Antiretroviral therapy (ART) for HIV/AIDS in developing countries has been rapidly scaled up through directed public and private resources. Data on the efficacy of ART in developing countries are limited, as are operational research studies to determine the effect of selected nonmedical supportive care services on health outcomes in patients receiving ART. We report here on an investigation of the delivery of medical care combined with community-based supportive services for patients with HIV/AIDS in four resource-limited settings in sub-Saharan Africa, carried out between 2005 and 2007. The clinical and health-related quality of life (HRQOL) efficacy of ART combined with community support services was studied in a cohort of 377 HIV-infected patients followed for 18 months, in community-based clinics through patient interviews, clinical evaluations, and questionnaires. Patients exposed to community-based supportive services experienced a more rapid and greater overall increase in CD4 cell counts than unexposed patients. They also had higher levels of adherence, attributed primarily to exposure to home-based care services. In addition, patients receiving home-based care and/or food support services showed greater improvements in selected health-related QOL indicators. This report discusses the feasibility of effective ART in a large number of patients in resource-limited settings and the added value of concomitant community-based supportive care services.

Emergency centres (ECs) provide emergency care to people with acute trauma and illness who require the services and expertise available at a hospital.1 However, the presenting complaints at an EC overlap considerably with those encountered at primary healthcare (PHC) level.2 Studies suggest that one-third to two-thirds of patients attend ECs with problems that could have been managed at a PHC level. 2-5The South African Triage Score (SATS) (previously known as the Cape Triage Score) 6-7 is routinely used at George Provincial Hospital to triage patients presenting to the EC to determine their acuity level and prioritise them accordingly. The five categories are red (immediate care), orange (very urgent care), yellow (urgent care), green (routine care) and blue (dead).A retrospective descriptive study at George Hospital in May 2010 to determine the after-hours case mix and workload 8 demonstrated that 65% of patients who presented to the EC after-hours were triaged green. This demonstrated that many low-acuity patients are seen in the EC. From the perspective of service delivery this 'inappropriate' attendance is problematic, as it competes for the attention of EC staff and potentially compromises the quality of care for more serious cases needing urgent treatment. A need was identified to determine the patient-specific reasons for presenting to a secondary hospital EC with PHC problems. MethodsGeorge Hospital is a secondary (level 2) provincial hospital in the Western Cape province of South Africa, providing healthcare to the population of the Eden and Central Karoo districts. The population numbers about 512 000, of whom about 140 000 live in George. 9 The health needs of the George community are served by 10 PHC clinics, a few mobile clinics, private practitioners, the private Mediclinic and George Hospital. There is no district hospital in the George subdistrict, and the PHC clinics offer no after-hours services. Everyone requiring healthcare after-hours, over weekends and on public holidays must therefore access the EC at George Hospital or use the private sector.The study was conducted between 5 March and 5 April 2012. A validated questionnaire 10 was refined to our setting after conducting a pilot study which included 30 patients.Convenience sampling was used. The SATS was used to identify all patients triaged as green. A questionnaire was then placed in the patient's folder by the nurse practitioner who did the triaging. The doctor who subsequently saw the patient obtained informed written consent from the patient. The duration of the presenting complaint, the referral source and whether the referral was appropriate were obtained. An inappropriate referral was considered to be a patient who was not admitted, did not need a procedure or special investigation, or was not referred to a specialty. The patient was then asked to select his or her two or three main reasons for attending the EC from a list of 17 options.Data were captured and analysed using Microsoft Excel 2003 software. Data were mainly descripti...

Introduction.Computed tomography (CT) and magnetic resonance imaging (MRI) are an essential part of modern healthcare. Marked increases in clinical demand for these imaging modalities are straining healthcare expenditure and threatening health system sustainability. The number of CT and MRI scans requested in the Eden and Central Karoo districts of the Western Cape Province, South Africa (SA), almost doubled from 2011 to 2013. Objective. To determine the appropriateness of CT and MRI scans and relate this to the requesting department and clinician. Methods. This was a retrospective analytical cohort study. All scans during October 2012 were analysed as a sample. Appropriateness of scans was determined using the American College of Radiologists (ACR) Appropriateness Criteria and the Royal College of Radiology Guidelines. Appropriateness was also correlated back to the requesting department and clinician. Results. Of a total of 219 scans, 53.0% were abnormal. Overall 6.4% of scans were considered inappropriate. Interns and registrars requested no inappropriate scans. The orthopaedics department scored the highest rate of appropriate scans (80.0%) and the oncology department the highest rate of inappropriate scans (20.8%). Conclusion. The limited resources available for healthcare in a developing country like SA should be a motivation to implement control mechanisms aimed at appropriate utilisation of imaging examinations. The Eden and Central Karoo districts have a low rate of inappropriate scans (6.4%). We recommend that the current preauthorisation system by consultants and other senior clinicians continues, but with increased clinician awareness of the ACR Appropriateness Criteria and the Royal College guidelines.

There is a world-wide increase in the incidence of cutaneous malignant melanoma among white people. Absence of accurate population-based data on the incidence of melanoma in South Africa prompted a study to determine the incidence, anatomical sites and pathological details of melanoma in Cape Town. In a prospective study from 1 January 1990 to 31 December 1995, all the histopathology reports of melanoma presenting in a geographically defined area of Cape Town, were actively retrieved from every pathologist practising in this area. The data evaluated included information on age, sex, ethnic group and location of residence. Details of melanoma comprised body site, Clark level of invasion, Breslow thickness in millimetres and histogenetic type. The histology slides were reviewed by a panel in those cases where the recorded information was ambiguous or incomplete. A final number of 595 reports of primary invasive cutaneous melanomas in white people was analysed. Of these 50.3% were men and 49.7% women. The overall age-standardized incidence rate was 24.4 per 100,000 per annum (27.5 for men and 22.2 for women). There was no change in the incidence rate over the study period. Most melanomas in both sexes (74% of women and 71% of men) were < 1.5 mm Breslow thickness. Results of this study indicate a high incidence rate of melanoma in white South Africans, comparable with that in Australia, which demands urgent preventive health measures.