South African Medical Journal (SAMJ)
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Persistent hypertension, albuminuria and low glomerular filtration rate in schoolchildren in Kano metropolis, Nigeria
No full textBackground. Screening for persistent hypertension, albuminuria and low estimated glomerular filtration rate (eGFR) in children may allow for early detection of kidney disease, paving the way for early intervention to slow disease progression.
Objective. To determine the prevalence of persistent hypertension, albuminuria and low eGFR and their associated factors in schoolchildren.
Method. The study screened 228 schoolchildren (aged 5 - 15 years) from February 2020 to February 2021. Information about participants’ sociodemographic profile and medical history was obtained through questioning. Participants’ height, weight and blood pressure (BP) were measured. Their spot urine was assessed for albumin creatinine ratio (ACR), and blood for serum creatinine and eGFR. Participants with abnormal findings had a repeat assessment after a minimum of 3 months for BP, ACR and eGFR.
Results. The median (range) age was 13.0 (11.1 - 14.0) years, with 117 males and 111 females. Seventy-eight of the children (34%) had at least one abnormality (hypertension 1.8%, albuminuria 28% and low eGFR 9%) at recruitment. At follow-up, 33 (42%) of the 78 children had persistent abnormal findings (hypertension 1.3%, albuminuria 10.1%, low eGFR 6%). Persistent albuminuria was seen more commonly in girls and in children with low eGFR. Older children (>10 years) were more likely to have low eGFR.
Conclusion. A two-point, multiparameter screening of children may reveal high-risk groups for kidney disease that would require further evaluation and long-term follow-up. Such screenings can be integrated into school entry health assessment programmes to allow for early detection of kidney disease
Community experiences of surgery in peri-urban Cape Town
No full textBackground. Surgical care is critical for addressing universal access to healthcare, but access to safe and timely surgery is limited, especially in poorly resourced settings.
Objective. To determine the surgical experiences of individuals in a peri-urban community in Cape Town, South Africa.
Methods. A cross-sectional household survey of individuals in a peri-urban Cape Town community was conducted with door-to door interviews by trained community assistants, who provided multilingual translation of study materials as needed. The study (i) describes the surgical burden of disease and outcomes; (ii) assesses health-seeking behaviour and barriers to care using the Three Delays framework; and (iii) uses descriptive statistics to characterise respondent demographics and surgical experiences and χ2 tests to compare awareness, attitudes and acceptability across genders and locations.
Results. Data from 432 valid responses of 450 surveys conducted showed that chronic diseases were common, affecting 240/431 (56%), with a higher prevalence in females than in males (171/285 (60%) v. 63/133 (47%), p<0.05). Most participants (208/432, 44%) lived within 10 km of their nearest healthcare facility, predominantly public facilities (417/432, 97%). The Three Delays framework showed that 87/432 (20%) delayed seeking surgical care, 114/432 (26%) experienced delays reaching facilities and 95/432 (32%) faced delays in receiving appropriate care, while 95/432 (22%) reported no delays. The surgical burden was substantial, with 260/428 (60%) having undergone surgery in their lifetime and 195 surgical procedures performed in the last 5 years. Postoperative disability affected 43/432 (10%) of participants, primarily manifesting as body function impairments (22/43, 51.2%) and activity limitations (7/43, 16.3%). Only 67% understood post-surgical treatment protocols.
Conclusion. This study reveals significant challenges in surgical care delivery in this peri-urban community. Key findings include a high chronic disease burden, substantial delays in accessing surgical care and significant postoperative disability rates. These results provide the first comprehensive assessment of surgical experiences in peri-urban Cape Town, highlighting the need for comprehensive interventions targeting chronic disease and surgical care, even in peri-urban areas close to public health facilities
Engagement in antenatal and HIV care among pregnant women before and after Option B+ policy implementation in South Africa
No full textBackground. Substantial gains have been made in South Africa (SA) in the prevention of vertical transmission of HIV over the past decade.
Objective. To determine whether engagement in antenatal and HIV care among pregnant women living with HIV (WLWH) differed after Option B+ implementation.
Methods. We analysed cohort data from a pregnancy and birth defects surveillance system in KwaZulu-Natal (KZN). We report on two co-primary outcomes related to engagement in HIV care: (i) timing and number of antenatal care (ANC) visits during the pregnancy period; and (ii) timing of antiretroviral therapy (ART) initiation (both self-reported ART use in interviews and observed initiation of treatment in maternal records). The association of policy era on the timing of ANC presentation was assessed using log-binomial regression modelling. We also report proportions initiating ART before or during pregnancy stratified by policy era.
