Browsing by Author "Lalloo, Umesh Gangaram."

Now showing 1 - 13 of 13

Clinical and epidemiological aspects of HIV and Hepatitis C virus co-infection in KwaZulu-Natal province of South Africa.
(2008) Parboosing, Raveen.; Lalloo, Umesh Gangaram.
HIV is known to affect the epidemiology, transmission, pathogenesis and natural history of HCV infection whilst studies on the effects of HCV on HIV have shown conflicting results and are confounded by the influence of intravenous drug use and anti-retroviral therapy. This study was conducted in KwaZulu-Natal Province in South Africa where HIV is predominantly a sexually transmitted infection. Intravenous drug use is rare in this region and the study population was naive to anti-retroviral therapy. For this study, specimens from selected sentinel sites submitted to a central laboratory for routine HIV testing were screened for anti-HCV IgG antibodies. HIV positive HCV-positive patients were compared to HIV-positive HCV-negative patients in a subgroup of patients within this cohort in order to determine if HCV sero-prevalence was associated with clinical outcomes in a linked anonymous retrospective chart survey. The prevalence of HCV was 6.4% and that of HIV, 40.2%. There was a significantly higher prevalence of HCV among HIV infected patients as compared to HIV negative patients (13.4% vs. 1.73% respectively). HCV-HIV co-infected patients had significantly increased mortality (8.3 vs. 21%). A significant association was found between HCV serostatus and abnormal urea and creatinine levels. Hepatitis B surface antigen seropo-sitivity was not found to be a confounding factor. This study has found that hepatitis C co-infection is more common in HIV positive individuals and is associated with an increased mortality and renal morbidity.
Community acquired pneumonia in HIV and non-HIV infected patients presenting to a teaching hospital in KwaZulu-Natal : aetiology, distribution, and determinants of morbidity and mortality.
(2004) Nyamande, Kennedy.; Lalloo, Umesh Gangaram.
No abstract available.
The ethical dilemmas of critical care specialists encountered in the admission of patients with HIV infection to intensive care.
(2012) Naidoo, Kantharuben.; Lalloo, Umesh Gangaram.; Singh, Jerome Amir.
South Africa has one of the fastest growing HIV epidemics in the world with 5.6 million people living with HIV/AIDS. As a consequence of the delayed implementation of the ARV rollout and failure to control the epidemic, the number of people living with HIV/AIDS who seek or need intensive care places a huge burden on precious, expensive and sparse intensive care unit facilities. Critical care specialists are faced with complex challenges when making decisions about the provision of such care. Aim: The aim of the study was to develop best practice criteria for admitting HIV-infected patients to intensive care. Methods: The study was done utilising: 1. A comprehensive literature review of the legal and ethical framework governing such decisions in South Africa and compared with that in different countries, both developed and developing. Further, legal precedents and clinical best practice that could inform policy and practice in South Africa were applied to the decision making process. 2. An audit of ICU beds in South Africa by first making a comprehensive and contemporary review of critical care facilities in South Africa, to place in context the ethical dilemmas faced by critical care specialists in the admission of HIV/AIDS infected patients to intensive care in a resource limited environment. 3. Critical care practitioners’ response to a standardised questionnaire regarding ethical decisions and provision of intensive care to five hypothetical clinical case scenarios. Results: The study showed that: The ICU bed availability in South Africa is limited and the problem is worse in the public sector with widespread variations across the provinces. The lack of skilled staff for ICU is insufficient for our needs in the public sector. For people living with HIV/AIDS, specific variables influence their survival in intensive care. The benefits of anti-retroviral treatment in intensive care are still being debated. Clinical prediction tools should be considered as an aid to clinical judgment on decisions about whom to admit to intensive care. Rational decision making should include central questions such as ‘ whether the patient too ill or too well for ICU care’ and whether there is a reasonable prospect of ‘reversibility of organ-dysfunction’? Non-invasive ventilation using a continuous positive airway pressure (CPAP) ventilation mask is showing promise for patients with Pneumocystis jeroveci pneumonia (PJP), especially in a resource-constrained environment. Further studies need to validate this. People living with HIV/AIDS are not discriminated against on admissions to ICU and are not subjected to medical futility decisions. Discussion: The shortage of ICU beds results in critical care specialists being under pressure to deliberate on resource allocation decisions for competing patients. Strong