Healthcare Gazette - 2016 Sep/Oct

HEALTHCARE GAZETTE

SEPTEMBER/OCTOBER 2016 • ISSN 2078-9750

TWO DIE IN HOSPITAL STRIKE PG 10

SAMWU LAUNCHES NATIONAL HIV/TB TESTING AND TREATMENT CAMPAIGN PG 28 5

17

NEWS

Rape survivor care crisis – mines the worst?

24

RESEARCH

New lung nodules on lung screening CT scans

30

FEATURE

SA’s new HIV/AIDS crunch

FOCUS

A better vision for glaucoma

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Contents | 01

Co n t ent s 18

NEWS 5 Rape survivor care crisis – mines the worst?

6 Shamed doctor claims R20 million 6 R120 million boost for SA’s surgical skills 7 Key interventions pay off for Lesotho’s mums and babies 8 Pre-election strife hinders EMS 10 Funding enables cancer treatment 10 Two die in hospital strike 11 A shot in the arm for SA’s poor bone marrow donor record 11 New smoking cessation drug outperforms competitors

16 Breast-conserving surgery plus radiotherapy equivalent to mastectomy 16 Reduced antibiotic prescribing safe 17 Brain clots predicting dementia 17 New lung nodules on lung screening CT scans

13

17 Recalls of unsafe drugs in the USA

FEATURES 18 Inhumane system may harm doctors and patients 24 SA’s new HIV/AIDS crunch

FOCUS

24

32 A better vision for glaucoma

12 Give us peer educators, not nurses, say sex workers

34 Osteoporosis – bone-balancing act

12 MSF moves to protect refugees

PROFILE

13 HIV treatment under control – now for sexy prevention?

38 Professor Gerhard Walzl – forging a new diagnostic path in TB

RESEARCH

16 Plant-based treatments offer modest improvement in menopause symptoms

40 The suffering behind the numbers – rape in SA requires a sustained public health response

CLINICIAN’S VIEW

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Plasmoquine Capsules contain chloroquine sulphate enclosed in a capsule, making them easy to swallow, with no bitter taste. This makes Plasmoquine Capsules the anti-malarial of choice for doctors prescribing in the treatment of rheumatoid arthritis as well as discoid lupus erythematosis (lupus syndrome)

Reg. No. Z/20.2.6/127 Each capsule contains 200mg Chloroquine Sulphate Monohydrate equivalent to 146.7mg Chloroquine base

Medchem Pharmaceuticals CC Tel no: 012H348 0752 • Fax: 012 348 0873 • Email: medchem3@gmail.com EALT H CARE G A ZETTE | S E PTEMBER/O C TO BER 2 0 1 6 SEPTEMBER_OCTOBER.indd 2

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Ed’s Letter | 03

Ed’s Letter EDITOR Chris Bateman

C H R I S B AT E M A N

ARE WE WORKING SMARTER?

N

obody is betting on the audit of 3 500 primary healthcare facilities’ staff and equipment solving our human resources crisis anytime soon. However, the WHO report Workload Indicators of Staff Needs is a solid step in the right direction. It offers a glimmer of hope that together with a marginally increased supply of mid-level workers, community health workers, nurses and local universityadjusted Cuban-trained medical graduates, the current inhumane system may exhaust and harm fewer healthcare workers and patients.

Clinical governance remains a huge issue as more juniors get less supervision, and work dangerously long shifts. In our features section we explore this terrain and hone in on how the R1 billion expansion of the antiretroviral programme to “test and treat”, and offer pre-exposure prophylaxis to members of HIVvulnerable groups might impact on our resource-

constrained environment – especially on our NurseInitiated Management of Antiretroviral Therapy (NIMART) staffers. While nurses work a maximum 12-hour shift, interns (though hardly exclusively) work 30 hours or more at a stretch, far longer than most colleagues overseas.

In our news section, Médecins Sans Frontières, finds that a quarter of all Rustenburg’s mining community women are raped in their lifetime, do not know what to do about it and way too few nurses there are trained in forensics or survivor care. If these first-of-a-kind findings are extrapolated to other migrant mining communities, that’s a lot of deeply traumatised, untreated women out there.

We’ve previously reported on public sector doctors falling easy prey to politicians able to score quick populist points off the human tragedies they do their best to avoid every day. One such senior Durban doctor is now determined to have his day in court, suing his health MEC

and province for R20 million after being frog marched out of his hospital for allegedly refusing to treat a patient, pilloried in the press and then totally cleared by an internal disciplinary hearing.

His colleagues will watch with empathic interest.

Among other news highlights are emergency medical service chiefs’ complaints of pre-election and service delivery violence preventing their staff from extracting patients; an uplifting story of Tygerberg hospital surgeons who sourced their own multimillion rand surgical skills laboratory equipment to create a state-of-the-art simulation unit that will benefit the entire sub-Saharan region; and the AIDS council considering “sexying up” the unpopular femidom as a possible prevention strategy.

Our focus section looks at the “invisible” progression of the world’s leading cause of blindness – glaucoma – and osteoporosis, the former affecting up to 7% of South Africans, and the latter onethird of women and a fifth of men over their lifetimes.

CONTRIBUTORS Bridget Farham Patricia McCracken Lauren Burley Copley Leverne Gething Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham MANAGING EDITOR Ingrid Nye PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens CHIEF OPERATING OFFICER Diane Smith | +27 (0)12 481 2069 sales@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renée Hinze Azad Yusuf Benru de Jager Ladine van Heerden Charmalin Simpson Ismail Davids CUSTOMER SERVICE AND ONLINE SUPPORT Gertrude Fani | +27 (0)21 532 1281 publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 tshepisom@hmpg.co.za LAYOUT AND DESIGN Tenfour Media Printed by Paarl Print HG online issues: https://issuu.com/ hmpg/stacks The Health and Medical Publishing Group is a wholly owned subsidiary of the South African Medical Association (www.samedical.org).

For information on subscribing to Healthcare Gazette, please contact sales@hmpg.co.za.

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News | 05

RAPE SURVIVOR CARE CRISIS – MINES THE WORST? HORRIFYING RAPE STATISTICS released by Médecins Sans Frontières (MSF) on 9 June 2016, out of the platinum mining boom town of Rustenburg, provide yet another illustration of the dire need for better healthcare worker training in rape forensics and safe survivor care.

Dr Sarah-Jane Steele, an epidemiologist, who led the rape and intimate partner violence questionnaire survey of 2 530 households (900 women) in the mining township in November/ December last year, said a quarter of all women surveyed had been raped. If generalised to the 247 780 women living in the entire Rustenburg municipality this would mean that 48 217 women were raped (including forced sexual acts), she added. The survey found 28% of women were raped by their sexual partner – a fifth telling nobody about it until her team came along. A total of 11 113 women per year were raped by a partner, the survey found. Steele said these were among the highest known estimates for both partner and non-partner sexual violence in sub-saharan Africa. The average age of women surveyed was 32 and antenatal HIV prevalence was 35%.

Rape was defined in WHO terms, i.e forced to have sexual intercourse or perform a sexual act/s that you did not want to, either with a non-partner, all current and prior sexual partners or only current partners. Current was defined as in the previous 12 months, prior as prior to that period, and lifetime as ever. The figures emerged in a study of sexual violence conducted to

gauge the implications for service provision and prevention in Rustenburg.

Steele said one of the main MSF recommendations was that the low healthcare worker awareness on how to handle rape survivors be “urgently quantified”. Her main concern, however, was the low reporting of patients to relevant support structures. She was asked by a delegate to the MSF Scientific Day what the levels of rape survivor referral and linkage were outside of the few local Thutuzela and Rape Crisis-staffed

healthcare facilities. Steele said a fuller MSF analysis was done in August, when the 120 nurses they had trained would be assessed for knowledge gain, while more rape survivor care and forensic support training was planned. “We want to get away from just one-day training to building around forensics and survivor care,” she added.

Tragically few women and girls knew what their treatment options were. Only 50% knew that HIV infection could be prevented. The findings have led to the study being described as a potential “canary in a coal mine”, given the lack of similar studies in migrant worker mining towns elsewhere. This points to a dire need for prevention and treatment and healthcare worker training in similar settings.

Rustenburg has a pre­ dominantly migrant labour force and is uniquely male in SA mining town terms (65% male), where women usually outnumber men.

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SHAMED DOCTOR CLAIMS R20 MILLION A DURBAN DOCTOR, summarily marched out of his hospital in full view of patients and colleagues and later suspended after allegedly refusing to treat a car-crash victim, has this June sued his employers for R20 million.

Dr Shaheen Seedat, a senior doctor at Mahatma Gandhi Memorial Hospital in Phoenix, issued the letter of demand to the KwaZulu-Natal (KZN) Department of Health in midJune, after being “wrongfully” accused of failing to clinically assess a severely injured 19-yearold man, brought to the hospital on 11 July 2015. The man later died. Seedat was reportedly called over to intervene in a “sign-over” dispute between an emergency services staffer and hospital staff. The aggrieved ambulance-man complained that hospital staff refused to accept the patient.

KZN MEC for Health, Sibongiseni Dhlomo, ordered

a probe headed by Dr Henry Sunpath, posting on his department’s website: “I am appalled by the manner in which a (man who was) critically injured in a motor vehicle accident was dealt with”. Seedat’s suspension was lifted in October 2015 after

an internal enquiry cleared him of refusing to treat the victim. Five witnesses, including three doctors and nurses who were on duty on the day, plus an expert witness, testified. However, the matter was then escalated to the HPCSA (and is still pending), which Seedat’s attorney Mervyn Sigamoney described as “absurd”. He said his client had “not laid a hand”

on the deceased. The internal disciplinary hearing should never have taken place as there was no case to answer and had fully exonerated his client, he added. Nobody in authority had yet apologised to Seedat, who suffered hugely negative media exposure that left him a patient pariah.

Dr Sunpath, a co-respondent in the civil proceedings, proceeded “recklessly” against Dr Seedat, “knowing” he was not the treating doctor. Sigamoney said he suspected that “another agenda is at play here”, and warned that the amount claimed could climb if the authorities continued to play hardball.

“My client’s career is compromised and the taxpayer gets punished,” Sigamoney added.

Samuel Mkhwanazi, the provincial health department’s spokesman, said it was “government policy not to comment on such matters”.

