotype Enteritidis is a universally recognized cause of foodborne disease. In South Africa, outbreaks of foodborne disease are generally under reported. We investigated the etiology of acute gastroenteritis in 216 patients who presented to a rural hospital in KwaZulu-Natal, South Africa, after consuming a meal at a school function.

MATERIALS AND METHODS

Stool specimens from 37 patients, as well as two food samples, were available for microbiological investigation. Similarity between isolates was investigated using phenotypic and genotypic techniques. Phenotypic investigations included morphological, biochemical, and antibiogram profiling. Genotypic relatedness was determined with pulsed-field gel electrophoresis analysis. The available epidemiological data were also described.

RESULTS

Salmonella Enteritidis was isolated from 18 patients and 1 food sample. Isolates were phenotypically and genotypically indistinguishable. Epidemiological data suggest a point-source outbreak with a possibility of continued transmission.

CONCLUSIONS

The results suggest a foodborne Salmonella Enteritidis outbreak due to contaminated food served at the school function. Epidemiological investigations continue to be extremely difficult in rural areas.

Aetiology of sexually transmitted infections in Maputo, Mozambique

INTRODUCTION

The study sought to ascertain the prevalence of the aetiological agents of genital discharge and genital ulcer diseases in Maputo, Mozambique.

METHODOLOGY

Consecutive consenting patients presenting to the Centro de Saúde do Porto in Maputo between March and April 2005 with genital discharge syndrome and/or genital ulcer diseases were recruited. Specimens were collected for the identification of STI pathogens.

RESULTS

Of 346 recruited patients, 164 were male and 182 female. The prevalence of confirmed single aetiological agents for male urethritis was as follows: N. gonorrhoeae, 35%; C. trachomatis, 10%; and M. genitalium 4%. For vaginal discharge, N. gonorrhoeae was found in 11% of the women tested, followed by C. trachomatis (6.5%), bacterial vaginosis (34%), and T. vaginalis (2%). The prevalence of genital ulcers was as follows: Herpes simplex virus type 2, 62%; H. ducreyi 4 %; and C. trachomatis biovar LGV, 4%. Five percent of patients with genital ulcers had a positive syphilis serology (RPR ≥ 1:8 and confirmed by TPHA) and 35% of all tested patients were HIV-1/2 infected. Cases of mixed infections were present in 5%, 11% and 3% of patients with male urethritis, vaginal discharge, and genital ulcers respectively.

CONCLUSION

The classic sexually transmitted infection aetiologies are still prevalent in Maputo. The study highlights the need for a periodic surveillance to inform syndromic management protocols.