regulatory and ethical frameworks exist to protect the rights of people living with HIV/AIDS and access to intensive care. The ‘Limitation Clause’ of the South African Constitution, as canvassed by the courts resulting in the refusal of renal dialysis in the case of Mr. Subramoney, a utilitarian judgment, would not be justiciable for people living with HIV/AIDS and access to intensive care. The National Health Insurance Plan envisages making more ICU beds available through a public-private sector partnership. There is a compelling need for regionalisation of intensive care services in the country. Respiratory failure in HIV/AIDS patients remains the commonest indication for intensive care unit admissions, and other diagnosis such as non-PCP pneumonia, sepsis, cardiac, gastrointestinal, and renal diseases, are becoming more common. The ART era has seen an improvement in ICU to ward survival rates of 70% (similar to that of the general medical population) as well as the three month and long-term survival outcomes post-ICU discharge. ICU prognostic systems should be regarded as an aid to clinical judgment. Daniels ‘accountability for reasonableness’ provides a moral framework for ethical decision-making and priority setting. In its determined efforts to control the pandemic of HIV/AIDS, some countries, notably Botswana and South Africa are accused of violating international treaties. Conclusion: South Africa has made many legal provisions to protect the rights of its HIV infected patients. People living with HIV/AIDS are neither discriminated against in admission to intensive care units, nor being subjected to medical futility decisions. With the advent of HAART, people living with HIV/AIDS admitted to ICUs, have similar outcomes to that of the general population. Admission guidelines for ICU as advised by the professional bodies for use by the general population should be equally applicable to people living with HIV/AIDS, i.e. is the patient too ill or too well to warrant ICU admission, and is there a realistic prospective of 'reversibility of organ dysfunction'?
A follow-up study of the respiratory health status of automotive spray painters exposed to paints containing isocyanates.
(1997) Randolph, Bernard Winston.; Lalloo, Umesh Gangaram.
In order to evaluate the respiratory health status of spray painters exposed to paints containing hexamethylene diisocyanates (HDI) and to obtain more insight into the relationship between occupational exposures to isocyanates and chronic obstructive airway diseases, a follow up study on 33 of an original cohort of 40 randomly selected workers was undertaken. The original investigation was conducted by the author in 1989. The subjects were studied using a standardised American Thoracic Society (ATS) approved respiratory health questionnaire, baseline pre and post shift spirometry and ambulatory peak flow monitoring. Bronchial hyperresponsiveness tests using histamine (PC20) were performed. Immunological tests including IgE, RAST (HDI), and house dust mite evaluations were also made. The subjects were stratified into exposed (n=20), partially exposed (n=5) and no longer exposed (n=7) groups. One subject was excluded from the group analysis because of his indeterminate isocyanate exposure. Warehouse assistants (n=30) in a non-exposed occupation were used as controls. The worker's compliance with safety regulations and the employers provision of safety requirements was assessed by means of a questionnaire. The environmental conditions in the workplace were measured by the evaluation of the isocyanate concentrations at the worker's breathing zone. Spray booth efficiency was measured using measurements of airflow velocities and airflow patterns within the booth. Longitudinal changes in respiratory health status was assessed by comparison with baseline data studied in 1989. The exposed group showed the largest mean cross-shift declines of 297 ml (± 83.8) in forced expiratory volume in one second (FEV1). The decline in the partially exposed group was 282 ml (± 102.7) and 54 ml (± 140) in the no longer exposed group. The results of the first study, when compared with the second study, showed a mean cross-shift decline in FEV1 of 130.5 ml. (± 203) (p=0.0002) and 297ml. (± 323) (p=0.0001) respectively. Furthermore, of the spray painters examined, 10 (25%) showed clinically significant cross-shift declines in FEV1 viz. decreases >250 ml in the first study (n=40) compared with 9 (45%) in the second study (n=33). In contrast to the HDI exposed spray painters, a closely matched control group (n=30) showed a mean cross-shift increase in FEV1 of 17.4 ml ( ± 63.04). Only 2 subjects had a diagnosis of asthma which was made in childhood and not related to occupation. The mean annual baseline decline in FEV1 was greatest in the exposed group 41.25 ml (25% showed a decline greater than >90 ml per annum). These values exceeded the predicted annual declines for both smokers and non smokers due to age. The decline in the no longer exposed group was 7.85 ml per annum. Immunological tests showed