Panjasaram Naidoo

Exploring the use of novel drug delivery systems for antiretroviral drugs

Novel drug delivery systems present an opportunity for formulation scientists to overcome the many challenges associated with antiretroviral (ARV) drug therapy, thereby improving the management of patients with HIV/AIDS. This paper provides a comprehensive review of the various ARV delivery systems that have been developed for achieving sustained drug release kinetics, specifically targeting drugs to the macrophages, brain and gastric mucosa, and for addressing formulation difficulties such as poor solubility, stability and drug entrapment. Studies on the potential of systems for alternative routes of ARV drug administration, i.e., transdermal, buccal and rectal, are also highlighted. The physico-chemical properties and the in vitro/in vivo performances of various systems such as sustained release tablets, ceramic implants, nanoparticles, nanocontainers, liposomes, emulsomes, aspasomes, microemulsions, nanopowders and Pheroid(TM) are summarised. Further studies that remain to be undertaken for formulation optimisation are also identified. This review highlights the significant potential that novel drug delivery systems have for the future effective treatment of HIV/AIDS patients on ARV drug therapy.

Polymeric Nanoparticles for Enhancing Antiretroviral Drug Therapy

There is a surge of interest internationally in the study of nanoparticles for enhancing antiretroviral (ARV) drug therapy. This paper presents a comprehensive review on polymeric nanoparticles for ARV drug therapy. Their main applications for targeting to macrophages and the brain, as well as other studies on modifications to enhance drug loading, decrease toxicity, and also to increase drug absorption are reviewed. The physicochemical characterization properties and their in vitro/in vivo performances are summarized. Further studies that need to be undertaken for formulation optimization are also identified. This review highlights the significant potential that nanoparticles have for the future effective treatment of HIV/AIDS patients on ARV drug therapy.

Barriers to HIV Care and Treatment by Doctors: A review of the literature.

Abstract This paper provides a review of the reported barriers that prevent doctors from managing HIV infected patients. The four most commonly reported barriers were: fear of contagion, fear of losing patients, unwillingness to care, and inadequate knowledge/training about treating HIV patients. Barriers to treating HIV infected patients is frequently reported in many countries and it is important for developing countries such as South Africa to learn from these experiences by identifying local problems so that constructive interventions and strategies can be developed to address these barriers, thereby improving the quality of patient care. Further research in respect of the local situation is required. Introduction Over the last two decades acquired immunodeficiency syndrome (AIDS) has emerged as one of the most serious public health problems in the world, and by the end of 2003 it was estimated that 5.3 million South Africans were human immunodeficiency virus (HIV) positive, which corresponds to 21.5% of the population.1 In the early phase of the HIV epidemic few doctors saw infected patients and treatment options were limited. As a result many doctors were reluctant to provide care to HIV infected patients and homophobia amongst doctors, fear of contact with patients and unwillingness to care were frequently reported.2 However, there has been an exponential increase in the number of HIV and AIDS related cases and more doctors are encountering infected individuals. This review summarizes our current knowledge of barriers to treatment of HIV infected patients by doctors. Method A comprehensive literature review was undertaken by searching the MEDLINE database, Psychlit, ISI Web, EBSCOHost, and Sabinet on line, for English language literature published between 1985 and 2004. The database search terms included keywords such as fear/s, barrier/s, concern, HIV, AIDS, attitudes, physician/s (doctor/s), practice, treatment, care and knowledge. A variety of combinations of these words were entered. All duplicate articles were removed and only studies that used doctors as the sample population were considered. Titles expressing comment, news items, opinion pieces or letters were rejected. Results Thirty two relevant studies were identified from the literature search. The four most commonly reported barriers were: fear of contagion, fear of losing patients, unwillingness to care, and inadequate knowledge/training about treating HIV patients.

