Towards Developing an Initial Programme Theory: Programme Designers and Managers Assumptions on the Antiretroviral Treatment Adherence Club Programme in Primary Health Care Facilities in the Metropolitan Area of Western Cape Province,South Africa

BackgroundThe antiretroviral adherence club intervention was rolled out in primary health care facilities in the Western Cape province of South Africa to relieve clinic congestion, and improve retention in care, and treatment adherence in the face of growing patient loads. We adopted the realist evaluation approach to evaluate what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, to inform guidelines for scaling up of the intervention. In this article, we report on a step towards the development of a programme theory—the assumptions of programme designers and health service managers with regard to how and why the adherence club intervention is expected to achieve its goals and perceptions on how it has done so (or not).MethodsWe adopted an exploratory qualitative research design. We conducted a document review of 12 documents on the design and implementation of the adherence club intervention, and key informant interviews with 12 purposively selected programme designers and managers. Thematic content analysis was used to identify themes attributed to the programme actors, context, mechanisms, and outcomes. Using the context-mechanism-outcome configurational tool, we provided an explanatory focus of how the adherence club intervention is roll-out and works guided by the realist perspective.ResultsWe classified the assumptions of the adherence club designers and managers into the rollout, implementation, and utilisation of the adherence club programme, constructed around the providers, management/operational staff, and patients, respectively. Two rival theories were identified at the patient-perspective level. We used these perspectives to develop an initial programme theory of the adherence club intervention, which will be tested in a later phase.ConclusionThe perspectives of the programme designers and managers provided an important step towards developing an initial programme theory, which will guide our realist evaluation of the adherence club programme in South Africa.     

Reproductive ecology of Aloe plicatilis,a fynbos tree aloe endemic to the Cape Winelands,South Africa

While the pollination ecology of many Aloe species is well-documented, knowledge on aloe seed ecology, and hence aloe reproductive ecology in its entirety is limited. The aim of this study was to investigate the reproductive ecology of Aloe plicatilis, a Cape fynbos tree aloe endemic to the Cape Winelands, South Africa. Results from a pollinator exclusion experiment conducted at an A. plicatilis population on Paarl mountain suggests pollination primarily by insects, although bird visitation significantly increased seed set/fruit indicating possible co-pollination with insects. The species' long-tubed flowers and production of concentrated nectar, with observations of malachite sunbirds as the most common avian visitors to A. plicatilis flowers indicate the importance of long-billed specialist avian nectarivores as floral visitors. Analysis of the relationship between plant size and inflorescence production for five populations combined revealed a significant, positive linear relationship between plant size and the logarithm of the number of inflorescences/plant. Natural fruit and seed set determined for three populations (1325, 27,930 and 251,616 seeds/population) suggests low reproductive output compared to several other Aloe species. The smallest (31 individuals) and least dense (75 plants/ha) A. plicatilis population produced the lowest seed set/plant (128 seeds) and per population (1325 seeds), suggesting an Allee effect. Evaluation of seed dispersal potential showed that potential dispersal distances were approximately three times the canopy height; however, the occurrence of A. plicatilis on mountains isolated from more continuous mountain ranges on which the species also occurs suggests the possibility of long-distance dispersal by strong, gusty, summer winds. Soil seed bank samples collected from 13 populations yielded close to zero seedling emergence, indicating the absence of persistent seed banks. A. plicatilis seeds stored under ambient laboratory conditions for 3, 18 and 24 months were germinated in an environmental control chamber and a laboratory. High percentage germination was recorded for 18- and 24-month-seed (86 and 80%, respectively), while germination of 3-month-old seeds was three times lower, suggesting the need for after-ripening. Germination of fresh and one-year-old seed under ambient nursery conditions at the Karoo Desert National Botanical Garden in Worcester yielded emergence percentages of 67 and 44%, respectively, and were therefore less successful than germination under more controlled conditions. This is the first known study to investigate the reproductive ecology of a tree aloe species and that of a Cape fynbos aloe. The study highlights the importance of further studies on aloe seed ecology, particularly for rare and threatened species.     