no correlation with declines in FEV1 . This study demonstrates the difficulties in correlating immunological status with clinical and lung function findings in workers exposed to HDI, as a means of predicting occupational asthma. Although measurements in cross-shift declines in FEV1 appear to be a suitable predictor of occupational asthma, in some cases it was found that the forced expiratory flow rate (FEF 25-75 %) was a more sensitive predictor of early changes in the small airways. The mean isocyanate concentration in the spray painter's breathing zone was 14.65 mg/m3 (±12.219), exceeding the current South African Occupational Exposure Limit - Control Limit (OEL-CL) of 0.07 mg/m3 for isocyanates. Fifty per cent of the subjects suffered from eye irritation and 40% had dermatitis of the hand. This was expected since none of the spray painters wore goggles or gloves. Whilst no subject had evidence of clinical asthma related to spray painting, a large proportion demonstrated significant cross- shift changes in lung function implying short- term adverse effects of exposure. In addition longitudinal declines in lung function which was worse in those who continued spray painting in the follow-up study, is of major concern. The lack of cases of clinical or occupational asthma may be due to the healthy worker effect. Recommendations include, routine spirometric lung function testing of all spray painters, the use of high volume-low pressure spray guns and the wearing of positive pressure airline masks complying with the South African Bureau of Standards (SABS) safety standard. In terms of current legislation it was further recommended that spray booths be regularly monitored, including the measurement of HDI concentrations, airflow velocities and airflow patterns within the booth and the implementation and enforcement of stricter control measures. Workers demonstrating excessive declines in both cross-shift and longitudinal spirometry, require special attention.
HIV transmission risk behavior among HIV-positive patients receiving antiretroviral therapy in KwaZulu-Natal, South Africa.
(Springer Science., 2014) Shuper, Paul A.; Kiene, Susan M.; Mahlase, Gethwana.; MacDonald, Susan.; Christie, Sarah.; Cornman, Deborah H.; Fisher, William A.; Greener, Ross.; Lalloo, Umesh Gangaram.; Pillay, Sandy.; van Loggerenberg, Francois.; Fisher, Jeffrey D.
The aim of this investigation was to identify factors associated with HIV transmission risk behavior among HIV-positive women and men receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa. Across 16 clinics, 1,890 HIV? patients on ART completed a risk-focused audio computer-assisted self-interview upon enrolling in a prevention-with-positives intervention trial. Results demonstrated that 62% of HIV-positive patients’ recent unprotected sexual acts involved HIV-negative or HIV status unknown partners. For HIV-positive women, multivariable correlates of unprotected sex with HIV-negative or HIV status unknown partners were indicative of poor HIV prevention-related information and of sexual partnership-associated behavioral skills barriers. For HIV positive men, multivariable correlates represented motivational barriers, characterized by negative condom attitudes and the experience of depressive symptomatology, as well as possible underlying information deficits. Findings suggest that interventions addressing gender-specific and culturally-relevant information, motivation, and behavioral skills barriers could help reduce HIV transmission risk behavior among HIV-positive South Africans.
HIV/AIDS and admission to intensive care units: A comparison of India, Brazil and South Africa.
(Health and Medical Publishing Group., 2013-03) Naidoo, Kantharuben.; Singh, Jerome Amir.; Lalloo, Umesh Gangaram.
In resource-constrained settings and in the context of HIV-infected patients requiring intensive care, value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines. These are often based on individual practitioners’ knowledge and experience, which may be subject to bias. We reviewed published information on legislation and practices related to intensive care unit (ICU) admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV. Each of these countries has legal instruments in place to provide their citizens with health services, but they differ in their provision of ICU care for HIV-infected persons. In Brazil, some ICUs have no admission criteria, and this decision vests solely on the ‘availability, and the knowledge and the experience’ of the most experienced ICU specialist at the institution. India has few regulatory mechanisms to ensure ICU care for critically ill patients including HIV-infected persons. SA has made concerted efforts towards non-discriminatory criteria for ICU admissions and, despite the shortage of ICU beds, HIV infected patients have relatively greater access to this level of care than in other developing countries in Africa, such as Botswana. Policymakers and clinicians should devise explicit policy frameworks to govern ICU admissions in the context of HIV status.
