Introduction: Human Immunodeficiency Virus remains as one of the largest pandemics in the world, with the prevalence of more than 70% of HIV-infected individual reside in Sub-Saharan Africa. Moreover, other sexually transmitted viral infection such as Human Papillomavirus and Herpes Simplex Virus also show a high prevalence in Sub-Saharan Africa. Recent studies show the presence of other viral STI in the genital region may have increased HIV shedding in the genital region. However, it not clearly known if the presence of ART or HIV may affect the shedding of other viral STI in the genital region and if the combination of other viral STI treatment and ART is necessary to treat an individual with multiple STI infection. Methods: This is a secondary data analysis study, based on analysing the data collected from a single-site, double-blinded randomized control study (2-IUD study). The research site was the Gugulethu Community Health Centre, Cape Town, South Africa and samples were collected between 2014 and 2018. Analysis was conducted on genital tract specimens of study participants obtained via the Menstrual Cup (MC) and Endocervical Swabs (ECS), collected at baseline, 3 and 6 months’ follow up visit from randomly selected 52 ART-Naïve participants and 56 age-matched women from the ART-Using group of the primary study. Logistic regression models were constructed to measure the associations between possible risk factors and viral STIs. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results: ART-Naïve women had higher rates of HIV shedding in the genital tract at each visit. However, more than half of women using ART, most of them virally suppressed, had detectable genital HIV at one or more visits. Most of the participants showed pre-exposure to HSV-2, but shedding of HSV-2 was substantially less common. HPV was detected in 72% of the participants, with no significant difference by ART status. Overall, 70.3% of samples had at least one viral pathogen detected - 60.4% among ART-Using women compared to 82.8% in ART-Naïve women (P<0.001). Compared to ART-Naïve women, ART-Using women were significantly less likely to have co-occurrence of viral shedding overall. However, ART-Using women with higher VL had levels of viral co-occurrence similar to those of ART-Naïve women. Conclusion: Our analysis demonstrated that the ART-Using women were less likely to shed HIV, HSV-2, HPV and viral STI co-infection in the genital tract compared to ART-Naïve women. This may be be driven by plasma VL levels where ART-Using women with lower VL are less likely to shed these viruses compared to women with elevated VL, including those not on ART.

Background: The tension between the increasing cost of healthcare provision and the need to provide a quality level of care to a rising number of people is a global phenomenon. A focus on one over the other could result in a rise in adverse patient outcomes, or a health system too costly to be sustainable. Clinical governance is an approach policymakers can use to walk the middle line of creating a healthcare service that meets quality of care standards in a cost-effective manner, as has been done in Australia, Burundi, Egypt, Spain, UK and Yemen (Goyet et al, 2019; Abd El Fatah et al, 2019, Mannion et al, 2015; Aguilar Martin et al, 2019). This study examines the practice of clinical governance in one LMIC setting that has been able to successfully do this balancing walk for 20 years. Understanding how this was done in the Western Cape province of South Africa helps inform how clinical governance can be used to continue adding value as the health system moves towards universal healthcare. In addition, this South African experience adds to the still small pool of relevant experience from low- and middle-income countries reported in the international literature. Methods: A mixed methods qualitative design was used for data collection and involved three phases: (1) a document review of all policies in the province to identify clinical governance structures; (2) observation of these structures in action, comparing lived to written experience of clinical governance; and (3) interviews with key stakeholders in the province to get their perspectives on past, present and future forms of clinical governance. The Donabedian model was used to frame analysis into three dimensions of care, viz. structure, process and outcome. Results: Beyond a comprehensive policy framework, collaborative structures and consultative leadership styles facilitated strengthened clinical governance in the Western Cape. For example, although corporate-governance-inspired structures, such as clinical audits and M&E events, may become punitive and corrosive, the potential negative impact on clinical governance outcomes and organisational culture was tempered by healthy communication and supportive relationships between colleagues. Family physicians have become the champions of clinical governance in a decentralized health system and when supported in this by policy and management, the quality of care in health systems thrive. Conclusions Clinical governance is an effective strategy or tool LMICs can use to ensure quality of care is maintained or improved upon, even in resource-challenged settings. But while some structures, processes and outcomes may be borrowed from other LMIC or HIC settings, these need to be contextualized to local conditions. Appropriate clinical governance champions need to be identified and given the appropriate mandate. Human relationships are key to the successful implementation of interventions of this nature and space needs to be created in policy for this to be cultivated.