Monitoring and management of the endangered Cape mountain zebra Equus zebra zebra in the Western Cape, South Africa

De Hoop Nature Reserve and a neighbouring conservancy contain the most genetically diverse subpopulation of the Endangered (IUCN) Cape mountain zebra ( Equus zebra zebra Linnaeus 1758). Although vital for the long-term stability of the meta-population, the population had received limited monitoring post-1999. We summarize data obtained during a population monitoring programme established in 2005. Ninety-nine individuals were identified indicating a decline in annual population growth from 6.6% (1995–1999) to 4.5% (1999–2005). The population was male biased and the deficit of females is likely to have prevented additional breeding herd formation resulting in excess nonbreeding males. These animals are currently of limited reproductive value to the meta-population and may be contributing to the decline in reproductive potential at De Hoop by competing for limited resources. One solution may be to translocate 'excess' males to reinforce existing small populations or establish new populations with females from elsewhere provided that a minimum of 78 animals is maintained at De Hoop to limit genetic loss. Population monitoring and effective management strategies for the De Hoop population and the meta-population are vital to ensure the long-term survival of Cape mountain zebra and for the success of other species recovery programmes.     

Linkage of HIV-Infected Infants from Diagnosis to Antiretroviral Therapy Services across the Western Cape,South Africa

Introduction

Early infant diagnosis (EID) of HIV infection is an important service to reduce paediatric morbidity and mortality related to HIV/AIDS. Although South Africa has a national EID programme based on PCR testing, there are no population-wide data on the linkage of infants testing HIV PCR-positive to HIV care and treatment services.

Methods

We conducted a retrospective analysis of all public sector laboratory data from across the Western Cape province between 2005 and 2011. We linked positive HIV PCR results to subsequent HIV viral load testing to determine the proportion of infants who were successfully linked to HIV care.

Results

A total of 83 698 unique infant HIV PCR tests were documented, of which 6322 (8%) were PCR positive. The proportion of PCR-positive children declined from 12% in 2005 to 3% in 2011. Of the children testing PCR-positive, 4105 (65%) had subsequent viral load testing indicating successful linkage to care. The proportion of successfully linked infants increased from 54% in 2005 to 71% in 2010, while the median delay in days to successful linkage decreased from 146 days in 2005 to 33 days in 2010.

Discussion

From 2005 to 2011 there has been a reduction in the proportion of children testing HIV PCR-positive, and an increase in the proportion of infected infants successfully linked to HIV care and treatment, in this setting. However a large proportion of infected infants remain unlinked to antiretroviral therapy services and there is a clear need for interventions to further strengthen EID programmes.     

Increasing Transfers-Out from an Antiretroviral Treatment Service in South Africa: Patient Characteristics and Rates of Virological Non-Suppression

Objectives

To determine the proportion, characteristics and outcomes of patients who transfer-out from an antiretroviral therapy (ART) service in a South African township.

Methods

This retrospective cohort study included all patients aged ≥15 years who enrolled between September 2002 and December 2009. Follow-up data were censored in December 2010. Kaplan-Meier survival analysis was used to describe time to transfer-out and cox proportional hazard analysis was used to determine associated risk factors.

Results

4511 patients (4003 ART-naïve and 508 non-naïve at baseline) received ART during the study period. Overall, 597 (13.2%) transferred out. The probability of transferring out by one year of ART steadily increased from 1.4% in 2002/2004 cohort to 8.9% for the 2009 cohort. Independent risk factors for transfer-out were more recent calendar year of enrolment, younger age (≤25 years) and being ART non-naïve at baseline (i.e., having previously transferred into this clinic from another facility). The proportions of patients transferred out who had a CD4 cell count <200 cells/µL and/or a viral load ≥1000 copies/mL were 19% and 20%, respectively.

Conclusions

With scale-up of ART over time, an increasing proportion of patients are transferring between ART services and information systems are needed to track patients. Approximately one-fifth of these have viral loads >1000 copies/mL around the time of transfer, suggesting the need for careful adherence counseling and assessment of medication supplies among those planning transfer.     

Mesozoic palaeogeography of the Southern Cape,South Africa

Four palaeogeographical reconstructions are presented for the southern Cape covering the period Late Permian to Late Cretaceous. This time spans the commencement to an advanced stage of breakup of Gondwanaland, during which the area moved from a mid-continental, high latitude, to an ocean-dominated, middle latitude position. These movements can be traced in facies changes and erosional cycles associated with the rift between West Gondwana and Antarctica (proto southwest Indian Ocean) and the later rift between South America and Africa (proto southeast Atlantic Ocean).     

