Katlego Motlhaoleng

The Use of Xpert MTB/Rif for Active Case Finding among TB Contacts in North West Province, South Africa.

Introduction. Tuberculosis is a major cause of morbidity and mortality especially in high HIV burden settings. Active case finding is one strategy to potentially reduce TB disease burden. Xpert MTB/Rif has recently been recommended for diagnosis of TB. Methods. Pragmatic randomized trial to compare diagnosis rate and turnaround time for laboratory testing for Xpert MTB/Rif with TB microscopy and culture in household contacts of patients recently diagnosed with TB. Results. 2464 household contacts enrolled into the study from 768 active TB index cases. 1068 (44%) were unable to give sputum, but 24 of these were already on TB treatment. 863 (53%) participants sputum samples were tested with smear and culture and 2.7% (23/863; CI: 1.62–3.78) were diagnosed with active TB. Xpert MTB/Rif was used in 515 (21%) participants; active TB was diagnosed in 1.6% (8/515; CI: 0.52–2.68). Discussion and Conclusions. Additional 31 cases were diagnosed with contact tracing of household members. When Xpert MTB/Rif is compared with culture, there is no significant difference in diagnostic yield.

The use of decentralized GeneXpert by trained non-laboratory technicians in rural clinics in South Africa

The GeneXpert automated molecular assay, that can diagnose TB in 2 h, was endorsed by the World Health Organization both for identifying TB and rifampicin resistance [5]. South Africa was one of the first few countries to implement GeneXpert [5] however GeneXpert units were located mostly within the National Health Laboratory Services (NHLS) and not at point of care [4]. Placing it at the point of care is possible, as it requires uncomplicated processing that can be done by persons with basic computer skills [5]. There is limited data on the use of this test in rural settings, as well as its use by non-laboratory technicians. This correspondence reports on the outcomes of the use of GeneXpert by lay counselors in Dr Kenneth Kaunda sub-district in the Matlosana Municipality, NorthWest Province, South Africa. The study received local ethics approvals from the University of Witwatersrand, regional hospitals and Provincial research committees. The Dr Kenneth Kaunda sub-district has one hospital and 16 clinics andan estimated TB incidence of 750/100,000 in 2011 [2]. Rooms at four primary care clinics were renovated to accommodate the four-cartridge GeneXpert machines. Prior to this project all TB samples were sent to the central laboratory for testing. Six lay counselors with basic computer skills received two weeks training on basic infection control measures, sample preparation and processing on an open bench. A trained technician from NHLS conducted a monthly external quality assurance at each clinic. Samples for testing were received from: contacts of TB patients and TB suspects presenting at the clinic. Procurement and renovation challenges resulted in two clinics starting four months later. GeneXpert testing was operational for tenmonths, and a total of 2196 specimens were tested, from 2181 participants (15 tests had to be repeated). The average number of specimens tested per day increased from 2 to 3 in the first month to a maximum of about 7 specimens by month three (Figure 1). Of 2181 sputum specimens that completed the testing, 538 were of contacts from 203 households, and 1643 from TB suspects. 9% (197/2181) of cases had MTB on GeneXpert testing, 1.5% (8/538) among household contacts and 11.5% (189/1643) in TB suspects. In the newly diagnosed TB cases, 7% (13/197) had rifampicin resistance. The overall error rate was 2.6% (57/2196). The error rate in the first month was 10.2% and this improved to 7.9% by month 2, and 3.9% by month 3. The lowest error rate achieved was 1.3%. Error rates reports were available on 44 specimens as follows: 21 signal loss in amplification; 10 syringe pressure reading high; 9 probe check failure, 3 cartridge integrity test failure and 1 temperature not within acceptable limit. Interventions to reduce error rates included additional training and quality assurance by the NHLS and operators with minimal error rates were paired to work with those with high error rates. All the GeneXpert Machines were fully functional throughout the study and did not need any repairs. This data review shows that GeneXpert can be operated outside of laboratories by non-technicians with minimal error rates. However, the costs of testing could increase if each clinic was to be equipped with GeneXpert and technicians [4]. Yet placing the assays in central laboratories increases the turnaround time for releasing the results to the patients especially if the laboratory is far. The use of non-laboratory technicians minimizes costs of

Knowledge, attitudes, and practices about influenza illness and vaccination: a cross‐sectional survey in two South African communities

Understanding knowledge and sentiment toward influenza and vaccination is important for effective health messages and prevention strategies. We aimed to characterize knowledge, attitudes, and practices surrounding influenza illness and vaccination in two South African communities and explore reasons for vaccine hesitancy.