Current international guidelines recommend that a cranial computed tomography (CT) be performed, on all HIV positive patients presenting with new onset seizures, before a lumbar puncture (LP) is performed. In the South African setting, however, this delay could be life threatening. This study sought to measure the number of cranial CTs that contraindicate an LP and to predict which clinical signs and symptoms are likely to pose an increased risk from LP. Methods: The study was performed at a district level hospital in the Western Cape. Data was collected retrospectively from October 2013 to October 2014. Associations between categorical variables were analysed using Pearson's Chi-squared test. Generalised linear regression was used to estimate prevalence ratios. Results 100 out of 132 patients were studied. Brain shift contraindicated an LP in 5% of patients. Patients with brain shift presented with: decreased level of consciousness, focal signs, head ache and neck stiffness. 25% of patients had a space occupying lesion (defined as a discreet lesion that has a measurable volume) or cerebral oedema. Multivariate analysis showed a CD4 count < 50 (p=0.033) to be a statistically significant predictor of patients with a space occupying lesion (SOL) and cerebral oedema. Univariate analysis showed focal signs (p=0.0001), neck stiffness (p=0.05), vomiting (p=0.018) and a GCS<15 (0.002) to be predictors of SOL and cerebral oedema.

Includes bibliographical references (leaves 93-97). / African traditional healers are themselves "patients" in the modern bio-psycho-social health system. Their "frameworks of meaning" of biomedical diseases provides a glimpse of the "voice of the lifeworld" of the patients who interact both with them and the modern allopathic health services. The main objective of this study was to ascertain African traditional healers' understanding of and beliefs about the medical conditions under discussion in the doctor-patient interaction to which they silently listen.

Includes bibliographical references (leaves 97-102). / To determine if a basic Xhosa course for non-Xhosa-speaking Health Care Workers, working in Primary Health Care Centres in Cape Town improves patient satisfaction for Xhosa-speaking patients, their perceived ability to communicate effectively with Xhosa-speaking patients, and job satisfaction levels.

Background: Globally, type 2 diabetes (T2D) is a significant cause of avoidable mortality and morbidity. It is a major risk factor for cardiovascular disease (CVD). Evidence-based guidelines lower cardiovascular risk in diabetics. Adherence to clinical guidelines for the prevention of CVD in South African primary care public sector facilities is unknown. Aim: This study determined adherence of Cape Town primary care clinicians to recommended clinical guidelines for the prevention of cardiovascular disease in T2D. Methods: This 2013 cross-sectional study extracted data from 300 folders of known T2D patients sampled from three Community Health Centres (CHCs). Compliance with guidelines, and patient demographic factors were analysed. Results: Most (71% or 194/273) hypertensive diabetics were appropriately managed with first-line- medication - an Angiotensin Converting Enzyme Inhibitor (ACEI). There was appropriate supporting documentation for only 39% not on first line therapy. A fifth (22%) with drug intolerance received the recommended alternative. Most were appropriately prescribed a statin (74%) and aspirin (69%). Other cardiovascular risk factors were poorly controlled: mean weights were in the obese range (BMI=31.3 [SD: 5.7]); the mean total cholesterol level was 5.5 (SD: 1.4); there was incomplete data for smoking (19% had no record) and 93% had no record of a family history of CVD. Conclusions: Whilst pharmacological interventions for the prevention of CVD were moderately implemented, patient factors – such as obesity and smoking were poorly addressed. Improving documentation, adherence to recommended clinical guidelines and, health promotion to address modifiable risks are required to improve quality of care for T2D.

Objectives: This study aimed to research efficacy and safety of procedural sedation and analgesia (PSA) administered by medical officers (MOs), without formal anaesthetic training, in a South African district hospital. Design: This is a retrospective descriptive study. Setting: The study took place in the Emergency Department (ED) of False Bay Hospital (FBH), a level one hospital in the Southern suburbs of the Cape Town Metro health district.