Life threatening haemoptysis : a clinical and radiological study.
(2003) Corr, Peter David.; Lalloo, Umesh Gangaram.
The investigation and management of patients with life threatening haemoptysis is a common clinical problem in South African Hospitals. Establishing the aetiology and origin of the haemorrhage and treating these patients is both difficult and expensive in terms of human and financial resources. The purpose of this study was to identify common local aetiologies for severe haemoptysis, review the investigation and treatment of these patients at Wentworth Hospital, Durban and to formulate a plan of management. Retrospective and prospective studies of consecutive patients treated at Wentworth Hospital were performed. In the prospective study a new embolic material gelatin linked acryl microspheres (embospheres) was used for bronchial artery embolization (BAE). The study demonstrated a change in the spectrum of aetiologies of haemoptysis, from bronchiectasis following tuberculosis to destructive pneumonias. The chest radiograph was always the initial imaging investigation but was found to be inaccurate in detecting the origin of the bleeding. High resolution computed tomography of the lungs (HRCT) was the single best investigation to detect the cause and origin of the haemoptysis. HRCT detected focal bronchiectasis and intracavitatory aspergillomas that were undetected on the chest radiograph. Pleural thickening detected on CT was a good indicator of the presence of transpleural collaterals. The major limitation with HRCT was that it could not be performed if the patient was too dyspnoeic to cooperate during the scan. The role of bronchoscopy appears limited in patients with severe haemoptysis to those patients who are potential surgical candidates. I found that bronchoscopy was not accurate in detecting the source of bleeding in the few patients in which it was performed. Bronchial arteriography remains the gold standard in the detecting the source of haemorrhage. Bleeding sites were detected on angiography in the presence of focal hypervascularity, neovascularity and the presence of broncho-pulmonary shunts. Bronchial arteries were hypertrophied in bronchiectasis but were normal in size in some patients who had acute pneumonias. Bronchial artery embolization was the treatment of choice for severe haemoptysis in the patients studied. The use of gelatin cross linked micro spheres has significantly improved the initial success rate following the procedure with less complications compared to the use of polyvinyl alcohol particles (PVA). It is important to identify systemic transpleural collaterals at arteriography and to embolize them to reduce recurrent haemoptysis. Patients with aspergillomas responded well to embolization. Recurrent haemoptysis remains the major limitation of BAE but is reduced with the use of micro spheres as embolic agents and thorough embolization of systemic collaterals on the affected side. Surgical resection was an option for a limited number of patients with focal disease in one lung and good respiratory reserve. The major limitation of the study was the absence of long term follow up to detect those patients with late recurrent haemoptysis.
Metabolic complications of antiretroviral therapy (ART) in a South African black population..
(2014) Magula, Nombulelo Princess.; Lalloo, Umesh Gangaram.; Motala, Ayesha Ahmed.