Geographical affinities of the Cape flora, South Africa

Aim The flora characteristic of the Cape Floristic Region (CFR) is dominated by a relatively small number of clades that have been proposed as ‘Cape clades’. These clades have variously been suggested to have African or Austral affinities. Here we evaluate the support for these conflicting hypotheses. In addition, we test the hypothesis that these clades share a common time of differentiation from their geographical neighbours. Location The Cape Floristic Region, South Africa Methods We use both published and unpublished phylogenetic information to investigate the geographical sister areas of the Cape clades as well as the timing and the direction of biogeographical disjunctions. Results Almost half of the Cape clades for which unambiguous sister areas could be established show a trans‐Indian Ocean disjunction. The earliest trans‐Indian Ocean disjunction dates from 80 Ma. Other disjunctions date from various times in the Cenozoic, and we suggest that the process of recruiting lineages into the Cape flora might be ongoing. Relatively few Cape clades show a sister relationship with South America and tropical Africa, despite their relative geographical proximity. Numerous Cape clades contain species also found on tropical African mountains; in all cases tested, these species are shown to be embedded within the Cape clades. While many Cape clades show a relationship with the Eurasian temperate flora, this is complicated by their presence in tropical Africa. The single case study addressing this to date suggests that the Cape clade is nested within a European grade. Main conclusions Although many Cape clades show Austral rather than African relationships, there are numerous other patterns suggestive of a cosmopolitan flora. This spatial variation is echoed in the temporal data, from which, although there is wide variance around the dates of disjunctions, it is clear the Cape flora has been assembled over a long time period. There is no simple hypothesis that can account for the geographical sources of the currently distinctive Cape flora. The phylogenetic positions of Afromontane members of Cape clades suggest a history of dispersal from the CFR, rather than the reverse.     

Nest boxes for Cape Parrots Poicephalus robustus in the Hogsback area,Eastern Cape,South Africa

Breeding propensity of tree-cavity nesting bird species are often limited by a shortage of natural nesting sites. Artificial nests can be used to provide alternative nest sites. Cape Parrots Poicephalus robustus are nationally endangered and nest in existing tree-cavities in high-altitude fragmented Afromontane forests in South Africa, assumed to be in short supply due to historic and current logging practices. To increase nest site availability, 179 wooden bird boxes and 28 bee boxes (to ‘pull’ bees) were erected during 2011–2012 in Hogsback, Eastern Cape. In 2016, no bird boxes were occupied by Cape Parrots. A total of 43% were used by other species, 51% were unused and 6% could not be inspected due to tree instability and inaccessibility. Two bird boxes were inspected by two pairs of Cape Parrots, but were never occupied. Occupancy of boxes by birds was not associated with nest, tree or habitat characteristics. However, occupancy of boxes by bees was associated with habitat type and tree species. Future conservation efforts will include locating natural Cape Parrot nesting sites and reforestation efforts to ensure the long-term availability of natural nesting sites.     

Monitoring of Antiretroviral Therapy and Mortality in HIV Programmes in Malawi,South Africa and Zambia: Mathematical Modelling Study

Objectives

Mortality in patients starting antiretroviral therapy (ART) is higher in Malawi and Zambia than in South Africa. We examined whether different monitoring of ART (viral load [VL] in South Africa and CD4 count in Malawi and Zambia) could explain this mortality difference.

Design:

Mathematical modelling study based on data from ART programmes.

Methods

We used a stochastic simulation model to study the effect of VL monitoring on mortality over 5 years. In baseline scenario A all parameters were identical between strategies except for more timely and complete detection of treatment failure with VL monitoring. Additional scenarios introduced delays in switching to second-line ART (scenario B) or higher virologic failure rates (due to worse adherence) when monitoring was based on CD4 counts only (scenario C). Results are presented as relative risks (RR) with 95% prediction intervals and percent of observed mortality difference explained.

Results

RRs comparing VL with CD4 cell count monitoring were 0.94 (0.74–1.03) in scenario A, 0.94 (0.77–1.02) with delayed switching (scenario B) and 0.80 (0.44–1.07) when assuming a 3-times higher rate of failure (scenario C). The observed mortality at 3 years was 10.9% in Malawi and Zambia and 8.6% in South Africa (absolute difference 2.3%). The percentage of the mortality difference explained by VL monitoring ranged from 4% (scenario A) to 32% (scenarios B and C combined, assuming a 3-times higher failure rate). Eleven percent was explained by non-HIV related mortality.

Conclusions

VL monitoring reduces mortality moderately when assuming improved adherence and decreased failure rates.     

Raptor conservation in the Northern Cape Province,South Africa

Anderson, M.D. 2000. Raptor conservation in the Northern Cape Province, South Africa. Ostrich 71 (1 & 2): 25–32.