Results. Data from 40 357 women, including 16 016 (40%) WLWH were analysed. During the Option B+ era, 24% of pregnant WLWH attended their first antenatal care visit during the first trimester, compared with 16% during the Option B era (relative risk 1.52; 95% confidence interval 1.41 - 1.64). The proportion of WLWH who initiated ART prior to pregnancy was also higher during the Option B+ era than the Option B era, though this result was limited by missing data.
Conclusion. Engagement in antenatal and HIV care improved after Option B+ implementation. In the Option B+ era, SA has made significant progress toward the goal of eliminating mother-to-child transmission of HIV
Gender-affirming care in South Africa: A cross-sectional survey of transgender and gender-diverse people in the Eastern and Western Cape provinces, South Africa
No full textBackground. Transgender and gender-diverse (TGD) people face significant discrimination in the South African (SA) health system, limiting their access to HIV services and gender-affirming care, which supports an individual’s gender identity when it does not align with their sex assigned at birth. Despite the critical role of these services for TGD people, access to care remains understudied in SA.
Objectives. To describe TGD people and their access to and need for social, legal and medical transition, including psychosocial care, hormone therapy and surgery, as well as HIV services, in the Eastern Cape and Western Cape provinces, South Africa.
Methods. A cross-sectional quantitative survey design was utilised, with 150 TGD individuals recruited via convenience sampling in the Western and Eastern Cape provinces. Interviews were conducted using structured questionnaires, with data captured on REDCap. Descriptive analysis was conducted using Stata 18.
Results. Of the 150 respondents, 74.0% were people assigned male at birth (AMAB) and 26.0% were people assigned female at birth (AFAB). Reported gender identities showed that 68.5% of AMAB respondents identified as transgender women/female, 56.4% of AFAB respondents identified as transgender men/male and 34.0% of all respondents identified as gender diverse or non-binary. Demographics showed a vulnerable population, with 18.7% with housing insecurity and 66.0% unemployed. While social transition was common (98.7%), access to legal transition (4.0%) was very low, as was access to all forms of medical gender-affirming care, with 44.7% of TGD people accessing psychosocial care, 32.0% accessing hormone therapy and 2.7% surgery. Of the respondents who had not legally transitioned, 71.4% wanted to. Most respondents who had not accessed medical gender-affirming care services expressed a need for psychosocial care (77.1%) and hormone therapy (68.6%). Gender-affirming surgery was more variable, with 33.3% of AFAB respondents wanting bottom surgery compared with top surgery (63.9%), and 49.5% of AMAB respondents wanting bottom surgery compared with top surgery (55.9%). Almost all (99.3%) respondents had had an HIV test in their lifetime, with reported HIV prevalence differing between AMAB (34.2%) and AFAB (7.9%) respondents. PrEP uptake among HIV-negative AMAB respondents was 30.4%, and 5.7% among AFAB respondents, while 78.0% of TGD people living with HIV were on antiretroviral treatment.
Conclusion. Findings demonstrate a critical gap between needed and actual access to legal and medical gender-affirming care services. There is an urgent need for the provision of integrated and accessible gender-affirming care and HIV services as part of comprehensive care for TGD populations within inclusive health systems nationally
E-cigarette, cannabis, hookah and tobacco use patterns in fee-paying South African high schools
No full textBackground. Monitoring adolescent substance use is crucial for informing public health strategies. However, in South Africa (SA), recent large-sample data on the use and co-use of tobacco, nicotine and cannabis among youth remain scarce.
Objectives. To describe the use and co-use of cannabis, hookah, tobacco cigarettes and electronic cigarettes (e-cigarettes/vapes) among SA high-school learners, and to examine how these patterns vary by school-based characteristics, including grade, school fee category and school gender composition.
Methods. A cross-sectional survey was administered to 25 149 learners in grades 8 - 12 from 52 fee-paying high schools across eight provinces. Learners reported their past-30-day use of cannabis, hookah, tobacco cigarettes and e-cigarettes/vapes. Key outcomes included current use of each individual product, any one of the four products, as well as dual-usage patterns. Multilevel logistic regressions examined associations between school grade, fee category (lower-, mid-, or high-fee), gender composition (co-educational, all boys, all girls) and the odds of single, any and dual product use.