Role and contribution of private healthcare sector doctors in the management of HIV-infected patients in the eThekwini Metropolitan area of KwaZulu-Natal

Private healthcare sector doctors have a pivotal role to play in the management of HIV and AIDS infection. These doctors need to have an accurate knowledge of the management of the infection, and a positive attitude towards the treatment of persons with HIV and AIDS. This study investigated the extent of private healthcare sector doctor involvement in the management of HIV and AIDS patients and their training needs. A cross sectional descriptive study of private general practitioners and specialists was undertaken in the eThekwini Metro of KwaZulu-Natal. Structured self-report questionnaires were sent to 931 private healthcare sector doctors. Of the 331 (35.6%) responses received, three doctors did not complete the questionnaire, 235 (71.6%) doctors managed HIV and AIDS patients, but 93 (28.4%) doctors did not; of these, 48 (51.61%) had not encountered HIV and AIDS patients, 25 (26.88%) referred such patients to specialists, six (6.45%) cited cost factors as reasons for not treating such patients, whilst ...

Factors influencing HAART adherence among private health care sector patients in a suburb of the Ethekwini Metro

ABSTRACT Background The advent of highly active antiretroviral therapy (HAART) ushered in a new era in the management of the AIDS pandemic with new drugs, new strategies, new vigour from treating clinicians and enthusiasm on the part of their patients. What soon became evident, however, was the vital importance of patient adherence to prescribed medication in order to obtain full therapeutic benefits. Several factors can influence adherence to HIV drug regimens. Many treatment regimes are complex, requiring patients to take a number of drugs at set times during the day, some on a full stomach and others on an empty one. Other factors that could contribute to non-adherence include: forgetting to take medications, cost factor, side effects, incorrect use of drug, social reasons, denial or poor knowledge of drug regime. If the correct regimen is not prescribed and if patients do not adhere to therapy, then the possibility of resistant strains is high. Improving adherence is therefore arguably the single most important means of optimising overall therapeutic outcomes. Although several studies regarding patient adherence have been performed in the public health care sector, data on adherence in patients from the private health care sector of South Africa remain limited. Many factors influence compliance and identifying these factors may assist in the design of strategies to enhance adherence to such demanding regimens. This study aimed to identify these factors among private sector patients. Method Descriptive cross-sectional study was conducted among all consenting patients with HIV who visited the rooms of participating private sector doctors from May to July 2005. A questionnaire was administered to consenting participants. Participants who reported missing any medication on any day were considered non-adherent. The data obtained was analysed using SPSS 11.5. A probability value of 5% or less was regarded as being statistically significant. Categorical data was described using frequency tables and bar charts. Pearsons chi-square tests or Fischers exact tests were used interchangeably as appropriate to assess associations between categorical variables. The study received ethics approval from the University of KwaZulu-Natals Nelson R Mandela School of Medicine Ethics Committee. Results A total of 55 patients completed the questionnaires and 10 patients refused to participate. There was no statistical difference between adherence to treatment and demographics such as age, gender and marital status. In this study 89.1% of patients were classified as non-adherent and reasons for nonadherence included difficulty in swallowing medicines (67.3%) (p = 0.01); side effects (61.8%) (p = 0.03); forgetting to take medication (58.2%) (p = 0.003); and not wanting to reveal their HIV status (41.8%) (p = 0.03). Common side effects experienced were nausea, dizziness, insomnia, tiredness or weakness. Reasons for taking their medicines included tablets would save their lives (83.6%); understand how to take the medication (81.8%); tablets would help them feel better (80.0%); and were educated about their illness (78.2%). The majority of participants (65.5%) were on two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI). All participants that were on a regimen that comprised protease inhibitors and two NRTIs were found to be non-adherent. Conclusion Some barriers to adherence among this cohort of private sector patients are similar to those experienced by public sector patients. It will be important for doctors to identify these problems and implement strategies that could improve adherence, e.g. using short message services (SMSs) reminders for those patients prone to forgetting to take their medicines, breaking the tablets into smaller pieces in order to overcome the difficulty of swallowing, if the medication is not available in a liquid form, looking at alternative medication with lesser or more tolerant side effect profiles and greater counselling on the drugs.