R120 MILLION BOOST FOR SA’S SURGICAL SKILLS

Prof. Ian Vlok demonstrates possible procedures on a R1m human dummy.

A R120 MILLION STATE-OF-THE-ART surgical skills simulation laboratory opened on the Tygerberg campus of Stellenbosch University (SU) on 19 July 2016, replicating real-time theatre scenarios and turboboosting healthcare for the entire sub-Saharan region, its facilitators claim. The facility is geared to train 1 200 physicians in its first year of operation.

Described by Prof. Nico Gey van Pittius, vice dean of research at SU as “set to revolutionise training in sub-Saharan Africa”, the laboratory houses eight fully

simulated theatre operating stations, “dry” and “wet” capacity, a 100-seater lecture theatre and a virtual ICU – all complemented and connected by versatile and breakthrough audiovisual capabilities. Going by the university acronym of the Sunskill Laboratory, surgical registrars in all disciplines, seasoned surgeons and primary care practitioners, nurses and related healthcare professionals will acquire and hone routine to goldstandard, high-end, niche skills.

Van Pittius said the laboratory would promote the increase of cross-disciplinary work, tapping

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News | 07

KEY INTERVENTIONS PAY OFF FOR LESOTHO’S MUMS AND BABIES

BY INTRODUCING FREE comprehensive family planning and maternal healthcare, and training 40 doctors in advanced obstetric life support in Lesotho, Médecins Sans Frontières (MSF) reduced one of the world’s highest maternal mortality rates while neonatal deaths plummeted, a Scientific Day organised by the global NGO heard this June in Johannesburg.

The 18-month intervention also saw MSF buy an ambulance, provide mobile outreach services and build maternal waiting houses alongside St Joseph’s District Hospital in Roma (45 km outside Maseru) and next to six other rural clinics to provide a safe space for women to await the onset of labour during their final days of pregnancy. SA’s Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa (CARMA) has similar projects, which all provinces are

expected to implement on a needs basis.

Dr Sandra Selmaier-Outtara, the principal investigator of a report entitled A steep mountain to climb, addressing Lesotho’s maternal mortality through free comprehensive family planning and maternal care said: “Many non-pregnant women walked 8 hours to get to a clinic”.

Besides freezing winters, other barriers to care included 75% of healthcare facilities being supported by the Christian Health Association of Lesotho (CHAL), whose Roman Catholicdominated membership ruled out contraception and non-lifethreatening abortion services.

This often led to MSF setting up facilities just outside the CHAL-run facility boundaries, with huge uptake of condoms and contraceptive implants and injectables. Other barriers to care included women having to pay

to have their babies delivered, lack of transport, a skeletal public health system, dismal services (25% of deliveries not attended by skilled health staff) and poor staff attitudes.

Selmaier-Outtara said that before MSF introduced free maternal care (FMC) the country’s maternal mortality rate was 146/100 000. Post FMC, this drop­ped to 87/100 000. Neo­natal deaths dropped from 5.1/100 000 to 1.3/100 000 and stillbirths from 26.4/100 000 to 19.1/100 000.

Lesotho has a 27% HIV pregnancy prevalence with 58% of all maternal deaths attributed to HIV/AIDS. Some 16% of hospital admissions are abortion-related. MSF focused on emergency training for difficult cases and secured funding to cover the medium-term costs of 2 298 mothers and neonates. Referral patterns inward to St Joseph’s preFMC increased from 1.3% (38/1 484) to 3.4% (79/2 298).

into uncharted areas of research, while his neurosurgery division chief and colleague, Prof. Ian Vlok, enthused about the savings on theatre time, cost, the safe acceleration of learning and improved patient outcomes.

“We have to be accountable for the skillsets that come out of here – basic surgical skills and proper, appropriate anatomical knowledge will be minimum entrance qualifications – the last thing we want to create is a bunch of loose cannons,” he stressed.

Vlok leads the three-man neurosurgical team at Tygerberg Hospital which initiated and then facilitated the collaboration with sponsors, Medtronic, a top global surgical equipment

supplier. Medtronics MD for Africa, Peter Fuller, said the R120m equipment costs would be “amortised” over the long term. Vlok said specialist training had always demanded a delicate balance between gaining surgical experience and not putting patients’ health at risk in order to do so.

On 26 July 2016, just 6 days after the launch, 40 international neurosurgeons converged on the laboratory to conduct intensive training sessions that included the most advanced keyhole surgery, showcasing equipment that ranges from R1m human dummies able to replicate human functions and disease symptoms, to endoscopes, high-definition

surgical microscopes, imageguided navigation equipment and surgery-enhancing CT scanners.

Prof. Martin Veller, dean of Health Sciences at the University of the Witwatersrand and former chair of the Association of Surgeons of South Africa (ASSA), said it was “exciting news with wonderful promise” but cautioned that technology “often goes well ahead of the evidence”. Putting 1 200 students through the laboratory per year could be “massive – depending on what they do and get out of it”. Evidence would be needed to show the laboratory’s impact on the training and clinical environment.

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PRE-ELECTION STRIFE HINDERS EMS

STANDBY PLAN FOR PROTEST-BLOCKED PATIENTS Frustrated EMS staff country­wide have a plan B for endemic civil strife. To reduce the loss of life and mitigate health complications, they train community members in first aid, liaise with community leaders and police, set up perimeter pick-up points for patients, and have standing instructions to withdraw from volatile environments.

THE PREelection violence which erupted in many of the country’s cities in late June and July 2016 prompted a political health chief and two of SA’s leading emergency service heads to publicly plead for emergency medical teams to be allowed free access to injured patients.

Dr Raveen Naidoo, national director of emergency medical services (EMS) and disaster

medicine and Dr Lee Wallis, also a top government disaster services advisor (and EMS chief in the Western Cape), said their staff were also frequently endangered and ambulances or other rescue vehicles sometimes hijacked or damaged during civil unrest such as protests over lack of service delivery or over ward list candidates. Their appeal came as civic protests erupted in Pretoria, East London, Port Elizabeth and Bronkhorstspruit with at least half a dozen killings, dozens of buses burnt, major roads barricaded and vehicles stoned. While neither had any reports of staff injuries, both said that in some provinces the hijacking of ambulances was more frequent and denial of access to township areas more widespread.

Wallis said the hijacking of rescue vehicles and ambulances to strip for vehicle parts and protestors blocking emergency

crews were common and “bother us on a weekly basis”. This “stressed out” crews and affected service delivery. Naidoo said that while he had no statistics, such incidents happened frequently, especially in the Eastern Cape.

On 14 June 2016 at Zithobeni township near Bronkhorstspruit, some 45 km from Pretoria, EMS staff were blocked from reaching a diabetic patient during protests over election list nominations.

Gauteng MEC for Health Qedani Mahlangu publicly implored members of the community to allow staff to do their work without hindrance following widespread pre-election civic strife. The Tshwane violence saw 5 people die, dozens injured, shops looted and 270 people arrested after the ANC’s nomination of former agricultural minister Thoko Didiza as its mayoral candidate for Tshwane.

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FUNDING ENABLES CANCER TREATMENT A NEW RADIATION TREATMENT that keeps liver tumours in check for 8 months longer than regular chemotherapy and which can shrink them sufficiently to enable life-saving surgery, is on offer at three major private hospitals in SA. A major funder gave it the thumbsup this June, and other large medical aids are expected to follow.

Discovery Health began increasing reimbursements in June this year for SIR Spheres, resin microspheres delivered via catheter into a groin incision that allows millions of them to be delivered into the hepatic

artery that feeds liver tumours.

Containing radioactive yttrium-90, the microspheres are small enough to be delivered straight into the tumour, but big enough to become trapped in small vessels keeping the tumour alive. According to Nigel Lange, the SA- born CEO of Sirtex for Europe, the Middle East and Africa, patients suffer fewer and milder side effects, in some cases the tumours shrinking sufficiently for previously inoperable cancers to become candidates for potentially curative surgery. Dr Waldemar Szpak, a radiation oncologist at the Rainbow Oncology Centre in Durban, said the most recent Sirflox trial showed liver tumours were kept in check for almost 8 months longer than regular chemotherapy alone when used early in patients with

metastatic colorectal cancer.

The Sirflox study, published in the Journal of Clinical Oncology in February 2016, is an international research collaboration to evaluate a new treatment option for patients with colorectal cancer that has undergone metastatic spread to the liver. It had “great potential” in managing other cancers involving the liver. Primary liver cancer is the 10th most common form of cancer in SA, with 2 000 new cases diagnosed annually.

Colorectal cancer is the fifth, with 4 700 new cases per annum. If it metastasises, it spreads to the liver, which is mostly fatal.

Costing up to R240 000, Vincent Palloti and Enthabeni hospitals and Donald Gordan Medical Centre offer the treatment.

TWO DIE IN HOSPITAL STRIKE

TWO STRIKING HOSPITAL cleaners, died in a confrontation with security guards at King Edward Memorial Hospital on 14 July 2016, following the non-implementation of a legal amendment rendering certain non- time-based temporary hospital staff permanent employees.

The South African Public Service Union (SAPSU) vowed

on 16 June 2016 to extend its week-long protest, demanding that temporary workers employed for longer than 3 months at government institutions be given permanent jobs. The strikes affected Mahatma Gandhi, King Dinizulu and King Edward hospitals. The pre-dawn killing involved security guards and an allegedly armed cleaner who approached them at the hospital.

The cleaners were shot and one body was found by police at the scene and another at the nearby Congella Park sports field.

Speaking at a press briefing on 16 June, the interim secretary general of the union, Moses Tsotetsi, said the legal section in dispute was the Amendment to Section 198 of the Labour Relations Act, which dealt with

temporary workers. He said the law needed enforcing, with no bargaining council involvement.

“Workers are unwilling to back down – they’re tired,” he said.

Many of those affected were security guards and cleaners younger than 40, and legally entitled to a salary of between R5 000 and R6 000, plus benefits.

This would increase to the level of government employees after 18 months. While it was not their intention to impact on essential health services, they had to fight for their rights and were consulting lawyers. Led by former Cosatu secretary general, Zwelinzima Vavi, SAPSU protestors marched to the Durban City Hall to deliver a memo to KwaZulu-Natal premier Willies Mchunu. A spokesperson for the KwaZulu-Natal health department was unavailable.