Results. Among sampled learners, 19.39% (95% confidence interval (CI) 18.91 - 19.88) reported current use of any product. Vape use was most prevalent (16.83%, 95% CI 16.37 - 17.30), followed by cannabis (5.13%, 95% CI 4.86 - 5.41), hookah (3.16%, 95% CI 2.95 - 3.39) and tobacco cigarettes (2.08%, 95% CI 1.91 - 2.27). Dual use was especially common among vape users, with more than one-third (34.31%, 95% CI 32.88 - 35.77) reporting concurrent use of at least one other product: 22.06% (95% CI 20.83 - 23.35) cannabis, 13.50% (95% CI 12.50 - 14.58) hookah and 10.13% (95% CI 9.25 - 11.08) tobacco cigarettes. Usage rates were highest among learners in Grade 12, in co-educational schools and in lower-fee schools. Multivariable regression analyses showed that advanced grade level was significantly associated with increased odds of current use across all product types. Compared with learners in all-boys schools, those in co-educational schools had significantly higher odds of cannabis use (odds ratio (OR) 1.53, p<0.05) and dual use (OR 1.42, p<0.1), while learners in all-girls schools had significantly lower odds of any product use (OR 0.75, p<0.05) and of vape use (OR 0.73, p<0.05). Regression results further revealed significantly elevated odds of hookah use and dual use among learners attending lower- and middle-fee schools compared with learners in high-fee schools.
Conclusion. The widespread use of e-cigarettes, along with dual use among e-cigarette users, in fee-paying high schools signals a significant public health concern, underscoring the need for comprehensive interventions. Elevated hookah and dual use in lower-fee schools, along with increased cannabis and dual use in co-educational settings, underscore the need for targeted interventions to address context-specific vulnerabilities among SA adolescents
Costing the national clinical guidelines for prostate cancer control and management in South Africa: Public sector perspective
No full textBackground. Prostate cancer (PCa) is the second most common cancer worldwide and the sixth leading cause of cancer deaths in men. In South Africa (SA), PCa accounts for ~13% of male deaths. The direct medical costs associated with PCa diagnosis and treatment according to the national clinical guidelines for prostate cancer control and management are not documented.
Objectives. To estimate the direct medical costs for localised PCa diagnosis and treatment according to the national clinical guidelines for prostate cancer control and management in SA.
Methods. The direct medical costs for diagnosis and treatment of prostate cancer were estimated from the payer’s perspective using a micro- costing approach, with a time horizon of 12 months. Cost items were identified from the national PCa clinical guidelines and quantified according to the treatment options for low- (LRPCa), intermediate- (IRPCa) and high-risk (HRPCa) categories. Cost data were obtained from different government databases. The unit costs and PCa incidence data from 2022 were then used to estimate total costs for treating all new PCa cases. Total costs were calculated for each treatment method listed in the clinical guidelines according to PCa risk categories.
Results. The total cost for treating 10 944 new PCa cases in 2022 was estimated at ZAR2.1 billion. Per patient costs ranged from ZAR7 265 to ZAR143 156 for LRPCa, ZAR8 926 to ZAR144 817 for IRPCa and ZAR14 874 to ZAR151 872 for HRPCa. The total cost for managing all patients with LRPCa, IRPCa and HRPCa were estimated at ZAR401.3 million, ZAR371.1 million and ZAR1.4 billion, respectively.
Conclusion. This study estimated the cost for diagnosis and treatment of localised PCa according to national clinical guidelines for PCa control and management. The costs increased with each risk category of the cancer. The study highlights the need for policy-makers to increase early detection and management, to reduce the need for high-cost interventions
The association between depot medroxyprogesterone acetate and meningiomas: Emerging data and their relevance to the South African context
No full textIn the past 2 years, evidence suggesting an association between depot medroxyprogesterone acetate (dMPA) use and meningioma has emerged. As dMPA remains one of the most widely used contraceptive methods worldwide, this finding has led to increasing media attention, and regulatory and legal proceedings. The South African Health Products Regulatory Authority (SAHPRA) has issued a statement acknowledging the association between dMPA exposure and the development for meningiomas. However, the paucity of local data on dMPA use and the incidence of and risk factors for meningioma in both the public and private health sector make it difficult to fully assess the implications in SA. This report discusses the relevance of the association between dMPA and meningiomas in the SA context. We provide a summary of the current data on the risk of meningioma with dMPA exposure, and suggest how this should impact on recommendations for the prescribing and use of dMPA from a public health perspective. We further identify gaps in local data, and propose where efforts should be directed to collect relevant data to inform a rational national contraceptive strategy