Includes bibliographical references. / Continuity of care (COC) is a fundamental concept in Family Medicine. The rollout of antiretrovirals in the primary care setting of the public health care system in South Africa was 'vertically' isolated from the other clinics. This isolation provides a rich environment to research COC. The present project describes the longitudinal COC in the Ubuntu ART/TB Clinic in Site B, Khayelitsha, which is one of the oldest clinics with a total of 6000 patients on ARVs since May 2001. An observational period of the last five visits of patients to the clinic was used to measure the COC as a simple Continuity Fraction (CF)(alternatively called the Usual Provider Continuity/UPC), which was compared with more complex formulas for measuring COC including the K-index, SECON, COC-index and Alpha-index. The nature of the appointments was also explored, in terms of whether the patient was attended to by a nurse or a doctor and whether it was a proxy visit. Since viral loads are a very good indicator of adherence, they were compared to the COC over the observation period of the last five visits. The data showed a nurse-driven clinic achieved a CF below 50% (0.5). The 0.5 COC score seems to be a benchmark for good COC, yet it is difficult to statistically verify. The CF scored higher than the other COC formula scores, yet correlated well with other COC formulae. The CF scores with nurses were more positively related to better virological outcomes than the other COC formulae, though none were statistically significant. Unscheduled and proxy visits were not associated with higher VLs. The statistical test of General Linear Modelling with Poisson Regression with robust error variance could be an alternative way of proving that better COC has a measure of impact on the outcomes. Due to the different role of doctors, doctor visit(s) resulted in higher sequentiality scores, but a decrease in suppressed VL. These COC scores also do not completely explain the good virological outcomes in this clinic, which is considered a well managed public sector clinic in Khayelitsha. The CF places a simple tool in the hands of a clinician at the primary level to measure individual provider continuity; however there is need to test its reproducibility in other contexts of chronic care in order to develop standards. The K-index emerged as a simple measure of the dispersion of the longitudinal COC within the nurse team managing the stable chronic patient. In a broader perspective, this study has put the measuring of COC onto the 'radar' of the public health system in South Africa.

Globally, Tuberculosis remains a devastating disease, despite the availability of treatment. The disease is associated with poverty, and those with the disease incur a high cost of accessing care, while simultaneously experiencing income loss due to a loss in productivity. A key challenge in TB programmes remains the accurate diagnosis of the disease, especially in people who are HIV positive. Diagnosing TB can be very resource intensive and the accuracy of diagnosis is dependent on a range of disease, health service organisation and provider behaviour factors. This thesis seeks to enhance understanding of how the behaviour of healthcare workers mediates the value of TB diagnostic algorithms, and how this may affect the costs, outcomes as well as the economic burden associated with the disease in South Africa. The work presented is based on empirical work done alongside a pragmatic cluster randomized control trial. Empirically, it examines the longitudinal economic burden of TB diagnosis and treatment in South Africa. The discrepancies between the time at which patients incur the greatest cost and income loss, and the available social protection are highlighted. Based on empirical work, a purpose-built state-transition mathematical model of TB diagnosis and treatment was developed to estimate the cost-effectiveness, from the perspective of the health service and the patient, of health systems interventions to strengthen TB diagnosis. Recognising healthcare workers as those who ultimately express policies, the behaviour of healthcare workers was included in the cost-effectiveness analysis by 1) using data from a pragmatic trial reflecting routine practice and clinical decision-making at the time of the study; 2) developing a conceptual framework of the relationship between behaviour at decision points and disease outcomes; and 3) investigating how these interactions may influence the value of the diagnostic algorithm. Possible public policy levers to improve TB diagnosis in healthcare facilities, as well as the potential mediators of costs and effects were explored. The thesis concludes with recommendations for further methodological work to expand on the approach explored in this thesis to improve how heterogeneity in estimates of cost-effectiveness is presented to decision-makers.

Introduction: Over the past few years, the capacity of the government of Mozambique to sustain the cost of payment of salaries to operationalize the Indoor Residual Spray (IRS), a widely recommended tool to control and prevent malaria, is facing numerous challenges. This is due to recent restrictions of the Official Development Assistance (ODA), an external aid scheme and the main source of financing of the Mozambican government budget. Objective: The objective of this study was to estimate the cost of IRS operationalization activities in Matutuine and Namaacha districts health directorates, in Maputo Province, Mozambique. Methods: A cost analysis using an approach from the provider’s perspective was conducted in two district health directorates in the Maputo province, Matutuine and Namaacha. The institutions were purposely selected since in 2014 in both districts the expenditure on salaries to operationalize IRS was funded by the government budget. Cost information was collected retrospectively and both economic and financial costs were calculated. Uncertainty of results was tested using “one-way” deterministic sensitivity analysis. Results: The average total annual economic cost was 117,351.34 US$. The average economic cost per households sprayed totalled 16.35 US$. On average the economic costs per person protected is 4.09 US$ in total. In the financial analysis, the average total annual financial costs totalled 69,174.83 US$. The average financial cost per household sprayed and per person protected were 9.84 US$ and 2.46 US$ respectively. Vehicles, personnel salaries and consumables were the major substantial cost components. Conclusion: Setting aside the ODA restriction and focusing on the aim of implementing IRS within the existing resources, the study makessuggestions for improving efficiency by focusing on areas with a higher need and pays attention to cost drivers in order to reduce the costs.