Aims To determine the prevalence and incidence of lipodystrophy (fat distribution [lipoatrophy and lipohypertrophy] and metabolic complications [insulin resistance-dysglycaemia and dyslipidemia]) in HIV-1 infected adult subjects of second generation Zulu descent at baseline and during 24 months of follow-up on antiretroviral therapy (ART). Methods The total study group included three groups: HIV infected ART naive patients eligible for ART (HIV-ART, n=150), age, gender and ethnically matched HIV infected not eligible for ART (HIV-no ART, n=88) and HIV negative (control, n=88) subjects. All participants had demographic, anthropometric, biochemical and radiological assessments at baseline; in addition, the HIV-ART group had follow-up assessments for 24 months on ART (tenofovir, lamivudine and nevirapine or efavirenz). Fat distribution was assessed using FRAM questionnaires, computerized tomography (CT) scans and dual energy absorptiometry X-ray (DXA). Disorders of glycaemia (diabetes mellitus (DM), impaired glucose tolerance and impaired fasting glucose) were defined using WHO criteria. Total, LDL, HDL cholesterol and triglycerides were measured for each group; CD4 cell count and HIV RNA for group 2 and 3, at baseline, 3, 6, 12, 18 and 24 months. Poisson approximations estimated incidence of disorders of glycaemia. Results At baseline, when compared with the control group, the mean BMI (kg/m2) was significantly lower in the HIV-ART and HIV-no ART subjects (26.4 vs. 28.6 vs. 29.1; p =0.01). Prevalence of lipoatrophy as measured by participant and physician examination questionnaires was similar in the three groups. Visceral and subcutaneous fat area by CT scan were similar between the groups but limb and trunk fat mass by DXA scan was significantly lower in the HIV-ART compared to control subjects. In the HIV-ART group, at the 24 month follow-up, there was a significant mean reduction in HIV RNA (p<0.0001) and increase in CD4 cell count (p<0.0001). The mean BMI increased to 29.4 kg/m2 and no lipoatrophy developed; DXA scan showed a 33.6% increase in trunk fat mass (mean difference 4.2 kg, p <0.0001) and 30.8% increase in total fat mass (mean difference 9.4 kg, p < 0.0001); visceral (p 0.005) and subcutaneous (p 0.0002) fat area also increased. At baseline, the prevalence of DM was 0% in HIV-ART and HIV-no ART and 4.9% in control subjects (p 0.005); the prevalence of “any dysglycaemia” was 3.7% in HIV-ART and HIV-no ART compared to 8.6% in control subjects. When compared with group 1, mean values in group 3 were lower for the following serum lipids: total cholesterol (p<0.0001), LDL (p=0.0007) and HDL (p<0.0001). There was no difference in mean total triglycerides in the three groups (p=0.3). During follow-up, in the HIV-ART group, using glucose-based WHO criteria, the incidence of diabetes mellitus was 2.3 per 100 person year follow-up (PYFU) and of “any dysglycaemia” 7.6 per 100 PYFU. The only independent predictor of DM was visceral: subcutaneous fat ratio measured by CT scan (HR 2.95 [95% CI 1.25-6.98], p 0.01). Significant predictors for development of “any dysglycaemia” included systolic blood pressure (HR 1.04 [95%CI 1.02-1.07], p=0.0006), serum albumin (HR 0.85 [95% CI 0.76-0.94], p=0.002), CD4 cell count (HR 0.988 [95%CI 0.978-0.997], p=0.01) and efavirenz (HR 6.27 [95%CI 1.65-23.80], p=0.01) Serum total (p<0.0001), LDL (p<0.0001) and HDL-cholesterol (p<0.0001) increased significantly during follow-up. Conclusion: In this cohort of South Africans with HIV-1 infection, at baseline (prior to ART) there was no significant fat redistribution or lipoatrophy and an absent to low prevalence of dysglycaemia. In the follow-up study, ART use was not associated with lipoatrophy although there was significant increase in BMI and in limb and trunk fat mass by DXA scan. ART was associated with increased incidence of dysglycaemia. These findings underscore the importance of clinical monitoring on ART. The association of efavirenz with dysglycaemia warrants further evaluation.
A pilot study of once-daily antiretroviral therapy integrated with Tuberculosis directly observed therapy in a resource-limited setting.
(Lippincott Williams & Wilkins., 2003) Jack, Christopher.; Lalloo, Umesh Gangaram.; Abdool Karim, Quarraisha.; Abdool Karim, Salim Safurdeen.; El-Sadr, Wafaa M.; Cassol, Sharon.; Friedland, Gerald H.
To determine the feasibility and effectiveness of integrating highly active antiretroviral therapy (HAART) into existing tuberculosis directly observed therapy (TB/DOT) programs, we performed a pilot study in an urban TB clinic in South Africa. Patients with smear-positive pulmonary TB were offered HIV counseling and testing. Twenty HIV-positive patients received once-daily didanosine (400 mg) plus lamivudine (300 mg) plus efavirenz (600 mg) administered concomitantly with standard TB therapy Monday to Friday and self-administered on weekends. After completing TB therapy, patients were referred to an HIV clinic for continued treatment. At baseline, patients had a mean CD4 count of 230 cells/mm3 (range: 24–499 cells/mm3) and a mean viral load of 5.75 log10 (range: 3.81–7.53 log10). Seventeen completed combined standard TB and HIV therapy; 16 of 20 (80%) patients enrolled and 15 of 17 (88%) patients completing standard TB therapy achieved a viral load <50 copies/mL and mean CD4 count increase of 148 cells/mm3. TB was cured in 17 of 20 (85%) enrolled patients and 17 of 19 (89%) patients with drug-sensitive TB. Treatment was well tolerated, with minimal gastrointestinal, hepatic, skin, or neurologic toxicity. The project was well accepted and integrated into the daily TB clinic functions. This pilot study demonstrates that TB/DOT programs can be feasible and effective sites for HIV identification and the introduction and monitoring of a once-daily HAART regimen in resource-limited settings.
