Browsing by Author "Eley, Brian"

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    The effectiveness and cost-effectiveness of community-based support for adolescents receiving antiretroviral treatment: an operational research study in South Africa
    (Wiley Open Access, 2018) Fatti, Geoffrey; Jackson, Debra; Goga, Ameena; Shaikh, Najma; Eley, Brian; Nachega, Jean B.; Grimwood, Ashraf
    INTRODUCTION: Adolescents and youth receiving antiretroviral treatment (ART) in sub-Saharan Africa have high attrition and inadequate ART outcomes, and evaluations of interventions improving ART outcomes amongst adolescents are very limited. Sustainable Development Goal (SDG) target 3c is to substantially increase the health workforce in developing countries. We measured the effectiveness and cost-effectiveness of community-based support (CBS) provided by lay health workers for adolescents and youth receiving ART in South Africa. METHODS: A retrospective cohort study including adolescents and youth who initiated ART at 47 facilities. Previously unemployed CBS-workers provided home-based ART-related education, psychosocial support, symptom screening for opportunistic infections and support to access government grants. Outcomes were compared between participants who received CBS plus standard clinic-based care versus participants who received standard care only. Cumulative incidences of all-cause mortality and loss to follow-up (LTFU), adherence measured using medication possession ratios (MPRs), CD4 count slope, and virological suppression were analysed using multivariable Cox, competing-risks regression, generalized estimating equations and mixedeffects models over five years of ART. An expenditure approach was used to determine the incremental cost of CBS to usual care from a provider perspective. Incremental cost-effectiveness ratios were calculated as annual cost per patient-loss (through death or LTFU) averted. RESULTS: Amongst 6706 participants included, 2100 (31.3%) received CBS. Participants who received CBS had reduced mortality, adjusted hazard ratio (aHR) = 0.52 (95% CI: 0.37 to 0.73; p < 0.0001). Cumulative LTFU was 40% lower amongst participants receiving CBS (29.9%) compared to participants without CBS (38.9%), aHR = 0.60 (95% CI: 0.51 to 0.71); p < 0.0001). The effectiveness of CBS in reducing attrition ranged from 42.2% after one year to 35.9% after five years. Virological suppression was similar after three years, but after five years 18.8% CBS participants versus 37.2% non-CBS participants failed to achieve viral suppression, adjusted odds ratio = 0.24 (95% CI: 0.06 to 1.03). There were no significant differences in MPR or CD4 slope. The cost of CBS was US$49.5/patient/year. The incremental cost per patient-loss averted was US$600 and US$776 after one and two years, respectively. CONCLUSIONS: CBS for adolescents and youth receiving ART was associated with substantially reduced patient attrition, and is a low-cost intervention with reasonable cost-effectiveness that can aid progress towards several health, economic and equality- related SDG targets.
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    Low HIV incidence in pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa
    (Public Library of Science, 2017) Fatti, Geoffrey; Shaikh, Najma; Jackson, Debra; Goga, Ameena; Nachega, Jean B.; Eley, Brian; Grimwood, Ashraf
    BACKGROUND Young Southern African women have the highest HIV incidence globally. Pregnancy doubles the risk of HIV acquisition further, and maternal HIV acquisition contributes significantly to the paediatric HIV burden. Little data on combination HIV prevention interventions during pregnancy and lactation are available. We measured HIV incidence amongst pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa. METHODS A cohort study that included HIV-uninfected pregnant women was performed. Lay community- based workers provided individualized HIV prevention counselling and performed three-monthly home and clinic-based individual and couples HIV testing. Male partners were referred for circumcision, sexually transmitted infections or HIV treatment as appropriate. Kaplan-Meier analyses and Cox's regression were used to estimate HIV incidence and factors associated with HIV acquisition. RESULTS The 1356 women included (median age 22.5 years) received 5289 HIV tests. Eleven new HIV infections were detected over 828.3 person-years (PY) of follow-up, with an HIV incidence rate of 1.33 infections/100 PY (95% CI: 0.74±2.40). Antenatally, the HIV incidence rate was 1.49 infections/100 PY (95% CI: 0.64±2.93) and postnatally the HIV incidence rate was 1.03 infections/100 PY (95% CI: 0.33±3.19). 53% of male partners received HIV testing and 66% of eligible partners received referral for circumcision. Women within known serodiscordant couples, and women with newly diagnosed HIV-infected partners, adjusted hazard ratio (aHR) = 32.7 (95% CI: 3.8±282.2) and aHR = 126.4 (95% CI: 33.8±472.2) had substantially increased HIV acquisition, respectively. Women with circumcised partners had a reduced risk of incident HIV infection, aHR = 0.22 (95% CI: 0.03±1.86). CONCLUSIONS Maternal HIV incidence was substantially lower than previous regional studies. Communitybased combination HIV prevention interventions may reduce high maternal HIV incidence in resource-poor settings. Expanded roll-out of home-based couples HIV testing and initiating pre-exposure prophylaxis for pregnant women within serodiscordant couples is needed in Southern Africa.
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    Prescribing practice at a tertiary level paediatric hospital in South Africa
    (University of the Western Cape, 2014) Sablay, Hyder; Mugabo, Pierre; Eley, Brian
    The objectives of the present study were to describe the type and frequency of prescribing errors and error frequency, to determine the error frequency for different drug classes, to identify potential drug interactions and drug-disease interactions to point out off-label prescribing and to evaluate risk factors of prescribing errors. Methods: This prospective cross sectional study was conducted over a period of 6 months from July 2012 to December 2012 in 2 specialist wards and 2 general medical wards at Red Cross War Memorial Children’s Hospital in Cape Town in South Africa. Only prescriptions generated by doctors in the above mentioned wards were assessed. Convenience sampling was used to select 200 prescription charts for analysis. Information relating to prescribing error, potential drug interaction, potential drug-disease interactions, off-label prescribing and potential risk factors of prescribing error were entered into excel spreadsheet and analysed using STATA versions 11&12. The mass of the patients was converted into weight-for-age z-score (WAZ) using WHO 2006 child growth standards. Univariate analysis and multiple logistic regression were used to identify risk factors of prescribing errors. Results: Of the 200 children on whom prescribing information was analysed, 40 (20%) were severely underweight and a further 25(12.5%) were moderately underweight. A total of 1402 prescribing errors were documented in 1282 drug items prescribed, a rate of 1.09 errors per drug item prescribed. Incomplete prescription information was the most common type of prescribing error, present in 65.6% of all drug items prescribed. The error frequency was high for all drug classes ranging from 57.9% of all respiratory drug items prescribed to 86.4% of all gastro intestinal system drug items prescribed. The number of potential drug-drug interactions was low i.e. 20 potential pharmacodynamics and 49 potential pharmacokinetic drug interactions were identified. The number of potential drug-disease interactions was also low i.e. 39 or 0.03% per drug item prescribed. Furthermore 57 off-label prescribing incidences were recorded. Senior doctors posed a significant risk factor for prescribing errors, an OR 1.95, 95% CI 1.46 – 2.61. Conversely, prescriptions written up in the general wards compared to the specialty wards (an OR 0.65. 95% CI 0.47-0.90) and prescribing during weekends compared to weekdays (an OR 0.71, 95% CI 0.53-0.96) were associated with lower prescribing error risk. Conclusion: This study provided valuable information about prescribing practices in children at RCWMCH. There is a need to improve prescribers’ practice at RCWMCH considering the type of errors observed viz. missing information, use of wrong drug name, abbreviations, legibility concerns and lack of clarity of the prescriptions, among others. Based on this study results further intervention studies are recommended to investigate the level of medical student’s training w.r.t prescribing practice.