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A SHOT IN THE ARM FOR SA’S POOR BONE MARROW DONOR RECORD INCREASING THE BONE marrow donor base in SA from the current 71 971 individuals to 100 000, with an emphasis on the current minority of black donors, is a top priority for Dr Charlotte Ingram, the new medical director of the SA Bone Marrow Registry (SABMR).

Ingram took over early this May from her veteran predecessor, Prof. Ernette du Toit, who retired aged 80, after founding the registry and linking it with 75 international registries (see HG Profile, Aug/ Sept edition). Ingram says her primary purpose is to save as many lives as possible, with the SABMR already performing well above its relative size in terms of phenotypes of stem cell donors, ranking in the top three

bodies globally for the relative percentage of unique HLA split phenotypes of stem cell donors.

SA’s high genetic diversity makes it difficult to source a donor from some of the less diverse phenotype registries, hence making it so important to increase its own donor base to be more representative of the population. The black donor base grew from just 6% to 7.5% of the total last year (5 379 donors), and Ingram wants to boost it to 10% through publicity campaigns and registration drives in association with the Sunflower Fund (which recruits bone marrow donors).

She was CEO for the clinical trial laboratory of the University of the Witwatersrand’s Health Consortium and headed up a molecular diagnostic unit for

a business initiative for the sub-Saharan African region.

For many years Ingram was actively involved in HIV research and management of HIV and anaemia for the Johannesburg Hospital Complex and aims to boost access to facilities for the diagnosis and treatment of blood diseases. According to the SABMR, healthcare workers would help greatly by encouraging all healthy adults to sign up for the bone marrow registry via the Sunflower Fund, which does Dr Charlotte Ingram recruitment.

NEW SMOKING CESSATION DRUG OUTPERFORMS COMPETITORS THE LARGEST YET GLOBAL clinical trial of approved smoking cessation medicines (published in The Lancet) showed that Champix (varenicline) outperformed bupropion or nicotine patches by a statistically significant margin in abstinence rates.

The study, dubbed EAGLES (Evaluating Adverse Events in Global Smoking Cessation), included 8 144 adult smokers and was designed to compare the neuropsychiatric safety of Champix and bupropion with a placebo and nicotine patch in adult smokers, with and without a history of psychiatric disorders.

No significant increase in the incidence of serious neuro­ psychiatric adverse events was shown with either of the two

medicines when compared with a placebo and the nicotine patch. Smoking abstinence rates in patients treated with Champix or bupropion, relative to a placebo and the nicotine patch, during the last 4 weeks of a 12-week treatment period were compared and Champix was found to have significantly higher continuous abstinence rates.

According to lead study investigator, Prof. Robert M Anthenelli, a psychiatrist at the University of California, the findings offer “important new information to prescribers and smokers to help them make an informed decision about cessation treatment options”.

The study was funded by the Champix manufacturers.

Dr Yussuf Saloojee, executive director of SA’s National Council Against Smoking (SANAC), added that factors such as cost, contraindications, side-effects, and patient preference should also be taken into account when recommending medications. He said a limitation of the study was that it recruited individuals who smoked, on average, at least ten cigarettes per day, which made it hard to generalise the findings to lighter, less severely dependent smokers.

This was particularly relevant to SA, where most smokers consumed fewer than ten cigarettes a day.

Behavioural therapy was another first-line treatment, he empha­sised.

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GIVE US PEER EDUCATORS, NOT NURSES, SAY SEX WORKERS

USING PEER EDUCATORS TO enrol sex workers into healthcare programmes is far superior to persuasion via traditional healthcare workers who are seen as prejudiced, and lacking understanding. This was shown

by Médecins Sans Frontières (MSF) research presented to a scientific forum at the University of the Witwatersrand.

The MSF research at two Mozambican sites in the Malawi-Beira transport corridor between January 2014 and June 2015, enrolled 1 810 sex workers to explore communitybased testing strategies.

Peer educators were able to reach out to their peers and gain trust, enrolling 1 461 sex workers in Tete and 349 in Beira, most of them from Zimbabwe, with a minority from Malawi. A full 59% of those in Tete were HIV positive and 54% of the Beira cohort was HIV positive, with HIV positivity increasing with age (29% - 43% for 18 years and younger, and around 78% by 35 years and older).

There was a good response to testing, in spite of stigma and prevention challenges, which included retention for retesting (24% traced for followup a year later), and sex workers experiencing prejudice and

being undervalued by non-sexworkers on the MSF team. The aim was to keep HIV negative sex-workers HIV negative; to link HIV positive sex workers to HIV care and treatment, and to provide community outreach via HIV testing and counselling, female and male condoms, lubricants, retesting and sexually transmitted infection and family planning services.

The team facilitated integrated, friendly services (antiretroviral drugs and viral load testing) plus in-country and crossborder referrals.

Integrating peer educators into the MSF outreach programme proved pivotal.

Presenter, Dr Humberto Jassitene, expressed excitement at the new SA HIV guidelines which recommend pre-exposure prophylaxis for sex workers, something he hoped to emulate “very soon”.

MSF MOVES TO PROTECT REFUGEES

Hundreds of men line up to receive food at one of the three tented camps that sprang up in Durban, the epicentre of xenophobic violence in 2015. Pic: courtesy MSF

AS MĒDECINS SANS Frontières (MSF) spurned all European Union (EU) funding for its projects worldwide after a series of cynical EU country moves to choke their inward refugee flow, SA activists in Johannesburg this June protested the proposed stiffening of local refugee laws.

The People’s Coalition Against Xenophobia, consisting of MSF, the Africa Diaspora Forum, Lawyers for Human Rights, Section 27 and a host of other related NGOs, intervened in various xenophobic crises that erupted across the country in 2008 and 2015, providing

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HIV TREATMENT UNDER CONTROL – NOW FOR SEXY PREVENTION? GOVERNMENT LAUNCHED A R2 billion HIV prevention and young women empowerment programme, the biggest this country’s ever seen, at the Pietermaritzburg Showgrounds on 24 June 2016 – and healthcare workers may soon start promoting sexual pleasure as a prevention tool.

The multisector, 3-year overseas-funded campaign, to be supplemented by an as yet undisclosed treasury amount, also aims to reduce teenage pregnancies and gender-based violence, keep girls in school, and create economic opportunities.

Dr Fareed Abdullah, the CEO of the South African National AIDS Council, speaking to HG before the launch, embraced “the pleasure principle” as part of a multi-pronged strategy to promote the poorly used female condom. Knowledge of femidoms among 15-year-old girls is

measured at 78%, but usage at just 7%. “It’s a great way to think about it because it’s the most effective women-controlled HIV prevention method. We’d like to increase its attractiveness to both sexes,” he added. Asked why the strategy was being considered so belatedly, he responded: “In all honesty, we haven’t embraced it.

We talk about HIV a lot, but not about sex and pleasure and how they drive new infections. I’m very open to those prevention experts who are making the case”.

SA increased the distribution of condoms from 353 million in

emergency healthcare and successfully improving healthcare access.

Explaining the Coalition’s 18 June protest, Dr Borrie le Grange, MSF’s SA commu­ nications chief, said the proposed Refugees Act Amendment Bill wanted to move refugee centres closer to the country’s borders and reduce the time they had to apply for refugee status by nearly two-thirds (14 days to 5 days), from when they entered the country. Awarding of asylum would be based on a refugee’s ability to sustain him- or herself and any dependants with the help of family or friends for at least 4 months, while limiting or prohibiting him or her from

working. This further rolled back the rights of refugees who MSF had learnt from working with them at the Central Methodist Church in Johannesburg (2008 - 2013), were reluctant to seek official healthcare, with provincial healthcare staff illegally demanding “green ID books” before treating anyone. “They’ve often been attacked or raped in getting here and finding food, shelter and employment take precedence over medical care,” he explained. MSF, through its primary healthcare interventions and accompanied referrals, had compelled health authorities in Johannesburg to change staff attitudes and care to comply with basic human rights.

2013 to 723 million in 2015, and femidoms from 7.6 million in 2013 to 20.7 million last year. The ARV treatment push has reaped rich rewards, although paradoxically, it has contributed to a HIV prevalence hike from 10% to 12% between 2008 and 2012, as more people survived. Incidence has however increased, especially among younger women, and is now the big worry. Studies estimate one in four (1 700) women between the ages of 18 and 24 are being infected with HIV weekly (latest incidence 2.8%).

22 April 2015. After days of waiting in limbo in one of three displacement camps outside Durban, Malawians line up to catch buses back home: all fugitives from violent xenophobic township attacks. Pic: courtesy MSF

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SALTPIPE... helping you breathe again References: 1. Chervinskaya A.V et al (1996) Application of dry rock salt aerosol in case of common cold, XYI Congress of the European Rhinologic Society. VII Congress of the International Rhinologic Society. Week of the Nose: Abstract Book.- 1996.– P. 104. 2. Cernomaz TA et al (2007), The effect of a dry salt inhaler in adults with COPD. Pneumologia. 2007 Jul-Sep;56(3):124-7. 3. Konovalov S.I et al (1993).

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O AT S the general quality of evidence was poor and further rigorous studies are needed, according to the researchers. The plantbased treatments were phyto-oestrogens, with individual products such as dietary and supplemental soy isoflavones. Black cohosh, although popular, does not appear to reduce menopausal symptoms.

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In the drive towards limiting antibiotic use, GPs in Britain are reducing prescribing these drugs for selflimiting upper respiratory tract infections. A study looking at outcomes found that this results in a slight increase in treatable pneumonia and peritonsillar abscesses, but no difference in the incidence of other serious illnesses such as mastoiditis, empyema, bacterial meningitis, intracranial abscesses and Lemierre’s syndrome.

Authors suggest caution in sub-groups at higher risk of pneumonia.

Van Maaren MC, de Munck L, de Bock GH, et al. 10 year survival

Gulliford MC, Moore MV, Little P,

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Franco OH, Chowdhury R, Troup J,

plus radiotherapy compared with

prescribing for self limiting

et al. Use of plant-based therapies

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respiratory tract infections in

and menopausal symptoms: A

in the Netherlands: A population-

primary care: Cohort study using

systematic review and meta-

based study. Lancet Oncology

electronic health records. BMJ

analysis. JAMA 2016;315(23):2554-

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2563. DOI:10.1001/jama.2016.8012

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Research | 17

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Biffi A, Bailey D, Anderson CD, et al. Risk factors associated with early vs delayed dementia after intracerebral hemorrhage.