The semi-arid Northern Cape is the largest and most sparsely populated province in South Africa. One of the main economic activities is sheep farming, and the properties are generally very large (>5 000 ha). A heterogeneous environment results in many habitats for a wide diversity of raptors. Fifty-one different species have been recorded, of which 37 are resident, 21 are common, and eight species are listed in the South African Red Data Book—Birds. As habitat degradation is limited, besides the areas immediately adjacent to the perennial rivers, raptors are still commonly encountered in many areas. Conflict with small-stock farming, however, results in some birds being inadvertently or directly persecuted each year. Two farmer questionnaire postal surveys (1976 and 1992) indicated a decrease in range and abundance of certain scavenging species, such as the Tawny Eagle. The more recent survey also indicated that most stock mortalities occurred in the mountainous areas, with the Black Eagle being the apparent culprit. In the Northern Cape there are both positive and negative anthropogenic effects on raptors. For example, 14 species have been recorded breeding on man-made structures, while 18 species have been documented to drown in farm reservoirs. Through the activities of the Raptor Conservation Group, the Northern Cape Nature Conservation Service and the Northern Cape Raptor Conservation Forum various threats are being addressed. Raptor conservation activities include: monitoring of raptor breeding populations, road censuses, farmer extension, establishment of raptor conservancies, rehabilitation of injured raptors, issuing of certificates to land-owners who have breeding raptors on their properties, presentation of the annual Gariep Raptor Conservationist Award, production and distribution of raptor pamphlets and booklets, modification of farm reservoirs to prevent raptor drownings, modification of powerlines to prevent electrocutions, and establishment of “vulture restaurants”. Through these efforts, the status of many raptor species is improving and species such as the Bateleur and Lappet-faced Vulture are becoming increasingly common.     

Effectiveness of Patient Adherence Groups as a Model of Care for Stable Patients on Antiretroviral Therapy in Khayelitsha,Cape Town,South Africa

Background

Innovative models of care are required to cope with the ever-increasing number of patients on antiretroviral therapy in the most affected countries. This study, in Khayelitsha, South Africa, evaluates the effectiveness of a group-based model of care run predominantly by non-clinical staff in retaining patients in care and maintaining adherence.

Methods and Findings

Participation in “adherence clubs” was offered to adults who had been on ART for at least 18 months, had a current CD4 count >200 cells/ml and were virologically suppressed. Embedded in an ongoing cohort study, we compared loss to care and virologic rebound in patients receiving the intervention with patients attending routine nurse-led care from November 2007 to February 2011. We used inverse probability weighting to estimate the intention-to-treat effect of adherence club participation, adjusted for measured baseline and time-varying confounders. The principal outcome was the combination of death or loss to follow-up. The secondary outcome was virologic rebound in patients who were virologically suppressed at study entry. Of 2829 patients on ART for >18 months with a CD4 count above 200 cells/µl, 502 accepted club participation. At the end of the study, 97% of club patients remained in care compared with 85% of other patients. In adjusted analyses club participation reduced loss-to-care by 57% (hazard ratio [HR] 0.43, 95% CI = 0.21–0.91) and virologic rebound in patients who were initially suppressed by 67% (HR 0.33, 95% CI = 0.16–0.67).

Discussion

Patient adherence groups were found to be an effective model for improving retention and documented virologic suppression for stable patients in long term ART care. Out-of-clinic group-based models facilitated by non-clinical staff are a promising approach to assist in the long-term management of people on ART in high burden low or middle-income settings.     

Duinefontein 2: an Acheulean site in the Western Cape Province of South Africa.

Excavations at Duinefontein (DFT) 2 near Cape Town, South Africa have recovered numerous stone artefacts and animal bones on an ancient surface sealed within iron-stained eolian sands. U-series analysis of an overlying calcrete places the sands before 150 ka ago, while the large mammal taxa imply an age between 400 and 200 ka ago. The artefacts include a classic Acheulean handaxe and probable biface shaping flakes that support this age estimate. The principal mammalian species are long-horned buffalo, black wildebeest, greater kudu, Cape zebra, and grysbok/steenbok, which imply a grass-and-bush mosaic instead of the historic small-leafed shrubland.Hippopotamus and reedbuck indicate that water stood nearby, probably in dune swales. The large mammal bones are mostly vertebrae and other axial elements, often in near-anatomical order. Both proximal and distal appendicular elements are rare. Bones with carnivore damage are common, but ones with stone tool marks are scarce. The sum suggests a water-edge attritional death site where people played a minimal role and carcasses were disarticulated mainly by carnivore feeding and by trampling. Stone tool marks tend to be equally rare at other Acheulean attritional death sites, and the implication may be that Acheulean people rarely obtained large mammals, whether by hunting or scavenging. Human scavengers at DFT2 would not have encountered a disproportionate number of distal (versus proximal) limb elements, and it follows that the tendency for distal elements to dominate many archeological assemblages need not reflect scavenging versus hunting. Even if DFT2 was not itself a locus of intense human activity, it provides a useful baseline for evaluating bone damage, skeletal part representation, and other variables at sites where people were deeply involved.