Prevalence and Correlates of Smoking Among People Living With HIV in South Africa

Introduction Smoking likely exacerbates comorbidities which people living with HIV (PLWH) are predisposed. We assessed prevalence and correlates of smoking among PLWH in South Africa, which has 7 million PLWH but inadequate reporting of smoking. Methods A cross-sectional survey was conducted among randomly selected adults with HIV infection in Klerksdorp, South Africa. Current smoking was assessed by questionnaire, exhaled carbon monoxide (eCO), and urine cotinine. Results Of 1210 enrolled adults, 753 (62%) were women. In total, 409 (34%) self-reported ever smoking: 301 (74%) were current and 108 (26%) were former smokers. Using eCO and urine cotinine tests, 239 (52%) men and 100 (13%) women were defined as current smokers. Nearly all smokers (99%) were receiving ART, and had a median (IQR) CD4 count of 333 cells/μL (181-534), viral load of 31 IU/mL (25-4750), and BMI of 21 kg/m2 (19-24). Adjusted analysis among men showed higher odds of smoking with marijuana use (OR = 7.5, 95% CI = 4.1 to 14.6). Among women, 304 (43%) reported using snuff, compared to only 11 (3%) of men, and snuff use was inversely associated with smoking (OR = 0.1; 95% CI = 0.05 to 0.2). A subset of participants (n = 336) was asked about alcohol use, which was positively associated with smoking for men (OR = 8.1, 95% CI = 2.8 to 25.9) and women (OR = 8.5, 95% CI = 2.9 to 26.8). Conclusion Smoking prevalence among PLWH in South Africa is alarmingly high. Prevention and cessation strategies that consider marijuana and alcohol use are needed. Implications As long-term HIV care continues to improve, more people living with HIV (PLWH) will die of diseases, including tuberculosis, for which smoking plays an important causal role. The prevalence of smoking is markedly higher among PLWH in high-resource settings, but data for Africa and other low-resource settings that shoulder the brunt of the HIV epidemic has previously not been well documented. We report an alarmingly high prevalence of smoking among PLWH in South Africa, particularly among men, and a strong association between current smoking and use of other substances.

Latent tuberculous infection in schoolchildren and contact tracing in Matlosana, North West Province, South Africa

This is a cross-sectional study to estimate the prevalence of latent tuberculous infection (LTBI) and the annual risk of tuberculous infection (ARTI) among a sample of children aged 5 and 7 years in Matlosana, South Africa. LTBI prevalence was significantly higher in children aged 7 years (n = 704) (19.7%, 95%CI 16.75-22.65) than in those aged 5 years (212/1401, 15.1%, 95%CI 13.23-16.97) (P = 0.0075). The ARI was 2.9% (95%CI 2.2-3.6).

Value stream mapping to characterize value and waste associated with accessing HIV care in South Africa

Introduction Inefficient clinic-level delivery of HIV services is a barrier to linkage and engagement in care. We used value stream mapping to quantify time spent on each component of a clinic visit while receiving care following a hospital admission in South Africa. Methods We described time for each clinic service (“process time”) and time spent waiting for that service (“lead time”). We also determined time and patient costs associated with travel to the clinic and expenditures during the clinic visits for 15 clinic visits in South Africa. Participants were selected consecutively based on timing of scheduled clinic visit from a cohort of HIV-positive patients recently discharged from inpatient hospital care. During the mapping we asked the participants to assess challenges faced at the clinic visit. We subsequently conducted in depth interviews and included themes from the care experience in this analysis. Results The 15 clinic visits occurred at five clinics; four primary care and one hospital-based specialty clinic. Nine (64%) of the participants were women, the median age was 44 years (IQR: 32–49), three of the participants had one or more clinic visit in the prior 14 days, all but one participant was on antiretroviral therapy (ART) at the time of the clinic visit (ART was stopped following the hospital visit for that participant). The median time since hospital discharge was 131 days (interquartile range; IQR: 121–183) for the observed visits. The median travel time to and from the clinic to a place of residence was 60 minutes. The median time spent at the clinic was 3.5 hours (IQR: 2.5–5.3) of which 2.9 hours was lead time and 25 minutes was process time (registration, vital signs, clinician assessment, laboratory, and check-out). The median patient cost for transport and food while at the clinic was ZAR43/USD2.8 (median monthly household income in the district was ZAR2450/USD157). Participants highlighted long queues, repeat clinic visits, and multiple queues during the visit (median of 5 queues) as challenges. Conclusions Accessing HIV care in South Africa is time consuming, complicated by multiple queues and frequent visits. A more patient-centered approach to care may decrease the burden of receiving care and improve outcomes.