Respiratory health survey in an Indian South African community : distribution and determinants of symptoms, diseases and lung function.
(1992) Lalloo, Umesh Gangaram.; Seedat, Yakoob K.; Becklake, Margaret.
A cross-sectional epidemiologic survey of the respiratory health status was conducted in the adult (15 years and older) Indian South African population resident in Lenasia, Johannesburg to study the distribution and determinants of respiratory symptoms, disease and lung function level. A slightly modified self-administered version of a standardised respiratory health questionnaire and a wedge spirometer was used. There were a high proportion of current smokers among men. Although women smoked less than men in other communities they nevertheless smoked on average more heavily than other Indian South African women. Indian men and women who smoked had a high prevalence of respiratory symptoms. The women also demonstrated an increased susceptibility to the effects of cigarette smoking when compared with women in other communities. Indians in this study had spirometric lung function levels that were lower than that recorded in recent studies in Blacks and Whites in South Africa. Respiratory symptoms, disease and lung function level were examined in a multiple logistic regression model which contained all the potential determinants recorded in the present study. Voluntary tobacco smoking, recent chest illnesses and any kind of heart trouble was associated with a significant risk for having most of the respiratory symptoms and diseases in men and women. In addition exposure to dust in the work environment, little or no exercise,>Std. 8 education a history of any kind of chest trouble and respiratory trouble before the age of 16 years was associated with an increased risk for having respiratory symptoms in men in this model. An increased risk for respiratory symptoms was demonstrated in women only with age. Age and standing height were the most important determinants of lung function level in men and women in the regression model. Dust exposure in the work environment was associated with a significantly lower lung function level in men. Alcohol consumption and a history of whooping cough was also independently associated with a lower lung function level in men but were of borderline significance. In women involuntary /passive tobacco smoke exposure and respiratory trouble before the age of 16 years were associated with a lower lung function level. Women who spent most of their lives in a rural area and those who had a university education had a higher lung function level. The deleterious effects of smoking on lung function were minimal in this study possibly because lung function was performed only in subjects in the 18-45 year age category. A "healthy smoker" effect was demonstrated in men. Men who ever smoked and were without cardiorespiratory symptoms had significantly higher lung function levels compared to men who never smoked and were without symptoms.
Survey of ethical dilemmas facing intensivists in South Africa in the admission of patients with HIV infection requiring intensive care.
(Health & Medical Publications Group., 2013) Naidoo, Kogieleum.; Singh, Jerome Amir.; Lalloo, Umesh Gangaram.
Background. Maturing of the burgeoning HIV epidemic in South Africa has resulted in an increased demand for intensive care. Objectives. To investigate the influence of ethical dilemmas facing South African intensivists on decisions about access to intensive care for patients with HIV infection in resource-limited settings. Methods. A cross-sectional, descriptive, quantitative, analytical, anonymous attitudes-and-perception questionnaire survey of 90 intensivists. The main outcome measure was the rating of factors influencing decisions on admission to intensive care and responses to 5 hypothetical clinical scenarios. Results. The number of intensivists who considered the prognosis of the acute disease and of the underlying disease to be most important was 87.9% (n=74). Most (71.6%; n=63) intensivists cited availability of an intensive care unit (ICU) bed as influencing the decision to admit. Intensivists comprising 26.8% (n=22) of the total group rated as probably important or least important the ‘resources available’; ‘bed used to the prejudice of another patient’ was stated by 16.4% (n=14); and ‘policy of the intensive care unit’ by 17% (n=14). Nearly two-thirds (65.9%; n=58) would respect an informed refusal of treatment. A similar number would comply with a written ‘Do not resuscitate’ (DNR) order. In patients with no real chance of recovering a meaningful life, 81.6% (n=71) of intensivists would withhold sophisticated therapy (e.g. not start mechanical ventilation or dialysis etc.) and 75.9% (n=63) would withdraw sophisticated therapy (e.g. discontinue mechanical ventilation, dialysis etc.). Conclusions. A combination of factors was identified as influencing the decision to admit patients to intensive care. Prognosis and disease status were identified as the main factors influencing admission. Patients with HIV/AIDS were not discriminated against in admission to intensive care.