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Walter JE, Heuvelmans MA, de

“Unsafe drugs were prescribed more than one hundred million times in the United States before being recalled” – the title of a paper in the International Journal of Health Services.

The authors looked at 17 drugs that were approved and then withdrawn in the USA between 1993 and 2010. They used these data to work out how many times they were prescribed between that period using data from the National Ambulatory Medical Care Survey. Nine of the drugs were prescribed more than one million times before they were withdrawn.

Jong PA, et al. Occurrence and lung cancer probability of new solid

Saluja S, Woolhandler S,

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Himmelstein D, et al. Unsafe drugs

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INHUMANE SYSTEM MAY HARM DOCTORS AND PATIENTS

By Patricia McCracken

Working very long hours and moving rapidly through the ranks makes it difficult for junior doctors to campaign consistently – does it take the death of Dr Ilne Markwat to change this once and for all?

T

HE YOUNG DRIVER WAKES with a start. He was in a queue for a red traffic light to change.

Now he’s marooned in the middle of the road. The queue has evaporated and the shock of the accident that might have been dawns on his fatigue-fogged brain.

“I’d been working a long shift as an orthopaedic registrar,” he recalls. “When I woke up and realised the dangers, I turned back to the hospital and slept in an empty patient’s bed before returning to my car.”

That experience doesn’t come from one of the junior doctors supporting the current Safe Working Hours campaign. It comes from Dr Mzikisi Grootboom, chair of SAMA, a junior doctor in the late 1970s.

Junior doctors’ working hours were a major campaign issue in the 1990s but despite such occasional doses of the oxygen of publicity, demands on junior doctors have grown worse, not better, believes Dr Grootboom.

The tragic death in June 2016 of Dr Ilne Markwat, who had started her junior doctor training at Paarl Hospital only in January this year, made resolving the issue urgent. It is believed that after a shift of at least 24 hours, Dr Markwat fell asleep at the wheel, her car slewing across the N1, hitting an oncoming vehicle and injuring its two passengers seriously. However, Minister of Health Dr Aaron Motsoaledi thinks it more likely that Dr Markwat lost control when her car was shunted from behind, “which might

happen even if the driver is fresh”. But even so, the very long shift that Dr Markwat had worked would have impaired her reactions, making her own death and the injury to two innocent passengers even harder to avoid.

The fact that this happened in a public space means authorities can no longer bury mistakes caused by a system SAMA labels “archaic”, say many junior doctors. They demand to know why regulations designed to protect them and their patients are not properly enforced, while authorities ponder how to weigh their budgets against the need for skilled staffing and continuity of care.

“

Working shifts of more than 16 hours affects vigilance, mental capacity and fine motor activity, which impairs a doctor’s performance and is a health risk to doctors and to patients” JUDASA national chair Dr Tshilidzi Sadiki

“A TRAGEDY WAITING TO HAPPEN”

“It was a tragedy waiting to happen,” says Dr Zahid Badroodien, chair of the Western Cape Junior Doctors Association of SA (JUDASA). “I was on shift in the emergency unit when I heard about Ilne’s death. My heart dropped with the shock. One life lost because of working conditions is too many. It should not take a death for the Department of Health to review this longstanding issue.

The HPCSA responded in August, reducing the 30 continuous hours for interns to 26 (including 2 hours for handover), promising to audit hospitals to ensure legally required restrooms were in place and recommending further reduced shifts at higher workload hospitals. The HPCSA’s internship training sub-committee said

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“

Junior doctors believe senior doctors still shrug off juniors’ concerns and fears and dismiss the experience of interning as an intense and necessary rite of passage

3 000 internship posts were funded but 3 700 were available. As more interns qualified the NDOH would need to increase funded posts to address huge patient pressure.

Dr Motsoaledi, though, is less conciliatory: “It is unfortunate and regrettable that this has been directly linked to working hours as an emotional issue. Ministers and MECs have even longer working hours”.

Paarl Hospital was one of the first in the region to be visited by the JUDASA Western Cape committee in November 2015 to engage with members: “We found interns there had specific concerns with working hours, supervision and high patient loads”.

Dr Badroodien and Dr Markwat were both part of the 2014 fifth-year class at Stellenbosch University, whose ethics assessment of factors contributing to errors among medical workers developed into a campaign for safer working hours for junior doctors. Led by Dr Koot Kotzé and Dr Helene-Mari van der Westhuizen, it launched with a petition on Change.org, which now has a target of 10 000 signatures.

Since then, apart from Dr Markwat, six other members of that class have had accidents after long shifts. The class’s literature review underlined the impact of extremely long working hours on interns and patients. An Australian Medical Association study, for example, showed that ability to function properly is already impaired after a 16-hour shift, the norm under European regulations, in contrast to SA regulations that allow shifts of up to 30 hours that, in reality, may run even longer.

JUDASA debated the issue at its July 2016 national executive committee meeting, resolving to police implementation of existing HPCSA guidelines in preparation for debating smarter workshift options with the HPCSA and NDoH, says JUDASA national chair Dr Tshilidzi Sadiki: “Working shifts of more than 16 hours affects vigilance, mental capacity and fine motor activity, which impairs a doctor’s performance and is a health risk to doctors and to patients – because when a doctor makes a mistake it can result in disability and even death.”

Options might include co-opting patient support for doctors who have worked

excessive hours and signal this by wearing a red armband, he suggests. But he believes junior doctors have been largely intimidated into silence with the threat of not being signed off by a supervisor as fit to work independently in a speciality at the end of a rotation: “Junior doctors are sometimes victimised when they raise legitimate issues such as the length of working hours.

Nobody wants to do anything to jeopardise a relationship with a supervisor”.

“AN INHUMANE SITUATION”

Working the same number of hours in a week or a month but administering shifts more intelligently might allow being on call today to be more like the experience of this generation’s senior doctors as juniors, says Dr van der Westhuizen: “Back then, you could take a break and sleep at the facility during a long call. Now patient loads are so heavy that most shifts are usually continuous”.

Although a cap on shift hours will be discussed, Dr Carter believes current policy should be enforced strictly by the HPCSA so managers ensure facilities have appropriate and acceptable rest accommodation and doctors do take breaks during shifts. Long shifts are a feature of hospital practice for doctors internationally, he adds, having evolved to allow for continuity of patient care: “Our information is that occasions when doctors have to work these very extended hours are not that frequent – but doctors say this is incorrect. We are not yet sure whose perception is incorrect. If what junior doctors are saying is correct, we must find out what factors are driving the change in experience”.

Junior doctors believe senior doctors still shrug off juniors’ concerns and fears and dismiss the experience of interning as an intense and necessary rite of passage because they trained under distinctly different conditions. Dr Grootboom agrees: “Once doctors emerge from this system, they forget about their younger colleagues and do not hesitate to subject them to this inhumane situation. Those who say that this situation is nothing new don’t stop to tell you how many mistakes were made and what the outcomes were. They don’t want

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Feature | 21

to and, fortunately for them, nobody can tell”.

Working conditions have changed significantly since many senior doctors emerged from training, he adds: “While I was training, older surgeons ran casualty units and trained junior doctors to deal with emergencies. In orthopaedics, we had an assessment meeting every morning to pinpoint developing problems and as a teaching device so we did not repeat mistakes. Someone senior was available if a junior doctor needed help and any intervention had to be approved before it was signed off. Junior doctors and registrars tend to carry the service load but they also need to be taught. Now it appears junior doctors are working long hours without supervision, doing procedures they’re not trained for and taking increasingly farreaching decisions.”

“A DISSERVICE TO DOCTORS AND PATIENTS” The situation has deteriorated since the early 2000s, with a gradual shift in norms, standards and clinical governance across specialities, believes Dr Grootboom. At one hospital visited by JUDASA Western Cape, a complement of more than 20 interns had dwindled to only 12 currently, reports Dr Badroodien – despite everincreasing patient numbers given SA’s infamous quadruple burden of disease.

Increases in patient numbers mask the fact that more doctors are being trained and employed, believes Dr Motsoaledi, including at the hospital where he trained, St Rita’s in Sekhukhune. The 18-month NDoH audit of about 3 500 primary healthcare facilities to prepare for rightsizing according to the WHO’s Workload Indicators of Staffing Need has just concluded, he notes, and the tertiary hospitals audit is starting.

Some provinces have used budget constraints as an excuse not to maintain adequate service levels, Dr Grootboom says: “Many hospital managers consider health personnel very expensive so deciding not to fill a post is an easy way to cut the budget. We are told posts are not frozen but often it is very difficult to get an appointment approved. We have

heard of KZN managers being advised of a moratorium on employing certain levels of staff. We were told it did not apply to healthcare workers but the reality is any manager wanting to employ people in these categories must wait for approval from the provincial department of health and office of the Premier. That often takes 3 to 6 months so the applicant has already gone to another province, the private sector or emigrated”.

Dr Grootboom believes the HPCSA should not allow an institution to train junior doctors unless it has a certain level of staff and supervision, with well-policed working hours and service delivery, yet despite its responsibility to monitor standards for intern service and regularly

“

Now it appears junior doctors are working long hours without supervision, doing procedures they’re not trained for and taking increasingly farreaching decisions” Dr Mzikisi Grootboom, chair of SAMA

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JOIN THE DEBATE The Safe Working Hours campaign’s Facebook page welcomes comments and experiences. Here is a selection: “There are more innovative ways of looking at this than simply cutting down hours.

Making hours safer is the first priority, coupled with stricter handovers and new roster models.” Farah Jawitz “I’m sorry, somewhere to rest on shifts? I wasn’t standing and treating patients because I had nowhere to sleep . . . there were too many patients and too few staff!” Lizle Oosthuizen “After being on call for 27 hours as a student in obstetrics, I went through a red robot on my way home. A car coming the other way just missed colliding with me. Realising that I had just narrowly escaped what could have been the end of my life, I pulled into the nearest garage shaking and exhausted. This madness of excessive hours on call starts when you’re a student and is considered . . . a norm. It’s time we stood up for our own lives in addition to the patients we treat.” Nikita Fensham “I was involved in a motor vehicle accident (the only accident I have ever had) when . . . post call in my community service year. I was on my way to a clinic after about a 26 hour shift without a break. Still had to work about another 5 hours . . .