Prevalence and Correlates of Snuff Use, and its Association With Tuberculosis, Among Women Living With HIV in South Africa

Introduction A higher proportion of people living with HIV (PLWH) smoke compared to the general population, but little information exists about the prevalence and correlates of smokeless tobacco use among PLWH. In South Africa, dry powdered tobacco is inhaled nasally as snuff. Methods A cross-sectional survey among PLWH attending three HIV clinics was conducted. Snuff use was assessed via self-report and urine cotinine. Results Given the low (3%) prevalence of snuff use among men, analysis was restricted to n = 606 nonsmoking women living with HIV. Half (n = 298, 49%) were snuff users, the majority of whom (n = 244, 84%) had a positive urine cotinine test. In adjusted analysis, snuff use was negatively associated with higher education (relative risk [RR] 0.55; 95% confidence interval [CI]: 0.39, 0.77) and mobile phone ownership (RR 0.83; 95% CI: 0.71, 0.98), and positively associated with ever having tuberculosis (TB) (RR 1.22; 95% CI: 1.03, 1.45). In adjusted analysis, with current TB as the outcome, snuff use was marginally statistically significantly associated with a twofold increase in odds of a current TB diagnosis (odds ratio [OR] 1.99; 95% CI: 0.98, 4.15). Discussion A high proportion of nonsmoking South African women living with HIV use snuff, which was a risk factor for TB. Additional research is needed to understand the relationship between snuff, TB, and other potential health risks. Implications PLWH have a higher prevalence of smoking than their seronegative peers, but there is a paucity of research on smokeless tobacco use in this population, especially in low-resource settings. TB is the leading cause of death among PLWH, and with improvements to HIV treatment and care, PLWH are at greater risk of tobacco-related diseases. We report an extremely high prevalence of snuff use among women living with HIV in South Africa. Further, in this population snuff use is positively associated with ever having a TB diagnosis, as well as currently having TB.

Relevance and acceptability of using the Quantiferon gold test (QGIT) to screen CD4 blood draws for latent TB infection among PLHIV in South Africa: formative qualitative research findings from the TEKO trial

BackgroundTuberculosis (TB) is the leading cause of mortality among people living with HIV (PLHIV), despite the availability of effective preventive therapy. The TEKO trial is assessing the impact of using a blood test, Quantiferon-TB Gold In-Tube Test (QGIT), to screen for latent TB compared to the Tuberculin Screening Test (TST) among PLHIV in South Africa.MethodsFifty-six qualitative interviews were conducted with PLHIV and clinical providers participating in the TEKO trial. We explored TB screening, diagnosis, and treatment guidelines and processes and the use of the QGIT to screen for latent TB infection at the time of CD4 blood draw. Thematic content analysis was conducted.ResultsConsiderable variability in TB screening procedures was documented due to lack of personnel and clarity regarding current national TB guidelines for PLHIV. Few clinics had started using the TST per national guidelines and many patients had never heard of isoniazid preventive therapy (IPT). Nearly all participants supported the idea of latent TB screening using routine blood drawn for CD4 counts.ConclusionsFindings indicate that screening for latent TB infection using QGIT from blood drawn for CD4 counts among PLHIV is an acceptable approach to increase latent TB detection given the challenges associated with ensuring systematic latent TB screening in overburdened public clinics.Trial registrationThe results presented here were from formative research related to the TEKO trial (Identifier NCT02119130, registered 10 April 2014).