Tuberculosis in medical doctors in KwaZulu-Natal, South Africa : personal experiences and perceptions related to their diagnosis and treatment.
(2011) Naidoo, Ashantha.; Lalloo, Umesh Gangaram.
Title: Tuberculosis in medical doctors in KwaZulu-Natal (South Africa): Personal experiences and reflections related to their diagnosis and treatment. Background: The high tuberculosis (TB) incidence and prevalence fuelled by the concomitant HIV epidemic in South Africa has resulted in a high rate of tuberculosis infection in health care workers. This is the first study to investigate the experiences and reflections of doctors who were diagnosed with active TB during their employment in high TB burden hospitals in KwaZulu-Natal, South Africa. Methods: Consecutive medical doctors working in both the public and private sectors and who were treated for active tuberculosis between 2007 and 2010 were contacted to participate in the study. Each participant completed an informed consent and a validated anonymous self-administered questionnaire. The study received ethical approval from the University of KwaZulu-Natal. Results: Forty doctors participated in the study. The mean age of participants was 33.67±10.63 years. The majority were between 21 and 40 years of age (males (52.5%), and employed in the public sector (95%). Four (10%) had MDR-TB. A number of participants were referred for costly special investigations which are not considered to be part of first line care in South Africa. For example, 15 participants (37.5%) underwent chest CAT scans during the diagnostic period. Eight doctors reported complications following invasive procedures. Nineteen (47.5%) of the 33 participants (82.5%) who had experienced sideeffects related to anti-TB drugs had considered defaulting on their treatment because of the side-effects of these drugs. Many participants expressed concerns about the uncaring attitudes of senior medical colleagues and hospital management. The majority of participants had introspected on their illnesses and experiences and committed themselves to become more caring and empathic towards their patients in future. Conclusions: All health care workers and particularly nurses and medical doctors working in environments with a high burden of infectious diseases such as HIV and TB, are at increased risk to TB infection. They encounter various personal and professional problems following contraction of TB infection. These experiences had impacted in many ways on their professional lives, and some doctors have since left the medical profession because of these experiences. The risks associated with TB must be minimised. Much more therefore remains to be done in the public health care system if these trends are to be reversed; this includes health policy changes, health system changes and attitudes of medical colleagues towards medical doctors who become “victims of illnesses acquired in the course of duty”.
Utility of Tuberculosis directly observed therapy programs as sites for access to and provision of antiretroviral therapy in resource-limited countries.
(The Infectious Diseases Society of America., 2004) Friedland, Gerald H.; Abdool Karim, Salim Safurdeen.; Abdool Karim, Quarraisha.; Jack, Christopher.; Gandhi, Neel R.; El-Sadr, Wafaa M.; Lalloo, Umesh Gangaram.
The overwhelming share of the global human immunodeficiency virus (HIV) infection and disease burden is borne by resource-limited countries. The explosive spread of HIV infection and growing burden of disease in these countries has intensified the need to find solutions to improved access to treatment for HIV infection. The epidemic of HIV infection and acquired immune deficiency syndrome (AIDS) has been accompanied by a severe epidemic of tuberculosis. Tuberculosis has become the major cause of morbidity and mortality in patients with HIV disease worldwide. Among the various models of provision of HIV/AIDS care, one logical but unexplored strategy is to integrate HIV/AIDS and tuberculosis care and treatment, including highly active antiretroviral therapy, through existing tuberculosis directly observed therapy programs. This strategy could address the related issues of inadequate access and infrastructure and need for enhanced adherence to medication and thereby potentially improve the outcome for both diseases.