Impact of Pharmacists’ Intervention on the knowledge of HIV infected patients in a public sector hospital of KwaZulu-Natal

Abstract Background The study site started its roll-out of the human immunodeficiency virus (HIV) prevention of mother-to-child transmission in 2006. All patients were counselled by trained counsellors, before seeing a doctor. At the pharmacy the medicines were collected with no intense counselling by a pharmacist as the patients would have visited the trained counsellors first. Subsequently it was found that there were many queries regarding HIV and acquired immune deficiency syndrome (AIDS). Thus a dedicated antiretroviral pharmacy managed by a pharmacist was established to support the counsellors. Objectives The objective of the study was to assess the impact of a pharmacist intervention on the knowledge gained by HIV and AIDS patients with regard to the disease, antiretroviral drug use (i.e. how the medication is taken, its storage and the management of side effects) as well as adherence to treatment. Method This study was undertaken at a public sector hospital using anonymous structured questionnaires and was divided into three phases: pre-intervention, intervention and post-intervention phases. After obtaining patient consent the questionnaires were administered during the first phase. A month later all patients who visited the pharmacy were counselled intensely on various aspects of HIV and antiretroviral medication. Thereafter patients who participated in Phase 1 were asked to participate in the second phase. After obtaining their consent again, the same questionnaire was administered to them. Quantitative variables were compared between pre-intervention and post-intervention stages by using paired t-tests or Wilcoxon signed ranks tests. Categorical variables were compared using McNemars Chi-square test (Binary) or McNemar-Bowker test for ordinal variables. Results Overall the mean knowledge score on the disease itself had increased significantly (s.d. 6.6%), (p < 0.01), after the pharmacists’ intervention (pre-intervention was 82.1% and post-intervention was 86.3%). A significant improvement was noted in the overall knowledge score with regard to medicine taking and storage (p < 0.05) and the management of the side effects. There was a non-significant difference between the adherence in pre-intervention and in post-intervention (p = 0.077). Conclusion Pharmacists’ intervention had a positive impact on HIV infected patients’ HIV and AIDS knowledge on both the disease and on the antiretroviral drug use and storage.

Identification of sources from which doctors in the private sector obtain information on HIV and AIDS

Abstract Background: Doctors need to constantly update their knowledge and obtain information in order to practise high-quality medicine. Antiretroviral drugs have been available only since around 1996, therefore many of the doctors who were trained prior to 1996 would not have received any formal training in the management of HIV and AIDS patients. Where doctors source their general medical knowledge has been established, but little is known about where doctors source information on HIV/AIDS. This study investigated where private sector doctors from the eThekwini Metro obtain information on HIV and AIDS for patient management. Methods: A descriptive cross-sectional study among 133 private general practitioners (GPs) and 33 specialist doctors in the eThekwini Metro of KwaZulu-Natal, South Africa, was conducted with the use of questionnaires. The questionnaires were analysed using SPSS version 15. A p value of < 0.05 was considered statistically significant. Results: The majority of the doctors (92.4%) obtained information on HIV and AIDS from journals. Continuing Medical Education (CME), textbooks, pharmaceutical representatives, workshops, colleagues and conferences were identified as other sources of information, while only 35.7% of doctors were found to use the internet for information. GPs and specialists differed significantly with regard to their reliance on colleagues (52.9% versus 72.7%; p < 0.05) and conferences (48.6% versus 78.8%; p < 0.05) as sources of HIV information. More than 90% of doctors reported that CME courses contributed to better management of HIV and AIDS patients. Conclusion: Private sector doctors in the eThekwini Metro obtain information on HIV from reliable sources in order to have up-to-date knowledge on the management of HIV-infected patients.

Knowledge, awareness and readiness of private sector doctors practising in the Ethekweni and Ugu districts of KwaZulu-Natal province for the implementation of the National Health Insurance

Background: The proposed National Health Insurance (NHI) aims to improve quality of care and equity in healthcare financing for all South Africans. Successful implementation requires participation by stakeholders, such as private sector doctors who play an important role in healthcare delivery. A study was conducted to determine their knowledge, awareness and readiness for the implementation of the NHI. Methods: A cross-sectional descriptive study was carried out by administering close-ended anonymous questionnaires to private sector doctors in the South region of KwaZulu-Natal. Data were analysed using SPSS version 15. 0. Results: The response rate was 70%; the majority were male with 56% of respondents in the age group 41–60 years. Over 68% had satisfactory knowledge about NHI, whilst 24 (3%) had good knowledge (p < 0.05); doctors with satisfactory knowledge indicated their preference for NHI information via circulars and newspapers. Some 64% believed that they have the necessary skills to implement the NHI, but are not completely ready regarding infrastructure and resources. Conclusions: The majority have satisfactory knowledge, awareness and believe they have the necessary skills to participate in the NHI. However, the government needs to increase knowledge and awareness, and to improve infrastructure and resources in order for effective implementation of the NHI.