Luckily nobody was injured, but my car had R40 000 damage.”

Dr Dalene von Delft

visit institutions training interns, it is toothless: “Every year HPCSA inspectors say: “Unless you comply, we will withdraw your accreditation at our next visit. But this is an empty threat because they never do so. The HPCSA tends to overlook its own rules and regulations, as well as problems within the SA health system. This is a disservice to the profession and to the population we are supposed to protect”.

Although the current HPCSA 30-hour shift regulation applies only to interns, both Dr Grootboom and Dr Carter agree the issue of extremely long working hours also applies

beyond internship to registrars and medical officers in particular and more generally to all doctors. There is a contradiction at the heart of the medical establishment, believes Dr van der Westhuizen: “Nurses have a strict 12-hour shift system. This is accepted working culture even though there is a shortage of nurses”.

“SAMA calls on all doctors in SA to join in a serious conversation about the plight of junior doctors,” says Dr Grootboom.

“We will see many more tragedies if these issues of staffing and working hours are not addressed. We risk creating a situation where the challenges that doctors face are so severe that nobody wants to choose medicine as a career.”

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SA’S NEW HIV/AIDS CRUNCH

By Patricia McCracken

Big promises on expanding SA’s HIV/AIDS response have been made in the world spotlight – but can our healthcare system deliver?

“

Globally, new infections rose in 74 countries between 2005 and 2015, according to a study by the Global Burden of Disease network

Charlize Theron at the International Aids Conference 2016: “We have every tool we need to prevent the spread of HIV.”

T

HAT INTIMIDATING MOMENT of opening the clinic door each morning to face a seemingly endless crowd of patients represents the daunting nature of primary healthcare (PHC) in Africa for Prof. Kara Wools-Kaloustian of Indiana University School of Medicine. That’s why she supported the Association of Nurses in AIDS Care Call to Action launched in July 2016, demanding international policy changes and greater investments in nursing to support nurse-led care.

This reality check placed a question mark over the world’s largest AIDS treatment programme in SA as it attempts to decrease the number of people living

with HIV/AIDS, expand treatment to all and introduce pre-exposure prophylaxis (PrEP).

Several discussions emerging from the 21st International AIDS Conference in Durban suggest that the practicalities of funding, human resources and integrating other healthcare needs could derail good policy intentions and create a perfect storm unless SA’s healthcare system is strengthened.

HOW MUCH MORE WORKLOAD FOR NURSES? SA’s 225 000 nurses are the backbone of its healthcare workforce. The success of co-opting them into Nurse-Initiated Management of Antiretroviral Therapy

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(NIMART) in 2010 has led to focus on using nurses to address other key areas such as non-communicable diseases (NCDs) and maternal and child death rates, says SA chief nursing officer Dr Nonhlanhla Makhanya. From September 2016, nurses will also be in the frontline for the new HIV/AIDS Treat All programme announced in the May 2016 health budget.

But SA’s high quadruple burden of HIV/AIDS, TB, NCDs and injuries from accidents and violence means professional nurses already see an average of about 30 clients a day. In reality, according to the 2014/15 District Health Barometer, this ranges from 18.6 clients per professional nurse per day in Mopani in Limpopo to 48.9 clients in the uMkhanyakude district of KwaZulu-Natal.

Such workloads are unsustainable believe nursing leaders like Kwena Daniel Manamee, deputy secretary-general of the Democratic Nursing Organisation of SA. This rightsizing debate may be resolved by applying the WHO Workload Indicators of Staffing Need (WISN) but so far only PHC facilities have been surveyed.

The next National Strategic Plan on HIV, TB and STIs for 2017 to 2022 will be launched in December 2016 and will include continued rollout of the new, all-in-one Treat All initiative, which aims to put all HIVpositive patients on treatment regardless of CD4 count to achieve two linked goals set by the WHO 90-90-90 initiative and

agreed by SA Minister of Health, Dr Aaron Motsoaledi. By 2020, the plan aims to have 90% of those living with HIV knowing their status; 90% of those who are HIV-positive on long-term treatment; and 90% of those on treatment virally suppressed.

The overall aim is both to reduce the impact of HIV on those already infected and to reduce new infections, ultimately bringing an end to AIDS as a global pandemic by 2030. The hope is that the new plan will achieve a similar kind of success among adolescents and adults as the PMTCT programme did by bringing down transmission of HIV from mother to baby in SA by about 90%. Introducing Treat All will by itself double the number of SAs on ARV treatment – an extra 3.4 million clients regularly needing attention from nurses and other healthcare workers.

WHO AREN’T WE TARGETING?

NIMART helped SA astonish the world in its about-turn from denialism to 3.4 million SAs on ARVs in 2015. But globally, new infections rose in 74 countries between 2005 and 2015, according to a study by the Global Burden of Disease network. “In some places where the epidemic had been under control, for example in some urban populations of men who have sex with men, it is re-emerging,” said WHO directorgeneral, Dr Margaret Chen.

Rural KZN end-stage AIDS patient being cared for by his wife, before the 2016 test and treat rollout was announced.

THE CHW CRISIS

The community health worker (CHW) sector is in turmoil and activists and volunteers who poured their energies into setting up these volunteer networks two or three decades ago are seeing their legacy crushed, believes Laura Kganyago, secretary general of the Women’s National Coalition.

A dramatic installation representing the graves of neglected and endangered CHWs, redolent with slogans and topped with blood-stained gloves, stopped delegates to the International AIDS Conference in their tracks at the entrance to Durban’s International Convention Centre.

“About 9 out of 10 CHWs are women, who are already exploited by being inadequately trained and equipped, receiving stipends of just R800 to R2 500 a month and not being protected by the Compensation of Injury on Duty (COIDA) legislation,” said Section 27 legal officer Violet Kaseke, who devised the installation.

Dr Motsoaledi proposes bringing about half the current nearly 80 000 CHWs into the formal PHC network and introducing formal training for community health nurses from 2019. But Kaseke fears this process may destabilise health outcomes: “This informal element of the health sector is critical to achieving SA targets for 90-90-90 and for TB control.”

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“

The practicalities of funding, human resources and integrating other healthcare needs could derail good policy intentions and create a perfect storm unless SA’s healthcare system is strengthened

Dr Motsoaledi acknowledged: “We have been mistaken in thinking we have only a heterosexual HIV epidemic in SA.” SA strategists have looked again at vulnerable groups, including sex workers and their clients, transgender people, those who inject drugs and prisoners. These might be comparatively small numbers but if not effectively treated could also be part of the reservoir of infection, prompting resurgence of the epidemic. In addition, girls aged between 10 and 19 years old in southern and eastern Africa have been found to be up to seven times more likely to be infected thanks to a complex web of biology, peer pressure, socio-economic circumstances and gender violence, added Prof. Quarraisha AbdoolKarim, associate scientific director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA) in Durban.

In June 2016, PrEP rollout started with sex workers. This daily dose of ARV medication is the first of a new generation of prevention methods and has also been piloted among teens in Soweto.

WHAT NEW TOOLS DO WE HAVE?

“Globally, progress on HIV prevention has stalled,” said Dr Margaret Chen. Like other speakers at the conference, she stressed that despite “enormous progress on HIV, particularly on treatment, this is no time for complacency”.

Prevention has fallen largely on deaf ears among adolescents and adults from the US to the Ukraine, from Brazil to Great Britain, as well as in SA. Meanwhile, researchers battle to identify an effective vaccine and, ultimately, a cure. Top international researchers like Françoise Barré-Sinoussi, the French scientist who identified the HI virus, have become cautious in their forecasts: “We hope to be able to induce a remission in AIDS symptoms but a cure still seems very difficult,” she said.

Although SA is a key site for a new HIV vaccine trial, nobody can forecast when an effective vaccine will be available.

By comparison, the Ebola vaccine was developed in about 18 months, said Dr Nelson Michael, director of the US Military HIV Retrovirology Program, because the Ebola virus is much less complicated

than HIV. As an integrated retrovirus, HIV “makes a formidable target,” said Dr Dan Barouch of the Center for Virology and Vaccine Research at Harvard University.

From 2018 onwards, a three-month version of a microbicidal vaginal ring, requiring much less commitment for adherence, may become available, said Dr Zeda Rosenberg of the International Partnership for Microbicides.

This method could also reduce bacterial vaginosis, which makes young women more susceptible to HIV infection, added CAPRISA director Prof. Salim Abdool Karim. There are about 16 million girls and women aged between 10 and 49 years in SA, so dispensing these vaginal rings could amount to about 60 million more health visits a year.

WHAT ABOUT THE GROWING NCD BURDEN?

As growing numbers of SAs have adopted urbanised lifestyles and diets, the burden of NCDs has increased significantly. NCDs are appearing in younger age groups of people living with HIV/AIDS, particularly if they started treatment late, possibly because the inflammatory response remains abnormal even during viral suppression, said Dr Paula Munderi of MRC/UVRI Uganda Research Institute on AIDS. In addition, people living with HIV/AIDS have increased risks of dyslipidaemia, type 2 diabetes and cervical cancer, for example.

And because treatment now helps them survive up to 35 or 40 years, general lifestyle risks from smoking and hazardous alcohol use to methamphetamine use and obesity contribute to NCDs. There is also no reason for HIV pro­ grammes to continue their tendency to overlook patients’ need for routine NCD screening. “It is relatively straightforward to screen for hypertension, diabetes and chronic obstructive pulmonary disease during an HIV visit,” said Prof. Wools-Kaloustan. A Ugandan survey found that 79% of HIVpositive patients surveyed had not been previously diagnosed as having hypertension.

She recognised that cancer diagnosis is “less amenable to point-of-care diagnosis” but noted Zambia’s success in using mobile clinics in areas with high HIV prevalence.

PHC is geared towards episodic treatment, usually for family planning, perinatal care,

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immunisation and accidents or injuries, said Prof. Wools-Kaloustan: “It’s not a chronic disease model that requires continuity”.