Other health-seeking behaviour of HIV and AIDS patients visiting private sector doctors in the eThekwini Metropolitan Municipality of KwaZulu-Natal

Objectives: Although allopathic medicines are used in the treatment of human immunodeficiency virus (HIV), many HIV-infected patients visit alternate medical and health practitioners, and take alternative therapies for their HIV condition. This study was conducted to confirm whether or not a sample of patients who visited private sector doctors used alternative medications, and whether or not they visited other healthcare professionals and/or healers for their condition. Design, setting and subjects: A descriptive, cross-sectional study was conducted on 256 HIV patients who visited private sector doctors in the eThekwini Metropolitan Municipality of KwaZulu-Natal. An anonymous, close-ended questionnaire was administered to the patients after obtaining their consent. Outcome measures: Variables included socio-demographic characteristics, other health-seeking behaviour, medicine and substance use. Results: Private sector HIV patients engaged in other health-seeking behaviour. The study found that a varying proportion of respondents visited alternate practitioners, such as traditional healers, herbalists, homeopaths and Ayurvedic practitioners, and obtained complementary medicines from pharmacies, while some visited psychologists, psychiatrists, dietitians and religious leaders. The respondents also drank alcohol and took illicit drugs. A significant clinical finding was obtained with alcohol consumption and psychologist intervention. It was found that those respondents who visited a psychologist did not consume alcohol, while those who took alcohol did not visit a psychologist (p-value < 0.05). The latter indicates that HIV patients adopted different mechanisms to help them to cope with their condition. Conclusion: This study concluded that patients with HIV/acquired immune deficiency syndrome in the private healthcare sector visited traditional healers and utilised other medicines, health professionals and/or therapies for their condition.

The willingness of private-sector doctors to manage public-sector HIV/AIDS patients in the eThekwini metropolitan region of KwaZulu-Natal.

ABSTRACT Background South Africa is severely affected by the AIDS pandemic and this has resulted in an already under-resourced public sector being placed under further stress, while there remains a vibrant private sector. To address some of the resource and personnel shortages facing the public sector in South Africa, partnerships between the public and private sectors are slowly being forged. However, little is known about the willingness of private-sector doctors in the eThekwini Metropolitan (Metro) region of KwaZulu-Natal, South Africa to manage public-sector HIV and AIDS patients. Objectives To gauge the willingness of private-sector doctor to manage public-sector HIV and AIDS patients and to describe factors that may influence their responses. Method A descriptive cross-sectional study was undertaken among private-sector doctors, both general practitioners (GPs) and specialists, working in the eThekwini Metro, using an anonymous, structured questionnaire to investigate their willingness to manage public-sector HIV and AIDS patients and the factors associated with their responses. Chi-square and independent t-tests were used to evaluate associations. Odds ratios were determined using a binary logistic regression model. A p value < 0.05 was considered statistically significant. Results Most of the doctors were male GPs aged 30–50 years who had been in practice for more than 10 years. Of these, 133 (77.8%) were willing to manage public-sector HIV and AIDS patients, with 105 (78.9%) reporting adequate knowledge, 99 (74.4%) adequate time, and 83 (62.4%) adequate infrastructure. Of the 38 (22.2%) that were unwilling to manage these patients, more than 80% cited a lack of time, knowledge and infrastructure to manage them. Another reason cited by five doctors (3.8%) who were unwilling, was the distance from public-sector facilities. Of the 33 specialist doctors, 14 (42.4%) indicated that they would not be willing to manage public-sector HIV and AIDS patients, compared with only 24 (17.4%) of the 138 GPs (p < 0.01). Conclusion Many private-sector doctors are willing to manage public-sector HIV and AIDS patients in the eThekwini Metro, potentially removing some of the current burden on the public health sector.