But the success of care models devised for NIMART, HIV/AIDS chronic care and Directly Observed Treatment, Short-course (DOTS) could be used to incorporate NCD screening, prevention and treatment for patients on longterm ART: “HIV/AIDS has become a chronic illness, so logically integrating HIV/AIDS care into NCD care would help decrease lingering stigmatisation.”

HOW DO WE MAKE THIS HAPPEN?

Political commitment and sustained funding are crucial to making these new treatment approaches work, emphasised Prof. WoolsKaloustan. Shortages, whether medication for patients or colleagues to help shoulder the load, all become demoralising and depressing, several nurses emphasised.

“Surely the level of saturation for taskshifting has been reached?” asked Jules Mugabo Semahore of the WHO in Rwanda.

Against a background of poor SA econo­ mic growth and health service uproars such as the dismissal of community health workers in the Free State, Dr Motsoaledi has to find the budget for both a much higher volume of ARV medication and the extra staff to prescribe and dispense it. He has already achieved a R1 billion increase in this year’s health budget at the expense of other ministries.

“We assessed the level of coverage we need to reduce infection and mortality, calculating the cost implications for 15 years to meet the 2030 target,” he explained. “We didn’t threaten the Treasury economists with death projections because that’s not their language. We outlined the

Gogos (grandmothers), the backbone of AIDS orphan care in SA, speak out at the recent International AIDS Conference in Durban. The photo shows the Stephen Lewis Foundation march. Photo ©International AIDS Society/Marcus Rose

economic impact, how if we do nothing more now, SA will pay dearly later on.

“No economy can expand with a high burden of sick people. The question is always, ‘Can the country afford this?’ We asked, ‘Can the country afford not to?’ We demonstrated that we must be able to mobilise resources now instead of waiting for a greater emergency.”

But the unsettled global economy and growing disenchantment with lack of progress on tackling HIV/AIDS are prompting international donors to withdraw funding for HIV/AIDS programmes, warned Ian SoutheySwartz, Lesbian, Gay, Bisexual, Transgender and Intersexed persons (LGBTI) programme manager of the Open Society Initiative for SA. “Fortunately, SA’s treatment programme doesn’t depend on donor funding, unlike other countries in Africa,” he added. “But we could see collateral damage because community support and prevention programmes will be hit and that might make it even more difficult to reach the 90-90-90 targets.”

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The overall aim is both to reduce the impact of HIV on those already infected and to reduce new infections, ultimately bringing an end to AIDS as a global pandemic by 2030

For more on the DENOSA-endorsed ANAC Call to Action, go to: www.nursesinaidscare.org

TACKLING NCDs WITH HIV/AIDS “Who’s talking about NCD 90-90-90?” asked Tolu Oni, senior lecturer at the University of Cape Town’s School of Public Health and Family Medicine. Multimorbidity was found in almost a quarter of patients at a Cape Town clinic but, unfortunately, the 2002 WHO Innovative Care for Chronic Conditions framework did not touch on this factor, she noted: “We have tended to associate NCDs with certain age groups or life phases but even the 18 - 35-year-olds are showing different hypertension and HIV comorbidity patterns. This highlights how much we still have to discover about the NCD cascade, and as NCDs such as type 2

diabetes increasingly affect adolescents we have an opportunity here to target prevention efforts in an age group where behaviours have not yet been set. We need young adult-friendly services with chronic management involving CHWs”.

Beyond diagnosing NCDs, success in tackling the new HIV/ AIDS co-epidemic also depends on driving adherence through community education and support led by CHWs and avoiding stockouts, says Prof. Wools-Kaloustan. She believes that effective strategies could involve looking at the broader social picture and include integrating medication pickups and monitoring with regular meetings of stokvels and microfinance groups.

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The Role of Workers in Fighting the HIV/Aids Pandemic

by Pule Molalenyane, SAMWU President

The HIV/AIDS pandemic is one that has troubled South Africa, its citizens and government alike. It has undoubtedly become of the greatest challenges facing millions of workers across the world, including South Africa. According to Statistics South Africa, 11.2% or 6.9 million South Africans are living with HIV with the highest prevalence noted for adults aged between 15 and 49 years which is about 17% of the entire population.

One can however not speak about this pandemic without making reference to the country’s high levels of unemployment and poverty. South Africa’s latest unemployment statistics now stand at 26% having reached its all time high of 31.20% in the first quarter of 2003. By broader definition, expanded unemployment is now at 36% with provinces Eastern Cape 44%, North West 43%, Limpopo 38% while both Free State and KwaZulu-Natal are at 39%.

The prevalence of HIV cannot be detached from the social and economic conditions that South Africans find themselves in. This given the fact that the most HIV prevalence is noted in provinces that have recorded high levels of poverty and unemployment. There is thus a good reason to assume that poverty helped hasten the spread of HIV. In some cases, poverty encourages women to engage in sex as an economic strategy for survival. Some of these women are then taken advantage by their clients who refuse to use condoms but the women have to give in to this demand because there is no other means available to them to generate economic activity.

South African workers, through trade unions have fought a bitter battle with the government for policy reforms in the way the government reacted to the HIV crisis in the country. First there was a move from the AIDS denialism, undoubtedly this era of had denialism had cost the country dearly with loss of life that would have otherwise been saved.

As South Africans, we should all bear responsibility for having allowed this late response particularly the government. A response which has resulted in the perpetual cycle of poverty, parentless and child-headed households. For many generations to come there will be thousands of families made up of children only, who will be parentless. There will be orphans begging on the streets of our cities who have lost everything. There will be countless others still traumatised at losing loved ones in a climate of silence and fear.

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In the early 2000s trade unions, in particular COSATU and the Treatment Action Campaign (TAC), through NEDLAC (National Economic Development and Labour Council) sponsored a national HIV treatment plan. This plan involved lobbying government to readily make available Antiretroviral drugs in the public health system particularly given the fact that workers and the working class would not be able to afford these life saving medication.

This plan further involved arguing that although the drugs would be expensive to rollout to the public, the cost-beneďŹ t would be greater for the government and employers and further arguing for the production of a generic drug led by South African Pharmaceutical companies and thus creating jobs in this sector.

The South African job market looses tens of thousands of workers as a result of HIV, this therefore means that a lot of skills are lost and thus employers have to spend more money on re-skilling new employees. It therefore made economic sense for employers to buy into this national treatment plan.

Today, unions are leading the charge in implementing employee wellness programmes in the work-place. As

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SAMWU we frequently encourage our members and municipal workers in general to participate in these programmes as they are intended to ensure that they live a long and healthy life and demystify all negativity and the stigma attached to living with HIV. South Africa has seen great changes, nowadays living with HIV is no longer perceived to be a life sentence. The works of organised labour has surely bore fruits. Recently, the Minister of Health Dr Aaron Motsoaledi announced that government is rolling out programmes that would see those living with HIV being immediately put on Antiretroviral drugs.

Our government has taken more of a proactive stance towards the HIV crisis. The country has seen a drop in new HIV infections which would mainly be attributed to a shift in government policies coupled with employee wellness programmes. The government has been a listening and responsive government on this issue having have increased its budget on the ďŹ ght against HIV. Today most government and recreational facilities along with workplaces are used as distribution points for the freely government issued condoms. As a way of changing lifestyle particularly the youth, government has

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phased out the Choice condoms and has introduced the flavoured Max condoms which according to Deputy President Cyril Ramaphosa provides maximum protection and pleasure.

We should as a country support government initiatives that seek to promote healthier and safe sex practices in particular among female youth. Many HIV/AIDS experts have argued that girls between the ages of 15 and 19 are eight times more likely to contract HIV compared to their male counterparts. Several social studies have attributed this to the sugar daddy phenomenon wherein older men give money to young girls in exchange for unprotected sexual relations.

Not only is this ethically wrong but is in some cases illegal as the law prohibits sexual relations with anyone under the age of 16 irrespective of there being consent or not. This is regarded as statutory rape.

To fight the sugar daddy phenomenon, we should encourage good family values while fathers should ensure that they do everything possible to be present fathers.

As some have argued, not only do these young girls get monitory benefits from this relationships but they also seek affection as most fathers are absent. Men should therefore come together and encourage active and proactive fatherhood.

As we approach the World International Aids Day which is celebrated annually on the 1st December, South Africans should pride themselves in the great strides that have been made in this regard. We further need to reflect on where we are as the working class and acknowledge that there is more that still needs to be done to eradicate the HIV crisis in the country. South Africa hosting the recent World International Conference on HIV should be testament that we have a great role to play, to ensure that we eradicate HIV out of our communities and workplaces.

We should also use this day as a remembrance of the knowns activists and comrades who sadly passed away suffering from HIV. Ours should be to carry the touch and continue with the great work that they have been doing so we realise the government objective of zero new infections and healthier and longer lives for those infected.

SAMWU congratulates and commends all those who stood firm against the the tsunami of denialism and take pride in the thousands of health workers and community health workers who are largely our members for the great work that they have been doing ensuring that they provide quality health care to those who are infected and affected by the HIV crisis. We should further acknowledge the work done by various Non Governmental Organisations who provide care and support to children orphaned as a result of HIV. COSATU and the TAC have undoubtedly played a mayor role in ensuring that South Africans receive quality healthcare, such strides and selfless acts should not go unno-

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ticed. This is one of the greatest achievements that we as the working class should pride ourselves for having have contributed immensely towards.

Had it not been for these interventions, our country would surely be on a brink of collapse as a result of this crisis.

South Africans are now benefitting from the social healthcare programmes of the government on every corner of the country. We will therefore be using our wide network of members and in particular health workers to advance the gains that have been made in this regard and to further do away with the old delusions, and myths that have for so long been attached to HIV. Although there has been great strides and progress in fighting the HIV crisis, we should be honest with ourselves and admit that there is more that still needs to be done. The state of the country’s healthcare needs serious improvements coupled with the retraining of some healthcare workers who do not treat HIV patients with the dignity they deserve. Some medical facilities remain unaffordable for ordinary South Africans, particularly the poor.

It is for this reason that SAMWU calls on our government to fast-track the implementation of the National Health Insurance (NHI). We appreciate the fact that the NHI is now officially government policy but its delay in implementation is disadvantaging South Africans. We are convinced that the NHI would assist government in realising universal healthcare coverage for South Africans.

South African workers should then make an undertaking to mobilise across all sectors and communities for the implementation and rollout of the NHI. We believe that this will help in ending the exorbitant charges levied for healthcare in the country and assist in seeing the end of commodification of the public health in the country.

As the working class, we should strive to recommit ourselves to making an unambiguous and dedicated fight against HIV. We should further take responsibility for ourselves, partners, communities and the workplaces, while not forgetting our class the working class. In addition, there should be strides made to ensure that the high levels of poverty and unemployment are reduced as there is a proven correlation between poverty and HIV. We should further work together as a nation to reinforce sex education particularly in the households. Sex talk can no longer be seen as a taboo, especially given the challenges that we face as a nation.

This is a commitment that SAMWU will proudly champion and preach to our members in the workplace and communities which they live in. We will further be encouraging our members to live healthy and protective sex lifestyles.

After all, prevention is better than cure!

Pule Molalenyane is Chairperson of the South African Local Government Bargaining Council and was elected SAMWU President at its 11th National Congress.

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A BETTER VISION FOR GLAUCOMA

By Leverne Gething

Glaucoma is the leading cause of irreversible blindness worldwide – an invisible disease that can progress so slowly that by the time it is discovered, most of the optic nerve fibres may have been damaged and much of the vision lost.

G

LAUCOMA IS THE ONLY eye disease classified among the legislated 27 chronic disease conditions in SA. It affects 5% to 7% of black persons and 3% to 5% of white persons in the country. However, the good news is that if recognised early, treatment can slow or prevent any further loss of vision.

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According to the South African Glaucoma Society, 50% of glaucoma sufferers worldwide are unaware that they have the disease

Glaucoma refers to a group of disorders that lead to damage of the optic nerve.

While often associated with increased eye pressure, glaucoma may occur with normal eye pressure. It is slowly progressive and leads to irreversible loss of vision, and can result in blindness. If diagnosed and treated early, blindness is preventable. Currently there is no method to prevent or cure glaucoma, although some people are more at risk of developing it than others.

This fluid maintains the structural integrity of the eye and nourishes structures in the eye. In glaucoma these drainage channels either stop working (open-angle type) or get closed (closed-angle type), resulting in elevated eye pressure. As the pressure rises, parts of the optic nerve gradually become damaged. Loss of nerve fibre function is reflected in loss of visual field.

First, the edges of the visual field blur and disappear. As the pressure in one or both eyes rises, it reduces blood supply to the nerves which send messages to the brain. These nerves then begin to fail, and part of the field of vision is lost. If left untreated the damage continues to spread and the view of the world becomes narrower, producing tunnel vision.

Vision loss due to glaucoma can’t be recovered, but if glaucoma is recognised early, it can be slowed or prevented. That is why it is so important that glaucoma is detected as early as possible.

PREVALENCE

TYPES OF GLAUCOMA

WHAT IS GLAUCOMA?

According to the SA Glaucoma Society, 50% of glaucoma sufferers worldwide are unaware that they have the disease. Far more alarming is that this percentage hovers at a staggering 90% in developing countries. It is estimated that 4 out of 50 South Africans over the age of 40 years suffer from the condition.

HOW DOES GLAUCOMA DEVELOP?

Aqueous humour, a clear watery fluid, is continuously produced inside the eye and escapes from it gradually to maintain the pressure inside. It circulates through the anterior segment of the eye and leaves through the drainage channels in the eye.

Glaucoma is classified as one of the following: Primary: which has two subtypes, namely open-angle and closed-angle. In SA, primary open-angle glaucoma (POAG) is the most common type.

Secondary: associated with other ocular problems, which can be open-angle or closed-angle type.

Congenital or developmental: due to malformation of the drainage channels in the eye, is usually evident either at birth or during the first year of life.

SPOTTING EARLY SIGNS

The only way early-warning signs of glaucoma may be recognised is through

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regular eye examinations that include measurements of eye pressure. POAG is not associated with any symptoms and is usually detected during routine eye examinations. Closed-angle glaucoma can also progress silently, but in an acute attack the patient presents with sudden onset of redness, severe eye pain and decreased or cloudy vision, with or without nausea and vomiting. Acute closed-angle glaucoma is a medical emergency and requires immediate treatment.

Glaucoma can present at any age, although POAG usually occurs after the age of 40 years. Males and females are equally affected, and it usually affects both eyes, although it may be more advanced in one.

The following risk factors should be noted and assessed: n high eye pressure (>28 mmHg) – eye pressure increases with age n advanced age – risk increases with increasing age n family history – higher occurrence in relatives of patients affected with glaucoma n ethnicity – more common and more severe in persons of African origin n short-sightedness (myopia) n medical diseases – diabetes, high blood pressure n long-term use of steroids n having ever received a blow to the eye n migraines.

A child who may have congenital glaucoma usually presents with: n a large eye n excessive tearing n abnormal sensitivity in bright light.

Once the disease advances, symptoms are more apparent: n poor sight in dim light n blurring of vision.

PREVENTION

Regular eye testing is the only way to detect glaucoma before it causes damage to sight. A check for glaucoma should be done: n before age 40, every 2 - 4 years n from age 40 to 54, every 1 - 3 years n from age 55 to 64, every 1 - 2 years n after age 65, every 6 - 12 months.

Anyone with high-risk factors should be

tested every year or two after the age of 35.

Patients should go to an optometrist to have their eyes tested and arrangements may then be made for them to visit an eye specialist or eye clinic.

Referral to a physician or GP for general examination will exclude systemic diseases such as diabetes and hypertension, and evaluate for neurological disorders. Diagnosis in children may require exam­ination under anaesthesia in theatre.

TREATMENT

Patients in whom the condition is detected will generally need treatment for the rest of their lives. Evidence from a number of studies has shown that early diagnosis and treatment of intra-ocular pressure (IOP) is effective in delaying or preventing disease progression.

A number of methods have been developed to reduce IOP and these include topical eye drops, minimally invasive laser surgical techniques and invasive surgical procedures.

Topical glaucoma eye drops are very successful in lowering IOP. The drops must be administered daily and the treatment is long term.

The cost of glaucoma medication in terms of inconvenience, side-effects and financial implications for each individual requires careful evaluation. As a listed chronic disease, the patient’s medical scheme or provider not only has to cover medication for glaucoma, but doctors’ consultations and related tests.

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Regular eye testing is the only way to detect glaucoma before it causes damage to sight

LATEST RESEARCH

Stem cells are being investigated as a possible treatment for glaucoma because they may have the potential to protect the optic nerve from further damage and slow the progression of vision loss.

A device that is likely to prevent a great deal of damage is a new iPad app with the capability to screen for glaucoma. This has been introduced into Africa after a study in Nepal funded by the University of Iowa found that the free app, called Visual Fields Easy, is able to screen dozens of patients per hour and detect subtle signs of glaucoma. It does not require a doctor and can alert the user to consult an ophthalmologist when next within range of one.

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OSTEOPOROSIS – BONE-BALANCING ACT

By Leverne Gething

Osteoporosis may only announce its presence when a bone breaks – and if the bone concerned is in the hip or spine, it can have severe consequences. In SA 1 in 3 women and 1 in 5 men will develop this disease in their lifetime.

O “

People often regard osteoporosis as a normal part of the ageing process . . . the reality is that fracture incidence increases exponentially as they grow older.

Prof. Stephen Hough

STEOPOROSIS, WHICH literally means porous bone, is a disease in which the density and quality of bone are reduced, greatly increasing the risk of fracture. Loss of bone occurs silently and progressively, often with no symptoms until the first fracture occurs.

The most common fractures associated with osteoporosis occur at the hip, spine and wrist, and the likelihood of these occurring increases with age in both women and men.

Stephen Hough, emeritus professor of medicine at Stellenbosch University, says that lack of awareness is arguably the single most important neglected area in management of the disease: “People often regard osteoporosis as a normal part of the ageing process and although they may obsess about it around the time of menopause or because a relative has the disease, the reality is that fracture incidence increases exponentially as they grow older.

“Fractures commonly occur in the wrist and spine. People who fracture their hips have a higher death rate (25% - 38%) than those who suffer a heart attack or develop cancer. Perhaps even more disconcerting is that in more than 50% of cases survivors can no longer take care of themselves and have to be institutionalised.”

RISK FACTORS

While anyone can develop osteoporosis, it is more common in older women. In most healthy postmenopausal women marked clinical risk factors are: n advanced age

n a prior fragility fracture n low body weight n family history of osteoporotic hip fracture n smoking n excessive alcohol intake n use of bone toxic substances (harmful chemicals used as food preservatives and flavour enhancers, as well as cadmium and lead) n evidence of inadequate calcium and vitamin D intake.

SYMPTOMS AND DIAGNOSIS

Typically no symptoms are present in early stages of bone loss, but once bones have been weakened by osteoporosis the following symptoms may be seen: n back pain caused by fractured or collapsed vertebrae n loss of height over time n a stooped posture and/or n a bone fracture that occurs much more easily than expected.

Diagnosis of osteoporosis centres on assessment of bone mass and quality through bone mineral density (BMD) scanning.

OPTIMAL TREATMENT

Nowadays osteoporosis is largely treatable and with a combination of lifestyle changes and appropriate medical treatment, many fractures can be avoided.

Bone is living, growing tissue which is also constantly being resorbed as it is being formed. The pathophysiology of osteoporosis is either excessive resorption,

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Physiotherapy can help strengthen bones as well as muscles, help prevent bone thinning and reduce falls

or poor formation – or both. To keep bones strong requires a diet rich in calcium and vitamin D, regular exercise and no smoking. However, Hough says that although lifestyle factors and countermeasures are important, they cannot compensate for established osteoporosis, which requires pharma­ cological medicine. “The effect of calcium and vitamin D on skeletal health, for example, provides only modest protection against bone loss, decreasing risk of fractures by just 12% - 15%, whereas laboratory-developed drugs halve the risk.

If a patient is consuming adequate amounts of dietary calcium, supplementation is not necessary. Up to 700 mg of calcium daily can be safely prescribed if dietary intake is not sufficient.”

Other drugs which form the backbone of osteoporosis management include the bisphosphonates, alendronates and zolendronates that prevent the loss of bone mass. Strontium ranelate also works in patients with lesser degrees of bone loss (where bisphosphonates appear to be less effective) and in the very old (>80 years), but cannot be used in those with poorly controlled hypertension or established heart disease.

The National Osteoporosis Foun­ dation of SA’s integrated approach recommendations for managing osteoporosis in postmenopausal women and men aged over 50 are that when a prior fragility fracture is present, treatment should be considered regardless of the results of BMD measurement. This does not imply that BMD measurements should not be done, since they have a major impact in the management of patients with osteoporosis.

Treatment should be considered when the DXA T-score is ≤–2.5 at the hip or spine, and in those with osteopenia (T-score –1.0 to –2.5) under certain circumstances.

ROLE OF PHYSIOTHERAPY Fractures in the elderly occur not only because the bones are weak, but also because people in this group are prone to falls. Falling is a common problem for people aged 65 years and over.

Physiotherapy can help strengthen bones as well as muscles, help prevent

bone thinning and reduce falls. A physiotherapist can help improve balance in those at greater risk of falling.

When bones in the spine collapse (a compression fracture) this can result in a tremendous amount of pain, which physiotherapy can help manage.

NEW RESEARCH DIRECTIONS

Guidance

and ry Tract Alimentaism Metabol -Formin nd Blood Blood a Organs stem scular Sy Cardiova logicals

Dermato

New research undertaken at the University of Western Australia’s School of Pathology and Laboratory Medicine has found that the two types of cells regulating bone remodelling – bone-resorbing osteoclasts and bone-forming osteoblasts – could also produce small sac-like structures containing MicroRNAs, or information, that could communicate with other cells.

The osteoclasts can send a message to osteoblasts about inhibiting bone growth, so if a way can be found to manipulate this to promote bone growth, it could lead to new osteoporosis treatments.

UCB Pharmaceuticals’ osteoporosis drug romosozumab is the first treatment capable of rebuilding weakened bones, and was discovered by researching a community in SA with abnormally dense bones. Trial results published this year demonstrated a 73% lower risk of vertebral fracture among postmenopausal women with osteoporosis who took romosozumab for a year, compared with a placebo, but investors were disappointed that it failed to show reduction in non-vertebral fractures.

Frail older women may only need a single dose of the bisphosphonate zoledronic acid (Reclast) to build bone strength, another study suggests. However, greater bone density did not translate into fewer fractures among these high-risk women, who were living in nursing homes and assisted-living facilities. The drug improved bone strength in the very old and frail as well as it did in younger and more robust seniors, but there was no association between increasing bone density and reducing fractures.

It is hoped that the US National Institutes of Health, which funded this trial, will fund a larger study to see if treatment with Reclast will actually reduce the risk of fractures.

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PROFESSOR GERHARD WALZL – FORGING A NEW DIAGNOSTIC PATH IN TB

S

Head of Stellenbosch University’s Immunology Research Group, Prof. Gerhard Walzl.

By Lauren Burley Copley

INCE HE WAS A LITTLE BOY, Prof. Gerhard Walzl always wanted to know “how” and “why”. Who could have foreseen that his curious mindset would lead to him playing a key role in developing a rapid diagnostic screening test for TB years later?

Austrian-born Walzl was just 3 years old when he immigrated to SA with his parents.

After doing his MB ChB at the University of Pretoria, he relocated to the Cape to complete his internship at Tygerberg Hospital.

Returning to his birth country for a research fellowship, he specialised first in internal medicine, then in pulmonary medicine at Tygerberg Hospital. Here he enjoyed the human side of his profession, doing interventional and ICU work.

“Several meticulous clinicians inspired me although at least one teaching professor was a terror! They set a great example by really caring about patients,” he recalls.

It was after moving to England to do a PhD in immunology in 1998 that a nurse’s cynical comment proved to be a defining moment in his research philosophy.

“Before ending a stint as locum senior registrar at St Mary’s Hospital in London to start research training, she said, ‘Well, there goes another perfectly good clinician to become a scientist where he’s no good to anyone’. That’s when I realised I couldn’t just do research and write good papers if it didn’t impact on health. I had to consciously focus my work on making a real difference.”

Since returning home in 2002 to start a TB immunology research group at

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Stellenbosch University, he’s made good on his promise. Now heading both the Immunology Research Group and the Division of Molecular Biology and Human Genetics at Stellenbosch University, Walzl has spent the last decade working tirelessly with a team of multi-national scientific collaborators to develop a new rapid pointof-care screening device for TB.

DEVELOPING NEW DIAGNOSTICS

Walzl says the hand-held battery-operated device uses blood obtained from a finger prick to make a TB diagnosis in less than an hour. While the final device is still under development, he and fellow researchers aim to produce “a clinically useful diagnostic tool with a sensitivity rate exceeding 90% within the next 3 years”.

Downplaying his individual role, he says research is “best done in teams”, stressing that the new tool is “the result of many people working in a multinational team”.

Walzl believes in choosing collaborators well and building research networks internationally as well as inside and outside his own institution. It comprises scientific collaborators from five African countries, the London School of Hygiene and Tropical Medicine and Leiden University in Holland.

With an estimated half a million new TB cases and 25 000 to 50 000 people dying from TB in SA annually, Walzl says it’s a “terrible disease that impacts on the poorest in our community”.

Convinced that fighting TB cannot be done in isolation, he’d like to see “even better interaction” between healthcare services, communities and researchers.

Turning to the development process, Walzl says they’ve patented the test’s biosignature and tested it on 700 people, publishing the results in Thorax journal. “This identifies the levels of around 17 inflammatory proteins in a patient’s blood,” he explains.

“We are now fine tuning the signature with the best markers. Our Dutch medical technology experts are helping us turn the test into a point-of-care device. Eventually, the aim is to produce a strip (similar to the dipstick used to test glucose or pregnancy), that will measure the entire biosignature.”

LOW COST, FAST RESULTS, INCREASED CONVENIENCE

If accepted after conclusive clinical trials, he’s confident the test will “decrease the need for more expensive tests that need to be conducted in centralised labs by 70%”. Another benefit is that healthcare workers can do it outside a laboratory with minimal training.

Costing around R37 and with virtually immediate access to results, it will enable patients with TB symptoms to be diagnosed and start treatment in a single visit.

“This will be much more convenient, as patients can avoid long diagnostic delays and won’t have to visit a clinic several times to be diagnosed or get their results,” Walzl remarks.

He stresses though, that as “part of the TB screening algorithm, it isn’t suitable for mass screening or as a stand-alone”.

Instead, it’s aimed at filling the niche in current screening, especially in highincidence remote rural settings with limited resources and poor access to laboratory facilities.

“

With an estimated half a million new TB cases and 25 000 to 50 000 people dying from TB in SA annually, Walzl says it’s a ‘terrible disease that impacts on the poorest in our community’

MODEST MINDSET

Reticent in the spotlight, fellow researchers oblige with their own observations about the humble man behind the microscope.

Describing Walzl as “a caring mentor and great listener”, they praise his willingness to “always listen to other opinions and create an environment for others to excel and develop”.

Together with his strong Christian beliefs, Walzl says his main driving force is his passion for people. The best advice he’s ever received is to “follow your passion, know your strengths and weaknesses and work hard if you want to be successful”.

Protesting against being labelled a “workaholic” by his wife, Walzl insists his love for the outdoors, hiking, jogging and roughing it in a tent in the Okavango Delta is making him “about 70% successful in achieving a good work/life balance”.

With seemingly boundless enthusiasm, his cheerful parting comment before hurrying off to another meeting is that he’s “already evaluating shorter TB drug trials and looking at monitoring treatment response more effectively”.

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40 | Clinician’s View

THE SUFFERING BEHIND THE NUMBERS – RAPE IN SA REQUIRES A SUSTAINED PUBLIC HEALTH RESPONSE

I

AMIR SHROUFI

is the medical coordinator for Médecins Sans Frontières (MSF) in SA. He is a medical doctor and public health specialist who began his career working for NHS in the UK, before joining MSF and working in Pakistan, Ukraine, Lebanon, Zim­babwe and most recently here in SA, where he has worked for the past 3 years.

N 2015 WE UNDERTOOK A household survey of women in Rustenburg, looking primarily at the experience of rape. While we will not have details until the August 2016 national conference on violence, we can already say a few things with certainty, reinforcing the conclusion that much, but not all, research in this area has drawn: rape is very common in SA. In Rustenburg 1 in 2 women have experienced sexual violence of some sort, with 1 in 4 women having been raped in her lifetime. There are over 12 000 rapes each year in this community of around half a million but only a tiny fraction are reported, to either police or healthcare workers.

Attempting legal redress alone is insufficient; the resulting illness and suffering requires a medical and psychosocial response.

Diseases such as HIV, and other sexually transmitted infections, are caused by rape and associated trauma can lead to the loss of pre-existing pregnancy, or to unwanted pregnancy. Many lives are lost, perpetrators often kill their victim and survivors are over four times more likely to take their own life. Psychological suffering from rape can be severe and is widespread; depressive as well as alcohol disorders are five times more common in those who have been raped.

Consider again that the risks above affect 1 in 4 women in Rustenburg and the scale of this problem begins to become clear, but there things that can help.

Antiretrovirals can prevent HIV if given early, antibiotics and vaccination can address other infections, unwanted pregnancy

can be avoided, and with counselling psychological suffering can be reduced.

Sadly most of those who are raped never receive these things.

To address this, government must act to ensure adequate services. This means more trained staff, more clinics able to provide comprehensive services to those who have been raped. The huge burden of psychological suffering among those who have been raped means that counselling and social support needs to be more widely and more consistently available.

Awareness raising is vital, we need campaigns to inform on the availability of care, so that known HIV and other STIs can be prevented, that unwanted pregnancy can be avoided and that through counselling and social support the long-term impacts on a victim’s life can be reduced.

Responses from government and others are necessary but not sufficient to achieve the change needed. Civil society, persistent grass-roots organisations, community groups, churches and other community structures will over many years need to bring about social change, changes to beliefs and behaviours so that all those who are raped seek care, and to ensure fewer rapes occur in future. Those organisations will need long-term funding, from government and donors, to fulfil this work.

Rape is a health issue as well as a legal issue, and places a large burden of ill health upon SA. However, with knowledge of, and access to, quality services, much disease and suffering can be prevented. However, the health system must improve the quality and accessibility of its services.

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